HUMAN RESOURSE MANAGEMENT IN PAKISTAN (Major Human recourses challenges in Pakistan public health system, Human Recourse system policies and ways to address those challenges) Introduction Human resources are the heart of the health system and health care managers have a critical role in determination of performance of the system . Our savings and investment level can be raised only when we are in a position to convert our unproductive and underutilized human and natural resources into dynamic and self-sustained capital and potential accelerator of economic growth.
The World Health Organization (WHO) has defined the health workforce as “all people primarily engaged in actions with the primary intent of enhancing health”. This definition is consistent with the WHO definition of health systems as comprising all activities with the primary goal of improving health. The health workforce is one of the most important pillars of the health system. Adequate numbers and quality of health workers have been positively associated with successful implementation of health interventions, including immunization coverage, outreach of primary care, and infant, child and maternal survival. 2] Human Resource Management is a key to improve productivity of people in the organization. Good Human resource management approach with strategic, ethical and social responsibility which further help to achieve organization goal and objectives. Human Resource management is an art to transform changes as employee commitment and opportunity through developing their knowledge & skills and motivating them. In developing country human resource players are considered necessary since they can serve as intellect of an organization.
A loyal, dedicated, skilled, efficient and productive human resources is valuable assets of an organization but not reflected on the balance sheet.  Pakistan story In 1947, Pakistan was created as British rule came to an end in India. In 1971, East Pakistan demanded independence, and after a bloody civil war it was transformed into what is now the country of Bangladesh. As one of the most crowded countries in the world, Pakistan faces enormous economic and social crises.
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Fortunately, however, it possesses an abundance of natural resources that can help it overcome these challenges  Pakistan is blessed with huge natural and human resources but most of these are in crude form. “According to official data, there are 127,859 doctors and 12,804 health facilities in the country to cater for over 170 million people. ”  “Infant mortality rate: 72/1,000 live birth, Maternal mortality rate: 260/100,000 live birth instead having 7. 8 Physicians/10,000 population, 3. Nurses and midwifes/10,000 population; overall 11. 6 Health care workforce /10,000 population in the country”  In Pakistan the health system remains functionally weak and the quality of health services is poor, despite very old constitutional support for health care as a right and a large Ministry of Health at federal and provincial levels [7, 8]. In Pakistan health sector performance has not been evaluated in terms of inputs, processes or activities and outputs for different types of resources including human resources.
Very little is known about compositions of health managers, their skills, and training, and spec ifically the policy for deployment. The first and foremost prerequisite for human resources progress is the proper attention to the health sector. No nation can dream of acquiring preeminence in any field with sick and disabled persons so developed nations invest quite a hefty amount in their health sector. In Pakistan, unfortunately, due attention is not paid to this important sector.
Human resources for health have recently been emphasized as a central component in providing a stronger health system to achieve the Millennium Development Goals . Absence or nonimplementation of appropriate human resource policies that address appropriate numbers of staff, their qualifications, deployment, working conditions, and gender distribution are associated with many problems in the health work force . Frequency of turnover of key managerial staff has also been associated with poor system performance . Human Resource Development and Management challenges
Pakistan has been categorized as one of 57 countries that are facing an HRH crisis, below the threshold level defined by WHO to deliver the essential health interventions required to reach Millennium Development Goals (MDGs) by 2015 . Health workforce strategy is usually low on a country’s agenda, despite the understanding that scaling-up health interventions to reach MDGs is not possible without a minimum level of health workforce. National health workforce strategies require reliable and timely information, rational system analysis and a firm knowledge base.
However, data analysis, research on HRH and technical expertise are still underdeveloped in many countries, in part due to low investment in HRH . Pakistan’s new draft National health policy 2009 mandated the development of strategies in various key areas, including HRH  There is a lack of clear long-term vision for human resource development and the federal MOH or provincial DOH does not have a unit, responsible for such an important health system function.  The imbalances in health workforce in terms of cadre, gender and distribution are well known in Pakistan.
The public sector continues to heavily invest its scarce resources in the development of medical colleges and universities rather than investing in improving quality and quantity of nursing institutions, public health schools and technicians training institutions. In the context of health system development, there is a serious shortage of qualified health system specialists such as health and human res ource planners, health economists, health information experts and health system and hospital managers.
Pre -service training of health professionals follows traditional methods and there is a mismatch between educational objectives, which focus on hospital based care, instead of addressing the needs of the communities for promotive, preventive curative and rehabilitative services. The Pakistan Medical and Dental Council (PM&DC) is responsible for registration, licensing and evaluation of the medical and dental practitioners, the attempts made by PM&DC have not materialized yet.
Regulation of private practitioners and different traditional categories of medical practice such as homeopathic doctors and Yunani Hakims is non-existent. Human Resource in health care is not appropriately planned in Pakistan, with the result that there are more doctors than nurses, dearth of trained midwives, urban concentration, brain drain from rural to urban areas and abroad, along with other issues related to curriculum, quality of graduates and their continuing supervision.
The service structure for health workers is poorly defined it, favors tenure over competence, largely ignores technical capacities and does not allow incentives or rewards for performance. The conduct of education for medical, nursing and related cadres is mostly conventional and does not utilize recent developments in the field of medical education. Though curricula have been revised from time to time, in majority of cases they are not locally contextualized and are not based on competencies and skills.
There is no organized system for continuing medical education for any health providers who are also largely unsupervised and at times ill equipped with newer knowledge/skills to tackle emerging diseases. This holds true for management cadres as well. The health system is currently not conducive to nurses, midwives and allied health professionals playing pivotal roles in ensuring the provision and delivery of effective primary health care services in th e absence of doctors.
Health authorities have yet to be convinced that PHC services can be successfully provided and delivered by nurses, midwives and allied health professionals making up local teams with the relevant staffing complement and skills mix.  All publicly employed doctors are forbidden from practicing privately and many of them receive non practicing allowances as part of their non salary allowances under the law of the country, That notwithstanding, most of them run lucrative private sector clinics while working in hospitals and often use the public sector leverage to boost practices in private facility settings.
A number of unethical practices such as refusing to see patients i n hospitals and referring them to private clinics are well established and are almost regarded as a conventional norm. Provider-driven over-consumption of health services, over-prescription, and over-use of diagnostics as well as violation of ethical guide lines in clinical practice are well established in Pakistan. In terms of the ethics of health care alone, frequent violations of the four basic principles of: the Right to autonomy, Right to privacy, Right to choose and Right to information are often seen. 17] High rate of frequent transfer and posting is also a major reason of low levels of performance in public health sector. A study was conducted on the 54 top provincial offices in the government of Sindh Department of Health over the period of 24 years (1981-2004). There were 689 transfers/postings made in the 54 key offices studied over the 24 year time period. Almost half (48. 9%) of these postings lasted no longer than 1 year. The offices affected highest were tertiary/district care hospitals (54 tim es) and district health offices (37 times) respectively. 18] Recommendation and priority actions towards Human resource development Since the Pakistan is enriched with human resources there is emerge need to develop strategy for optimum utilization of it especially in public heath sector. WHO reviewed the health system of Pakistan and suggested that there is need to develop a clear policy and strategies for human resource development according to the longer term stated health development vision for Paki stan and to the more pressing requirements of improving health service delivery in the country .
The report emphasize on mapping of health care providers and institutions through a national human resources for health (HRH) observatory, which should bring together all stake holders involved in human resource development. It suggested that to deal with standard setting and regulatory functions strategic planning in human resource development at federal and provincial levels is required. It reflected the essentiality to established position such as human resource planners, health economists, health information experts and health system managers, which are attractive enough to recruit qualified and experienced persons.
In addition, tackle their shortage in the short term through external fellowships and in the longer term through the development of accredited training programs in the country. A nursing directorate should be established in the MOH in order to strengthen leadership and to address the nursing crisis. There is need to review the role of the PM&DC, CPSP and other institutions in term of new developments and planned reforms. By providing problem based training the system can reorient the production of health workforce towards more focus on public health and community needs.
In order to provide the necessary support to the various reforms aimed at increasing access to health services and at improving health system performance; strengthening of partner institutions such as Health Services Academy (HSA), schools of public health, academia and professional institutions is required. Human resource policy in government bureaucracies should be developed to stabilize professional positions while having a clear transfer policy in place and improve the performanc e of the health care delivery system. 15] Efficient and effective development of a health care system needs of equitable gender distribution of women in the health workforce.  To meet out such needs ministry of health, Pakistan came up with national health policy in July 2009 which recommended that Federal and health authorities will play a vital role for the development of the health resource in Pakistan. This federal and Provincial Health authorities will forecast human resource needs based on requirements outlined in essential health services package and provincial strategies.
It will direct and facilitate the teaching institutions in reorienting their curricula and training t o being competency-based with enhanced exposure to the community and with responsiveness to the local needs and compliance with international standards. It includes that each district will be linked to a teaching institution so that the latter can provide technical support and supervision to the former to improve rural health care services.
All medical graduates will be recommended to be posted to rural centers for a period of at least 6 months after graduation. The Pakistan Medical and Dental Council will ensure that those undergoing post graduate training also rotate through district health centers. Provincial health authorities will appoint and retain relevant cadres of appropriate health personnel with special focus on staffing district primary care outlets and on recruiting women.
Provincial health departments will track human resources for health by establishing a database of doctors, nurses, midwives and allied health professionals working in the BHUs and RHCs across each province and those in training funded by the government.  Conclusion A healthy population is not only valued in its own right, but it also raises the human capital of a country thereby positively contributing to the economic and social development.
A considerable improvement in health sector facilities over the past year is reflected in the existing vast network of health care facilities which consist of 4712 dispensaries, 5,336 basic health units, 924 hospitals, 906 maternal and child health centers and 288 TB centers. Available HR is 122798 doctors, 7388 dentist and 57646 nurses.  A major strength of health care services in Pakistan is very strong outreach via about 95,000 Lady Health Workers (LHWs) and an increasing number of community midwives (CMWs).
Inspite of all there is a lack of clear long-term vision for human resource development, which is necessary to address the imbalances in health workforce with appropriate skills; and improved motivation, retention and productivity; Human resources in health care are not appropriately planned in Pakistan, with the result that there are more doctors than nurses and “brain drain”, along with other issues related to curriculum, quality of graduates and their continuing supervision.
The service structure for health workers is poorly defined it, favors tenure over competence, largely ignores technical capacities and does not allow incentives or rewards for performance. The conduct of education for medical, nursing and related cadres is mostly conventional and does not utilize recent d evelopments in the field of medical education. There is no organized system for continuing medical education for any health providers who are also largely unsupervised and at times ill equipped with the skills to tackle emerging diseases.
National Health Policy 2010 is include a vision for the role HRH strategy can play in helping to meet the country’s goals for improving health care services for all Pakistanis. In addition, the current HRH assessment will serve as evidence for a new HRH strategy to be dev eloped and implemented by the Ministry of Health. The national and provincial authorities will comprehensibly plan and forecast their human resource requirement for next 10 years according to the proposed services in the respective areas and take robust short term and long term steps to achieve the balance in manpower. 6] Provincial health authorities will also develop, implement and maintain a database of health human resource, including the private sector. Nationwide campaigns will be launched to promote the permanent roles that nurse, midwives and allied health professionals may play in providing and delivering effective services to the public. By: - Mr. Vikas Jain References 1. Martinez J, Martineau T. Rethinking human resources: an agenda for the millennium. Healt h Policy and Planning 1998 2. The world health report 2006: working together for health .
Geneva, World Health Organization, 2006. 3. Dr. Zareen Abbasi Assistant Professor Department of Public Administration University of Sindh, Jamshoro, Human Resource Management in Pakistan , The Elite Scientific Publications, Faisalabad, Pakistan, 2009 4. World Atlas . com [http://graphicmaps. com/webimage/countrys/asia/pk. htm] 5. http://southasia. oneworld. net/todaysheadlines/healthcare-in-pakistan-too-expensive-to-afford 6. CCF Case study, establishing an HRH coordination process, Pakistan, page 1, 2 7. Siddiqi S, Haq IU, Ghaffar a, Akhtar T, Mahaini R.
Pakistan's maternal and child health policy: analysis, lessons and the way forward. Health policy 2004; page 117-130. 8. Bhutta ZA, Ali N, Hyder A, Wajid A. "Perinatal & Newborn Care in Pakistan: Seeing the Unseen! " Maternal and Child health in Pakistan. Challenges And Opportunities: Edited by Zulfiqar A Bhutta. Ameena Saiyid, Oxford University Press 2004. 9. Narasimhan V, Brown H, Pablos-Mendez A, Adams O, Dussault G, Elzinga G, et al. Responding to the global human resources crises. The Lancet 2004; page 14 -72. 10. Martineau T, Martinez J.
Human resources in the health sector: guidelines for appraisal and strategic development Brussels: European Commission, Directorate General for Development, "Health and Development Series" 1997. 11. Buchan J. What difference does ("good") HRM make? Human Resources for Health 2004 12. Global atlas of the health workforce. Geneva, World Health Organization (http://www. who. int/globalatlas, accessed 12 December 2009). 13. Narasimhan V et al. Responding to the global human resources crisis. Lancet, 2004 14. National health policy 2009. Islamabad, Ministry of Health (final draft) (http://www. health. gov. pk, accessed 5 May 2010). 5. Report of the Health System Review Mission – Pakistan, World Health Organization United Nations Children Fund, Department for International Development, United Kingdom, The World Bank, February 19-28, 2007, Islamabad 16. Corruption in the health sector in Pakistan , Pakistan Health Policy forum 17. Abdul Hakeem Jokhio B. S. , Ph. D. Department of Community Health Sciences, Aga Khan University, H ealth System Managerial Staffing Patterns: Public Sector Experience From P akistan, 18. World Health Organization. World Health Report 2003-Shaping the future. Geneva; 2003. 19. Pakistan Economic Survey, 2007
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