Strengthening the nursing workforce to advance universal health coverage in the Eastern Mediterranean Region

Regional Committee for the Eastern Mediterranean Sixty-sixth session Provisional agenda item 3(b) EM/RC66/4 September 2019 Strengthening the nursing workforce to advance universal health coverage in the Eastern Mediterranean Region Executive summary 1. The Eastern Mediterranean Region of the World Health Organization (WHO) is facing significant challenges in responding to the current and growing burden of communicable and noncommunicable diseases. In addition, rising numbers of refugees and displaced populations are increasing the burden on already-strained health care systems. This has implications for the quality, relevance and performance of the health workforce. 2. The health workforce is critical to achieving universal health coverage (UHC). Core functions of the health workforce include protecting and improving the health and well-being of communities and individuals. To make best use of their efforts, health workers should be available, accessible and have the right skills and competencies to deliver the required health services. Nurses and midwives make up more than half the health workforce. Evidence suggests that adequate numbers of well-educated nurses are particularly well suited to tackling the rise in communicable and noncommunicable diseases, and that they contribute significantly to improved maternal, infant and child survival and to reducing adverse health events. 3. The need to strengthen nursing in order to achieve UHC has been well articulated in global and regional WHO resolutions and strategies on the health workforce and nursing. Global and regional efforts to tackle the challenges of the nursing workforce are continuing. The three-year Nursing Now campaign (2018–2020) has been initiated to raise the profile and status of nurses worldwide. The Seventy-second World Health Assembly in 2019 designated 2020 the “Year of the Nurse and Midwife”, highlighting the key role of nurses in achieving WHO’s global public health targets. In addition, the first WHO report on the state of the world’s nursing will be launched in 2020. 4. However, despite global and regional commitment to strengthening nursing, progress has been slow. While the global shortage of nurses and midwives is expected to decline by 2030, the shortage is predicted to increase in the Eastern Mediterranean Region. In the past 10 years, the densities of nurses and midwives have not changed in almost all countries of the Region; in fact, densities have declined in 11 countries and the ratio of nurses and midwives to doctors has decreased in nine countries in the same period. This trend is likely to continue if the current level of production of health professionals is maintained. Within countries of the Region, the shortage is often made worse because health professionals prefer to work in large acute- care settings in urban areas, where job prospects and career opportunities are greater, rather than in primary- care facilities in rural areas. 5. The changing context of health systems presents both opportunities and challenges to improve the availability, skills mix, roles and competencies of health workers, including nurses. Building on current momentum, this paper presents updated information and data to guide policy dialogue on nursing and promote accelerated action to strengthen the nursing workforce as a means to advance UHC. In moving forward, investment in strong policies to scale up the production, employment, deployment and retention of nurses will be required so that health services have an adequate nursing workforce to ensure access to services, particularly in protracted emergencies and for refugees and displaced populations. Introduction 6. Globally, Member States of the World Health Organization (WHO) have made commitments to work towards achieving universal health coverage (UHC). UHC means ensuring that all people and communities have access to good-quality health services, including promotive, preventive, curative, rehabilitative and EM/RC66/4 2 palliative services, without facing the risk of financial hardship or impoverishment. All Member States of the WHO Eastern Mediterranean Region have signed the UHC2030 global compact, demonstrating the depth and breadth of their political commitment to achieving UHC by 2030 (1). 7. The Astana Declaration on Primary Health Care of 2018 affirmed that UHC could not be achieved without well-organized and effective primary health care that has available, accessible and competent doctors, nurses and midwives working in teams (2). At the core of their functions is protecting and improving the health of communities and individuals (3). 8. One of the targets of the Sustainable Development Goals (SDGs) on health and well-being (SDG3, 3C), is to “substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries…” (4). Nurses and midwives make up more than 50% of the health workforce, and evidence suggests that well-educated nurses in adequate numbers are particularly well suited to tackling the rise in communicable and noncommunicable diseases, and that they contribute substantially to improved maternal, infant and child survival and to reducing adverse health events (5–8). 9. Over the years, the World Health Assembly has made commitments to strengthening nursing and midwifery through several resolutions, most recently in 2011 (WHA64.7) (9). During the Seventy-second World Health Assembly in 2019, the year 2020 was designated the “Year of the Nurse and Midwife”, highlighting the key role of nurses in achieving WHO’s global public health targets (10). Also in 2020, two reports will be launched, the first State of the world’s nursing report and the third State of the world’s midwifery report. Furthermore, to raise the profile and status of nurses worldwide, a three-year global Nursing Now campaign (2018–2020) has been initiated to influence policy-makers and support nurses to lead, learn and build a global movement (11). Eight countries of the Eastern Mediterranean Region have already launched the Nursing Now campaign nationally, and the President of Pakistan declared 2019 the Year for Nursing. 10. Regional efforts to tackle challenges in nursing have been guided by a number of global and regional strategies and frameworks (12–16). Over the years, the WHO Regional Office for the Eastern Mediterranean has worked with Member States to develop national nursing strategies to scale up nursing and midwifery capacity, strengthen nursing education and training capacity and programmes, promote positive practice environments, and develop strong leadership and advocacy (17). Some guidance documents have been developed, such as guides on nursing and midwifery education standards, and nursing specialization (18,19). However, as the Eastern Mediterranean Region has been associated with increasing political, economic, health system and social instability, problems facing nursing and midwifery services remain and the rate of progress has not been as fast as desired despite global and regional efforts (17). It is therefore crucial for the Region to take comprehensive and accelerated action to meet health care demands now and in the future. 11. Changes in the context of health systems, such as the growing burden of chronic diseases, ageing populations, emergencies and humanitarian crises, increasing patient expectations, and advances in technology, affect the way health services are organized and provided, emphasizing the need for integrated person-centred care and continuity of care (20). These changes present both opportunities and challenges related to the quantity, skills mix, roles and competencies of nurses. This implies that future strategies should take the requirements of the changing context into consideration to ensure that the right mix of nurses is deployed in the right practice settings with the right skills and competencies needed to meet their goals (21). 12. Building on the current momentum, the attention of the Regional Committee is requested to encourage accelerated action based on the updated information and data presented in this paper to guide policy dialogue to strengthen nursing in the Region. While global and regional strategies and commitments have focused on nurses and midwives together, and data on the two are usually merged, this paper focuses on nurses, who are the larger group, working in a wider range of health care settings with varying scopes of EM/RC66/4 3 practice and challenges. Strengthening the nursing workforce will contribute to achieving not only healthy lives and well-being (SDG 3), but also gender equity (SDG 5) and employment and economic growth including job creation and social protection (SDG 8) (22). Countries should be able to train and employ sufficient numbers of nurses with the appropriate competencies and skills to meet the health needs of their people, improve health outcomes and advance UHC. The nursing workforce in the Region 13. The rising global need for health workers over the next 11 years presents challenges to be able to deliver and sustain UHC by 2030, not only for health workforce policies and plans in the countries of the Region but also for all other components of the health system. Most countries of the Region are facing shortages in their overall health workforce. As of 2017, seven Member States of the Region (Afghanistan, Djibouti, Morocco, Pakistan, Somalia, Sudan and Yemen) still fall below the workforce density threshold (23 doctors, nurses and midwives per 10 000 population), indicating too few health care staff to be able to deliver basic health interventions (23) (Fig. 1). More than half the countries in the Region are below the threshold level of 44.5 doctors, nurses and midwives per 10 000 to ensure interventions to advance UHC (12). 14. The regional median density of nurses and midwives in 2017 was 22.2/10 000 population, which is less than a third of the Organisation for Economic Co-operation and Development (OECD) average of 90/10 000 population (23,24) (Fig. 2). Furthermore, the higher densities of nurses and midwives in countries of the Gulf Cooperation Council skew the overall density in the Region because of their dependence on expatriate nurses. The regional median density of nurses and midwives excluding Gulf Cooperation Council countries would be 14.5 nurses and midwives/10 000 population – much lower than the regional median including Gulf Cooperation Council countries and the OECD median (Fig. 2). Source: Regional Health Observatory (23) Fig. 1. Density of doctors, nurses and midwives in the WHO Eastern Mediterranean Region, 2017 or latest available date 1.1 5.1 7.2 14.9 9.1 9.8 15.2 26 23 26.7 30.1 36.75 43.4 55.3 67.64 53.9 63.7 69.6 81.1 82.3 79.9 94 87 124 23 44.5 0 20 40 60 80 100 120 140 Health Workforce Density (D,N,M per 10 000 pop) (2017) Millenium Development Goal critical shortage benchmark (doctors, nurses, midwives per 10 000) Sustainable Development Goal benchmark required to achieve universal health coverage (doctors, nurses, midwives per 10 000) OECD Average Median EM/RC66/4 4 Source: Regional Health Observatory (23) Fig. 2. Density of nurses and midwives per 10 000 population in the WHO Eastern Mediterranean Region, 2017 (OECD: Organisation for Economic Co-operation and Development) 15. In the 10 years between 2007 and 2017, densities of nurses and midwives did not improve in most countries of the Region; in fact, densities declined in 11 countries (Fig. 3). While the global shortage of nurses and midwives is expected to decline slightly from 9.0 to 7.6 million by 2030, the shortfall in nurses and midwives in the Eastern Mediterranean Region is predicted to increase from 0.9 to 1.2 million, if current production trends continue. Source: Regional Health Observatory (23) Fig. 3. Density of nurses and midwives per 10 000 population in the WHO Eastern Mediterranean Region in 2007 and 2017 0.8 3.2 5.1 5.1 7.3 7.9 8.5 14.4 14.5 17.3 18.7 22.2 25.7 32.7 36.4 40.9 43.7 46.5 56.8 57.0 58.8 65.0 67.0 90.0 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 Density of nurses and midwives per 10 000 (2007) Density of nurses and midwives per 10 000 (2017) Non-GCC State Median OECD Average GCC State EM/RC66/4 5 16. Although the numbers of nursing education programmes and nursing graduates have increased over the past few decades, the density of nurses has not increased substantially in most countries. This means that the increase in production capacity has not kept pace with the increase in population and mobility of health workers. Available data on densities of graduates in some countries indicate that medical graduates outnumbered nursing and midwifery graduates in 2016 (23). 17. An appropriate skills mix of the health workforce is essential to ensure the delivery of effective and good-quality health services. The ratio of nurses and midwives to doctors can be a proxy indicator of the skills mix. Although no global benchmark exists for the ratio of nurses and midwives to doctors, compared with the OECD ratio of 2.72 (24), the regional median for the ratio is 2.1 (Fig. 4). The ratio has declined in nine countries in the past 10 years. A similar trend will likely continue in those countries if the current level of production of professionals is maintained. For example, Pakistan has a ratio of 0.5 nurses and midwives to doctors, and the medical and nursing schools admit comparable numbers of students, about 15 000 medical students a year (25) and 16 000 nursing students a year (26). This implies that the ratio of nurses to doctors will continue to be below 1 in the coming years. Scaling up the production capacity for nursing is essential, and this requires increased investment in nursing and the adoption of stronger education and training policies and plans (20). 18. Maldistribution of the workforce can result in uneven access to health services and be a barrier to improving health care coverage for those most in need. In the Eastern Mediterranean Region, available data indicate that more than 80% of nurses work in urban hospitals, resulting in a lack of nurses in rural areas. This also affects the availability of nurses in primary health care settings. For example, in Pakistan, almost all nurses work in hospitals and about 90% work in urban areas. In Afghanistan, only 23% of the population lives in urban areas but about twice as many qualified health workers, including nurses, work in urban areas than rural areas (21). The challenges facing the health workforce, including nurses in acute-care settings, could be addressed through labour market analysis to ensure access to good-quality health services. Source: Regional Health Observatory (23) Fig. 4. Ratio of nurses and midwives to doctors in the WHO Eastern Mediterranean Region in 2007 and 2017 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 Ratio of nurses and midwives to doctors (2007) Ratio of nurses and midwives to doctors (2017) EM/RC66/4 6 19. While ministries of health are the main employers of nurses in the Region, private sector involvement in the provision of health services is growing rapidly, which will further increase the demand for nurses (27). Competition from the private sector and dual practice (working in both the public and private sectors) in many countries of the Region contribute to health workforce shortages and high workloads in the public sector, making it difficult for the public sector to achieve better health outcomes (28). To tackle some of these problems, effective public sector engagement is needed as well as clear policies and regulations to ensure that quality of services and patient safety are integrated into private health care delivery. 20. The recent Astana Declaration on Primary Health Care has generated new momentum to define the roles of nurses within the multidisciplinary primary care teams needed for UHC. In the Region, efforts are being accelerated to promote primary care based on family practice as an efficient and effective way to strengthen primary care (29). Countries with a strong primary care system and established multidisciplinary primary care teams tend to develop models of care that are capable of managing complex health problems, ensuring access to services, especially for refugees and displaced populations, providing continuity of care, facilitating the coordination and integration of services, and achieving better clinical outcomes (30). Such initiatives are being undertaken in some countries of the Region. For example, in Lebanon services at primary health care centres are provided by interdisciplinary teams where nurses are important members of the team in managing chronic illnesses and mental health problems. In Oman a community health nursing programme has been developed and nurses are working in the multidisciplinary team to respond to health needs of the population. 21. Health workforce mobility is still a challenge in the Region and some countries are losing their trained nursing workforce because of increasing mobility. Mobility of nurses affects both source and destination countries. Many countries have difficulty in achieving a stable supply and demand of nurses because of constantly changing health care employment needs and competition for the recruitment of health care workers (31). Mobility also contributes to increased workloads, loss of skilled and highly educated nurses, falling standards of care, job dissatisfaction, burnout, and high rates of turnover and attrition (31). Countries with political, economic and security troubles are particularity vulnerable to this loss of human talent. As a result, their health services are further deprived of their most highly educated health professionals (32). 22. GCC countries continue to rely heavily on a non-national nursing workforce that comes from within and outside the Region. For example, more than 90% of the nursing workforce is non-national in Kuwait (33), Qatar (34) and United Arab Emirates (35), and 60% in Saudi Arabia (36). Oman and Bahrain have managed to reduce the proportion of non-national nurses; in Oman, it fell from 88% in 1990 to 38% in 2017, while in Bahrain it decreased from 51% to 48% between 2012 and 2016 (38). The challenge of attracting new recruits to nursing is a growing concern, not only in the Region, but also around the world (25, 39). To improve enrolment of nationals in nursing programmes and thereby reduce the reliance on foreign nurses, countries are working to attract more candidates into the profession. Some countries, such as Bahrain, Saudi Arabia and more recently Pakistan, have introduced free education for nursing at the undergraduate level and some grants for postgraduate nursing education. The United Arab Emirates is currently running a media campaign to promote the image of nursing and is developing a national strategy to make nursing a more attractive profession for its nationals (40). Quality of nursing education and practice 23. The quality of nursing education and nursing graduates remains a concern in the Region (41). High- quality nursing education can help produce nurses who are able to provide better nursing services, thus contributing to better health (42). While a bachelor of science degree in nursing is a requirement for entry into nursing practice in several countries, multiple qualification levels are offered for entry into the nursing profession in most countries of the Region in view of the existing shortages of nursing workforce, such as a two-year associate qualification and a three-year diploma. Almost all countries have established bridging programmes that offer an opportunity for nurses with diplomas and associate degrees to upgrade their qualification to further their careers. EM/RC66/4 7 24. Most countries lack formal independent accreditation of nursing education programmes but some are now seeking formal accreditation. Proper accreditation mechanisms can assure the quality of nursing education programmes so they produce high-quality nurses who meet international nursing education standards. Accreditation can also encourage the development and implementation of standards of education and consequently contribute to good-quality nursing services (43). 25. In recent years, specialized nursing practice has gained more attention. Masters’ degrees in nursing are available in a number of countries of the Region, but the availability of doctorate programmes is still limited. The Islamic Republic of Iran has 19 doctorate programmes in nursing and Egypt has 13; other countries (Jordan, Lebanon, Pakistan and Sudan) have established at least one programme. Graduate-level programmes are essential to prepare nursing faculty members and clinical teachers, particularly to help accelerate scaling-up of the production of well-qualified nurses (44). 26. Regulation of the nursing workforce aims to protect and promote the health and safety of the public through regulating the quality and practice of nurses (45). Most countries in the Region have national bodies to regulate nursing either through a separate nursing council (e.g. Jordan, Pakistan and United Arab Emirates), or through multiprofessional bodies for regulating health professionals (e.g. Bahrain, Qatar, Somalia, Sudan and Tunisia). While the regulatory bodies have shown strategic commitment to strengthening nursing, implementation of regulatory strategies is slow or delayed in several countries (41,46). Strategic management of the nursing workforce 27. Strategic management of nursing capacities is important to ensure the availability of nurses, and their appropriate recruitment, deployment and utilization. In countries where policies governing practice and service development are unclear, the nursing profession suffers from the absence of a career structure, professional progression and clinical advancement. In 18 countries of the Region, a government chief nursing officer or equivalent exists at the health ministry to manage the nursing profession. Overall, countries with nursing management structures at the higher level of government have more opportunities to be involved in policy dialogue to ensure higher levels of commitment to the national agenda for nursing development (17). 28. Increased attention to improving the work environments, staffing, salaries and incentives of nurses, involving nurses in decisions and policy-making, and assuring greater managerial support to nurses can help preserve the nursing workforce and improve the quality and safety of care (47,48). The regional framework for action on the hospital sector, which is being presented to this session of the Regional Committee in another technical paper, emphasizes the importance of addressing the availability and performance of the health workforce by improving their employment and working conditions. 29. The scope of practice for nurses needs to be reviewed and defined to allow them to use their knowledge and skills to better contribute to health services. Globally, nurses’ roles are well defined and acknowledged (49). However, evidence shows that nurses do not always have the opportunity to use the full range of competencies provided by their education in most countries, which is an underutilization of available talent and resources (50). Regionally, this is in part related to sociocultural and political challenges and a lack of clarity about professional roles, functions and responsibilities (45). Defining the roles and scope of practice of nurses is needed to make best use of their capacities and improve their performance. 30. While most countries of the Region have job descriptions for nurses, their scope of practice is not yet well defined. In fact, very few countries have developed legal documents to enact the scope of nursing practice (only Jordan, Lebanon, Qatar, Sudan and United Arab Emirates). Other countries are in the process of developing scopes of practice for nurses (Bahrain, Islamic Republic of Iran, Oman and Saudi Arabia). Discrepancies between scope of practice and actual practice are prevalent in the Region. In most countries, the range of interventions nurses can perform with regard to health promotion, prevention and rehabilitation is limited. Nurses can have a more active role in providing emergency and recovery services and care for EM/RC66/4 8 refugees and displaced populations (15). In addition, new nursing roles and functions will likely emerge within the context of health system strengthening and meeting the targets of the SDGs (41). Reorientation of nursing education and training is an important consideration for Member States to address limitations of the scope of practice of nursing. 31. Despite the increasing number of specialized nurses in several countries of the Region (Islamic Republic of Iran, Jordan, Lebanon, Pakistan and Oman among other countries), the role of advanced practice nurses is still not well recognized in many of these countries and employment opportunities within their specialized role are limited. In this context, the Islamic Republic of Iran is developing a strategy to better use specialized nurses within the Iranian health system and to expand their role, especially in managing noncommunicable diseases and primary care. Jordan is in the final stages of establishing an advanced practice nursing post in the health ministry. 32. Reliable and up-to-date information on the health workforce is lacking in the Region, although some countries have better information on the nursing workforce (e.g. Bahrain, Islamic Republic of Iran, Oman and United Arab Emirates), and others are in the process of improving the availability of information (e.g. Jordan, Lebanon and Saudi Arabia). Maintaining accurate and up-to-date information on the nursing workforce is crucial for monitoring trends in the workforce and the implementation of nursing policies, including on performance of nurses. The use of technology can facilitate more effective planning, recruitment, deployment and retention of nurses (51). The United Arab Emirates is moving towards implementing key performance indicators to monitor nurses’ performance using technology. Investing in the nursing workforce 33. Scaling up and strengthening nursing services require increased investment in education, employment and retention of more nurses. Emphasis should also be placed on ensuring effective legislation and regulation of nursing education and practice as well as employment practices that take into account monetary and non-monetary incentives. Substantial investment in nursing education and training will help attract more students to nursing and improve the production of well-qualified nurses to meet current and future demand for health services (52). Investing in partnerships and using communication strategies, such as media campaigns promoting nursing as a career choice, have been associated with improved public perception of nursing and the attractiveness of nursing, and increased enrolment in nursing (53). 34. Beyond strengthening health services, investing in the health workforce, especially in nurses, improves women’s economic empowerment and participation, extends UHC, contributes to global health security and accelerates economic growth (54,55). Furthermore, investing in nursing is also an investment in the young men and women who make up most of the population of the Eastern Mediterranean Region and will be the next generation of health workers. It is therefore important to understand their career goals and aspirations and develop strategic interventions to attract them into the nursing profession (46). Conclusions 35. Global and regional resolutions and strategic directions have guided nursing development in the Region. However, the Region still suffers from long-standing underinvestment in nursing, which has resulted in slow progress and has sometimes impeded progress. Changes in the health system and the commitments to UHC and primary health care require strong policies and political commitment to scaling up the production, employment and retention of nurses as a means of strengthening integrated people- centred care, accelerating economic growth and achieving UHC. 36. Increasing the production of qualified nurses will entail increasing investment to recruit more young people into the nursing profession, scaling up nursing programmes, and reorienting nursing education and training programmes to primary health care. In addition, defining and expanding nurses’ roles and scopes of practice, and making use of their capacities in emergency and recovery services and care for displaced people including refugees, need to be supported by appropriate regulations. Adopting new technologies in EM/RC66/4 9 the education and practice of nursing, ensuring enabling practice environments with adequate payment, and providing appropriate incentives to work in remote and hardship areas will all be vital. 37. The Regional Committee for the Eastern Mediterranean is invited to discuss this technical paper and adopt the resolution calling for accelerated action to strengthen nursing in order to advance UHC in the Eastern Mediterranean Region. Recommendations to Member States 38. Develop and implement national strategies and action plans for strengthening the nursing workforce, taking into account labour market dynamics through multisectoral platforms, policy dialogue and partnerships to ensure harmonized actions. 39. Invest in nursing education, employment and retention to implement national strategies and plans to scale up the nursing workforce. 40. Develop appropriate communication and advocacy strategies to attract women and young people into the nursing profession and to improve public perceptions of nursing. 41. Strengthen the primary health care nursing workforce by defining and expanding nurses’ roles and scope of practice to make best use of their capacities, particularly in emergency and recovery services and care for displaced people. 42. Reorient nursing education and training with emphasis on primary care competencies to meet the needs of primary health care services and the health needs of the population. 43. Ensure the quality of nursing education at all levels by developing and implementing accreditation systems built on well-established standards for nursing education and training. 44. Ensure work environments that allow nurses to use their knowledge and skills productively through well-defined standards of nursing practice, appropriate remuneration, opportunities for career development and continuing professional development, among others. Recommendations to WHO 45. Work with Member States to assess the nursing situation, and to develop and implement national strategic plans of action in line with the Regional Framework for Action: strengthening nursing and midwifery in the Eastern Mediterranean Region 2016–2025. 46. Work with Member States to make use of existing information systems or establish new systems to collate data and information on the nursing workforce to guide policy development, implementation and monitoring. 47. Monitor and evaluate the progress made in the implementation of the Regional Framework for Action: strengthening nursing and midwifery in the Eastern Mediterranean Region 2016–2025. 48. Facilitate regional networking and create forums for the exchange of experiences and success stories in nursing and midwifery education, practice, leadership, governance and regulation. 49. Utilizing the momentum of the Nursing Now campaign and the Year of the Nurse in 2020, create forums to raise the profile of nursing, build on the commitments for accelerated actions and mobilize nursing champions from the Region. 50. Report to the Regional Committee every three years until 2030 on progress in implementing this resolution. EM/RC66/4 10 References 1. In landmark initiative, countries of the Region sign UHC2030 Global Compact to progress towards universal health coverage. 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