Training community based nurses in impoverished areas of developing countries: A practical solution to a rapidly emerging global shortage of health workers force

(	Manzoor Butt Correspondence: Dr Manzoor Ahmed Butt Rawalpindi, Pakistan Email: drmanzoor@ymail.com

Background The developing countries of the world face a chronic shortage of medical doctors, nurses and skilled health care workers. This is truer about women's health care workers because many women do not prefer to be examined and managed by male health workers due to their religious, social and cultural reasons. Health workers are the heart and soul of health systems. A new progress report [1] estimates a global shortage of 7.2 million health workers, with 83 countries facing a health worker crisis. The relative shortages of doctors, nurses and midwives are still most acute in sub? Saharan Africa. This is currently one of the major obstacles to achieving the MDGs [2] and other international health goals including universal health coverage. The following graph depicts fertility and mortality in various regions of the world [3]. If we intend to change the dire situation in Sub-Saharan Africa, South Asia, Middle East & North Africa, and elsewhere, we have to enroll and train existing and new Nurses and other health care workers for primary and secondary health care. Source: [3] Pakistan has an organized infrastructure for delivering health care even in small villages but there is an extreme lack of nurses and health care workers. There is one doctor, one nurse and one bed for 1400, 3261 and 1531 people respectively. 76% deliveries occur at home [4]. The main part of budget allocated for health goes to teaching institutions and major hospitals of federal and provincial capitals; very little is left for towns and small villages. Like many developing countries, ours is a male dominant society where only very few females enjoy full rights and have access to opportunities of even very basic human needs. This is even more true in the health sector, where unfortunately there is a great lack of female doctors and nurses combined with a large number of female 'quacks' in the country. The female doctors are neither easily available nor easily affordable and women do not prefer to be examined by male doctors. There are a lot of government hospitals which provide free or low fee treatment to women but those are not preferred because of: [6] - The casual and offhand behaviour of doctors - More than one male doctor examining the patient at one time - The fear of crowds of medical students present at time of examination - The fear that doctor may misuse this opportunity for some evil deed Formal and qualified nurses are not willing to work in small cities, towns and villages. They prefer government hospitals of federal and provincial capitals. This is justified if they work in a proper manner on merit on rotational basis but this seldom happens. They use all means to stay in these hospitals until someone more resourceful replaces them.

Introduction
This article describes the importance of training locally existing non formal nurses / health care workers in developing countries with Pakistan as an example. If we have to overcome the shortage of nurses / health care workers, we have to include those who are already in field. It would be easier to educate and train them as compared to only including new ones. The author has used his own example to indicate and prove that it is possible to include non formal nurses and train them towards formal training course.

Present situation in Pakistan
To understand the exact situation in Pakistan, we have to concentrate on basic health statics. The following figures are taken from Global Health Observatory [5]

Click here for Figure 2: Basic statistics

Click here for Figure 3: Utilisation of health services

Click here for Figure 4: Millenium development Goals

The access of people to medical facilities varies greatly from very privileged to absolutely devoid. Both the government and private health services are available to people. Our upper and middle classes have full access to government as well as private health facilities. The real problem is with the masses and the people who live below the poverty line.

What does the term nurse mean in Pakistan
The following categories are usually included under this term;

1) Classified Nurse: The female must have passed high school examination in science to get admission into this course. She takes a four years course in Nursing during which she has to reside in hospital. Due to proper education and training, they work ethically and are aware of importance of working in own limits.
2) Lady Health Visitor (LHV): The female must have passed high school examination in science to get admission into this course. She takes a short course of about two years and she is basically trained in women's health and midwifery.
3) Lady Health Worker (LHW): This type was produced by government to induce health education and create awareness about women's health. They are usually only middle pass and a local resident.
4) Locally Trained Nurses: This is the most available variety. Some of them are high school graduates but most of them are usually middle passed or less. They are neither adequately educated nor properly trained.
5) Midwives or Traditional Birth Attendants (TBA): In Pakistan, TBAs are usually uneducated and non-trained. 81% of deliveries are conducted by them.
6) Community based Midwives : They are enrolled and trained by UNICEF through its partner institutions. They are hope for future.

The health care delivery system and needs of the population are changing rapidly
A major part of our budget goes to defense needs. Despite all efforts for reduction of poverty, more and more people are going below the poverty line. Our population is growing rapidly. There is a rapidly increasing burden on the government funded health care system. There would be an increasing need of health care workers, especially the nurses. We have to shift more care from hospital to primary care; most important in this context is Health Education, Mother and Child Health, Family Planning and Contraception, Immunization, Infection control and other disease control.

The total population of Pakistan (in thousands) was 141,256.2 in the year 2000. It would be 181,384.7 in the year 2010 and 227,781.1 in the year 2020. Total Numbers of people (from age group 0 to 60+ years) requiring daily care was 8,292.1(in thousands) in the year 2000. It is expected to be 10,908.2(in thousands) in 2010 and 14,254.5 (in thousands) in year 2020. This means the total Numbers of people (from age group 0 to 60+ years) requiring daily care would increase by 32% in the year 2010 and 72% in the year 2020 as compared to year 2000 [7]

The role of nurses in the delivery of primary care
The community based nurses and health workers play the largest part in the delivery of primary care. They are the first contact of people who not only seek their help for primary care but also in acute emergencies and accidents.

The emerging challenges to nurses
There is an urgent need to train and organize the nurses and health Workers.They have to play a vital role in the delivery of primary care in coming years because of tendency of people to avoid hospitals. Non formal nurses / health workers lack adequate knowledge and skills especially regarding antenatal care and safe childbirth. They have to address their shortcomings by adopting professional development strategies and CME. The practical way is to induce these trainings at jobs.

What is the solution
The author describes his efforts and strategy to address the problem of shortage of skilled nurses and health care workers in his community in this section. He devised and launched a program for organization and training of local nurses and health Workers in antenatal care in his community-----Shamsabad, Rawalpindi.

Object of the program
1- To evolve a platform for training of existing and new nurses / health workers on CME pattern.
2- To create and maintain a "Data Base" of existing and new nurses / health workers so that all recent knowledge and skills could be conveyed to them.
3- To evolve an easy to understand manual in local language for education and training of existing and new health workers
4- To help the nurses / health workers to evolve their own organizations that could strive for them in accordance with the following guideline principals of WHO ;
i) Cater for their education& training
ii) Provide support and protection to them
iii) Enhance their effectiveness
iv) Tackle imbalances and inequalities
Who would benefit by this program
Our doors are open for all existing and new nurses / health workers. We are specially focusing on locally available nurses initially but we will help all regardless of their age, gender, race, religion, creed and method of treatment. All health concerns like doctors, nurses, midwives, TBAs, Hakims, Homeopaths, laboratory technicians, dental technicians, and community health workers are welcome.

The strategy for Training
Step 1: Identification and registration of existing and new nurses / health workers for training
Step 2: Determination of Extent of training
Step 3: To impart training
Step -4: To evaluate the candidates after completion of training

The syllabus and extent of training
There are three levels of education and training (Primary, secondary and tertiary) depending upon the extent of curriculum. In author's opinion, every care provider must have very clear understanding and skills of Monitoring of Vital Signs {Pulse, BP, Temperature and Respiratory rate}, weight recording, Cardio-Pulmonary Resuscitation, Sterilization and Asepsis.

Main syllabus
Nutrition, Anemia, Brief Anatomy (maternal & foetal), Brief Basic knowledge about breast examination, Brief Basic knowledge about Menstrual cycle , Family planning (both regular & Emergency), Gynaecological examinations, Antenatal Care, Rhesus incompatibility, Pre-Eclampsia, Eclampsia, CPR, Foetal growth & well being, Vaginal bleeding during pregnancy (Ectopic pregnancy, Miscarriage & abortion, Antepartum Hemorrhage, Post Partum Hemorrhage, Placenta Praevia, accidental Haemorrhage, Hydatidiform mole), Twin pregnancy, Labour (normal & abnormal), Various methods of delivery (Normal delivery, mal-positions, hygiene, avoiding trauma, analgesia, and danger signs and how to manage hemorrhage), Postnatal care of mother (Normal and danger signs such as endometritis, bleeding, Eclampsia), Puerperium, Brief knowledge of D&C, E&C, Resuscitation of newborn, Immediate Post-natal care of the child, breast feeding, vaccination,. Etc

The extent of training
i) Primary Level of Training: This is mean for community health workers. It would be in form of short and basic courses. Incentives for learners: No big incentives are required; just certificates of appreciations would be sufficient.
ii) Secondary Level of training: This is meant for those who intend to adopt it as profession. Incentives for learners: Certain incentives like certificates plus some financial support in form of scholarship are necessary.
iii) Tertiary level of training: This is full and advanced training to evolve life saving nurses. Incentives for learners: Definite incentives like certificates, financial support during learning plus employment opportunity are essential.

Conclusion
35.9% of the population lived in urban areas in 2010. 46.6% or 29.9 million of the urban population live in slums.[8] More people are shifting from rural to urban areas. The government health care system is unable to cater for needs of all, especially for those in rural and sub urban areas. There is shortage of nurses that cannot be overcome by enrolling and training new nurses. In author's opinion, the practical approach to overcome the shortage of nurses in impoverished areas of developing countries is to include already existing non formal nurses in the community. They should be organized and trained through CME approach and accommodated in health care delivery system at community level. The author has success in addressing women health problems at his community level through locally trained nurses. [9] He also imported same training to community resource persons (CRPs) from remote villages of the northern areas ( Chitral) of Pakistan. The results are more promising in the remote areas than in main cities due to more need in those areas. It is also very useful to use more pictographs than text. Non formal nurses / health workers lack education, using simple local language and descriptive images are the vital part of training.

References
1) A Universal Truth: No Health Without a Workforce, Third Global Forum on Human Resources for Health Report by Global Health Workforce Alliance and World Health Organization, available at: http://www.who.int/workforcealliance/knowledge/resources/hrhreport2013/en/
2) Millennium Development Goals, http://www.un.org/millenniumgoals/
3) Population estimates and projects, fertility and mortality, region wise, World bank, available at: http://datatopics.worldbank.org/hnp/popestimates#
4) Position in 2004, Page-32, Population Growth & its Implications-July 2004 by National Institute of Population studies, Islamabad.
5) WHO Statical Profile, Pakistan; available at : http://www.who.int/gho/countries/pak.pdf?ua=1
6) Skilled Health Workers - A Solution to Primary Health Problems in Pakistan, by Dr Manzoor Butt, available at: http://www.mejfm.com/journal/july2006/Skilled%20Health%20Workers%20-%20A%20Solution%20to%20Primary%20Health%20Problems%20in%20Pakistan.htm
7) Pakistan, Appendix 3: Sensitivity analysis. Numbers of people requiring daily care, total population, proportion of total population requiring care, and dependency ratio by region, country and year, based on three severest Global Burden of Disease study disability categories (levels 5, 6, 7). Source: www.who.int/docstore/ncd/long_term_care/emro/pak.htm
8) Urban health profile, Pakistan, available at: http://www.who.int/kobe_centre/measuring/urbanheart/pakistan.pdf?ua=1&ua=1
9) Women's Health Problems in Pakistan, Dr Manzoor Butt. Available at: http://www.mejfm.com/Newarchives2013/Women.pdf