Written by Dr Sheraz Ahmad Khan (PhD, MPH, MBBS). Health Services Academy, Islamabad.
Dr Maidah (MBBS, IPFPH). Shaikh Zayed Medical and Dental College, Lahore.
One key strategy for achieving Universal Health Coverage (UHC) under the Sustainable Development Goals is to train, attain, and retain enough qualified HRH. The World Health Organization (WHO) defines HRH as “all people engaged in actions whose primary intent is to enhance positive health outcomes.” They include physicians, nurses, pharmacists, midwives, dentists, allied health professionals, community health workers, and other social service providers.
HRH is among the six key building blocks of strengthening health systems that are equitable and responsive. In Pakistan, the HRH situation reflects a mix of progress and challenges. There is a low availability and inequitable distribution of physicians and nurses geographically (across provinces and urban-rural disparity). With a rising population, healthcare demands will rise, further stretching the limited HRH. Addressing the HRH limited supply and their maldistribution is needed to improve healthcare delivery’s effectiveness, safety, and efficiency.
Physicians’ and nurses’ distribution in Pakistan
WHO recommends a minimum density of one doctor and 2.5 nurses per 1,000 population to ensure effective health coverage. However, significant disparities exist in the distribution of doctors and nurses nationwide. Some regions in Pakistan have the WHO-recommended density for doctors, while others face a severe shortage of nurses.
Physicians’ distribution is highly uneven across Pakistan. In Punjab, Azad Jammu and Kashmir (AJK), Gilgit-Baltistan (GB), and the Islamabad Capital Territory (ICT), the number of registered physicians is 1.12 per 1,000 compared to the 1.11 required. Sindh fares even better, with a population density of 1.69 physicians per 1,000. However, in Khyber Pakhtunkhwa (KP), the physician density is only 1.04. Balochistan is the most deficient, with a density of 0.57 physicians per 1,000 population. These disparities leave large segments of the population without access to healthcare in these regions.
The situation is worse for nurses, who play a vital role in patient care and service delivery. Across Pakistan, no region meets the WHO-recommended nurse-to-population ratio of 2.5 per 1,000 population. Punjab, AJK, GB, and ICT have a nursing density of only 0.69 per 1,000, while Sindh has 0.63 per 1,000. In KP, the density is 0.54, and in Balochistan, it is just 0.19 nurses per 1,000 population. Nurses’ shortage impacts healthcare delivery. The reversal of the nurse-to-doctor ratio makes the country’s healthcare system heavily dependent on physicians, leading to burnout.
Pakistan’s projected HRH needs
Pakistan’s population is growing at 2.5% annually, which will increase demand for health care. The population is projected to reach 283 million by 2030. To meet the WHO-recommended ratios by 2030, Pakistan will require 283,500 doctors and 946,890 nurses. However, as of 2023, only 153,437 nurses (20% of the required) and 298,143 doctors (105% of the required) were registered in the country.
Bridging the current and projected future gaps
Pakistan’s medical education system produces enough doctors to meet the future demand, which is at par with the current population growth. The country’s medical colleges produce approximately 17,415 doctors annually, and by 2030, Pakistan is expected to have 420,048 doctors, surpassing the required 283,500. However, this surplus of doctors will only be effective if their maldistribution is addressed. Undersupplied regions such as KP and Balochistan will need a boost in production capacities, targeted recruitment and retention of doctors to fill the existing and projected gaps. Better salaries, housing, and professional development opportunities can attract doctors to these areas, adjusting the maldistribution.
The current production rate of 34,000 nurses per year will not fill the gap of 317,313 nurses by 2030. At the current production rate, it will take Pakistan approximately nine years beyond 2030 to meet the estimated nurse-to-population ratio for 2030. To address this gap, Pakistan must increase its production capacity from 34,000 to 79,474 nurses annually to meet the 2030 target. Addressing the nursing shortage will require substantial investment in nursing education and training. In addition, providing better working conditions, competitive salaries, and opportunities for career advancement will be essential in retaining nurses within the workforce. Pakistan Nursing Council must also focus on producing advanced-degree nurses to fill leadership and research roles. In 2023, there were only 30 PhD and 377 Masters of Sciences in Nursing in Pakistan.
Conclusion
The condition of HRH in Pakistan’s healthcare system needs to be improved. Significant disparities exist in the quantity and distribution of healthcare professionals. Provincial and urban-rural equity will remain challenging despite a sufficient projected supply of doctors to meet future demands. There is an urgent need to cater to the nursing shortage. Pakistan needs to enhance its training capacities and improve the working conditions to satisfy the healthcare demands of an increasing population. Closing these gaps is crucial for creating a resilient healthcare system that can achieve UHC and contribute towards the health-related outcome of the SDGs.
