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HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
To Assess the Extent of Absenteeism
in the Health Sector in Pakistan
Dr. Mubina Agboatwalla
Tariq A Niazi
1
TAP Workshop, Washington DC
23rd – 26th March 2010
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Objective
To ascertain the fraction of medical professionals absent from
their place of posting and the impact of this on the quality of
health services as well as the loss to the national exchequer.
2
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Economic and Demographic Indicators of
Pakistan
Economic Indicators Year
GNI per capita (US $) 2007 870
GDP per capita average annual growth rate (%) 1990-2007 1.6
Annual average rate of inflation % 1990-2007 10
% Of population below int’l poverty line of US $
1.25 per day 2005 33
Demographic Indicators
Population annual growth rate (%) 1990-2007 2.2
Crude death rate 2007 7
Crude birth rate 2007 27
% of population urbanized 2007 36
Source: State of the World Children (UNICEF 2010)
6
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Basic Indicators of Pakistan
Source: State of the World Children (UNICEF 2010)
7
Basic Indicators Year
Under-5 mortality rate 2007 90
Infant mortality rate (under 1) 2007 73
Neonatal mortality rate 2004 53
Total adult literacy rate % 2000-2007 55
Primary school net enrolment/ attendance % 2000-2007 56
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Health Indicators of Pakistan
Health Indicators
Total 90
Urban 95
Rural 87
Total 58
Urban 90
Rural 40
% of routine EPI vaccines financed by Govt: 2007 Total 31
At least once 61
At least four time 28
Skilled attendant at
birth39
Institutional
deliveries34
% of population using improved sanitation facilities
Antenatal care coverage(%) 2000-2007
Delivery care coverage (%) 2000-2007
% of population using improved drinking water sources
8
Source: State of the World Children (UNICEF 2010)
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Expenditure as Percentage of GDP
Education Defence
2003 1.86 4.6
2004 2.2 3.9
2005 2.13 4.9
2006 2.21 3.9
2007 2.48 3.2
2008 2.44 3.2
Year Expenditure as Percentage of GDP
Source: Economic Survey of Pakistan 2009-2010
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Health Budget (2001-2009)
Source: Planning and Development Division
11
Pak Rupees US Dollars %
In Billion In Million of GDP
2001-2002 24.28 285.65 0.58
2002-2003 28.82 339.06 0.59
2003-2004 32.81 386.00 0.58
2004-2005 38.00 447.06 0.57
2005-2006 40.00 470.59 0.51
2006-2007 50.00 588.24 0.57
2007-2008 60.00 705.88 0.57
2008-2009 64.00 752.94 0.55
Years
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Health Expenditure as % of GDP
0.57
0.51
0.55
0.570.570.58
0.46
0.48
0.5
0.52
0.54
0.56
0.58
0.6
2003 2004 2005 2006 2007 2008
Years
(%)
Health expenditure % of GDP
12
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Health Statistics of Sindh
The required number of doctors in Sindh with reference tothe population is 30,000.
The number of doctors available in the Governmenthospitals is 13,000.
Additional doctors required in government hospitals is17,000.
The total number of government hospitals in Sindh is 1,366.
Nearly 26% of population does not have access to drinkablewater while 58% of population has no sanitation facilities.
14
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Pakistan People Health Initiative (PPHI)
PPHI started to reopen the closed Basic and Rural HealthCentres in the Rural Areas of Sindh.
To combat the problem of shortage of doctors and to ensureavailability of doctors in these Basic Health Facilities,
PPHI gives extra incentives and allowances to doctors,especially female doctors. The salary package is much morethan regular government doctors, more so for femaledoctors.
PPHI is presently functioning in 17 districts of Sindh andlooking after 526 BHUs, 26 Maternity Homes, and 322Dispensaries.
The government medical officer gets a monthly salary ofRs16,000 ($188.235).
15
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
PPHI provides an amount of
Rs 20,000 ($235.294) for 1 health facility.
Rs 24,000 ($282.352) for 2 health facilities.
Rs 30,000 ($352.941) for 3 health facilities.
Rs 32,000 ($ 376.47) for a female doctor.
Pakistan People Health Initiative (PPHI)
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Methodology
Study conducted in 10 districts of Sindh.
Random selection of three health facilities in seven districtsand four facilities in three districts, giving a total of 33 healthfacilities.
This Includes:
Basic Health Units (BHUs) 07
Dispensaries 13
Maternal and Child Health Centres (MCH) 02
Rural Health Centres (RHCs) 09
Urban Health Units (UHUs) 02
Total 33
17
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Information obtained about the Health facilities from
Planning & Development Dept, of the Provincial Sindh
Government.
The budget allocation for Health facilities obtained through
the ADP (Annual Development Plan) and the Provincial
budget.
Information also obtained on the number of posts
sanctioned, the number of vacant posts as well number of
doctors working on detailment.
19
Methodology
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
The study utilized structured and open-ended questionnaires.
Questionnaires were specifically designed for the study andcomprised of the following.
Doctors Questionnaires
Nurses Questionnaires
Technicians Questionnaires
Patient Questionnaires
Hospital Incharge Questionnaires
Exit Interviews from Patients
20
Methodology
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
The official timings of the HF: 9.00 am to 2.00 pm.
Unannounced visits made to HF at any time during this period , to discover what fraction of medical professionals are present at their assigned post.
Medical professionals included doctors, nurses and technicians.
After a gap of 2 weeks unannounced visits again made to the health facility to see if the health personnel were on duty.
Two observations were made for each health personnel
22
Methodology
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Results
The data was obtained from the following.
Male Doctors: 65
Female Doctors: 14
Technicians: 51
Nurses: 22
Patients: 103
( Male:75, Female:28)
23
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Absenteeism Rates
Doctors: 38.3%
Male Doctors: 33.5%
Female Doctors: 43.5%
Nurses: 27.8%
Technicians: 24.11%
24
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Doctors, Nurses, Technicians Absenteeism
26
DistrictsDoctors
(%)
Nurse
(%)
Technician
(%)
Karachi 42 27 21
Hyderabad 35 26 -
Sukkur 33 20 19
Ghotki 66 35 29
Kashmoor 36 50 36
Khairpur 28 25 28
Shahdadkot 36 17 8
Umarkot 33 15 27
Dadu 32 33 29
Badin 42 30 20
Average 38.3 27.8 24.11
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Urban and Rural Distribution of Doctors
Absenteeism rate amongst Males and Females
District
Urban District Male (%) Female (%)
Karachi 41 43
Hyderabad 27 43
Sukkur 33 33
Average 33.67 39.67
Ghotki 33 1 00
Kashmoor 39 33
Khairpur 38 19
Shahdadkot 26 46
Umarkot 33 -
Dadu 25 39
Badin 33 47
Average 32.43 47.33
Doctors
Rural District
28
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Absenteeism Rate of Doctors in Government
and PPHI Facilities
29
Health Facility Number of Doctors Absenteeism Rate (%)
PPHI 15 32.2
Government 58 40
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Patients Perceptions about Doctors
n % n % n %
Was the Doctor always present?
Yes 16 26.7 7 26.9 23 26.8
No 44 73.3 19 73.1 63 73.2
If the Doctor was absent then did the
Dispenser/Nurse act as Doctor?
Yes 38 86.4 8 42.1 46 64.3
No 6 13.6 11 57.9 17 35.8
When the doctor was not present did
the patients need to wait longer than
usual for the doctor?
Yes 33 75 18 94.7 51 84.9
No 11 25 1 5.3 12 15.2
Rural Urban Total
30
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Patients Perceptions about Doctors
n % n % n %
How long did the patient need to wait if
the Doctor was not present?
<30 Mints 18 40 7 33.3 10 23.3
>30 Mints 26 60 12 67.7 38 77.2
In any of the visits did the patient have
to go back without treatment if the
doctor was not present?
Yes 34 56.7 7 26.9 41 41.8
No 26 43.3 19 73.1 45 58.2
If the doctor was absent who examined
the patient?
Dispenser 29 48.3 3 11.5 32 29.9
Nurse 5 8.3 12 46.2 17 27.2
Health Technician 16 26.7 9 33.3 25 30
No one 10 16.7 2 7.6 13 12.2
Did the patient get the medicines
prescribed by the doctor?
Yes 26 43.3 12 46.2 38 44.8
No 34 56.7 14 53.8 48 55.3
Rural Urban Total
31
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Patients Perceptions about Nurses
33
n % n % n %
Was the Nurse always present?
Yes 4 21 13 52 17 37
No 15 79 12 48 27 63
When the nurse was not present did you
need to wait longer than usual for the nurse?
Yes 9 47.3 12 100 21 74
No 10 52.7 6 26
In any of the visits did you have to go back
without treatment if the nurse was not present?
Yes 11 73.3 10 83.3 21 78
No 4 26.7 2 16.7 6 22
Rural Urban Total
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN 35
0
20
40
60
80
100
(%)
01- 06 07- 10 11- 15 16- 20 21- 26
No. of Days
Official Un-Official
Comparison of official and un official
Attendance - Doctors
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN 36
Comparison of official and un official Attendance - Doctors
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Health Facility Incharge Perception of Health
Personnel Regularity
Doctors
(%)
Nurses
(%)
Technician
(%)
Regularity of Doctors / Nurses /
Technician31.9 37.5 48.8
Are any measures in place to assure
regularity of Doctors / Nurses /
Technician
11.6 6.5 14
37
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Private Practice by Health Personal
0
20
40
60
80
100
(%)
Private practice 88.6 9.1 23.7
Satisfaction with pay
scale
31.3 9.5 10.5
Doctors % Nurses % Technician %
38
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Absenteeism & HF Distance
Urban Areas: All HFs within 10 km of the doctors residence.
Rural Areas: 54.5 HF more than 25km from residence.
Absenteeism: < 25 km : 30%
Absenteeism: > 25km : 38%
39
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Salary & Non Salary Allocations
40
In thousands
Source: Sindh Budget
Years
Expenditure in PAK Rs. Expenditure in USD Percentage
Salary Total Salary Total SalaryNon
Salary
Non
Salary
Non
Salary
32,457.76 16,139.53 2004-2005 2,758,910 1,371,860 4,130,770
70%
48,597.29 67% 33%
30%59,948.71 17,753.53 42,195.18 5,095,640 1,509,050 3,586,590 2005-2006
2006-2007 4,124,580 1,659,950 5,784,530 48,524.47 19,528.82 68,053.29
77,284.94 28%21,481.76
29%
72%
71%
55,803.18 6,569,220 1,825,950 4,743,270 2007-2008
2008-2009 5,929,090 2,008,540 75% 25%7,937,630 69,754.00 23,629.88 93,383.88
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Expenditure on Salaries in Government and
PPHI Health Facilities
41
Rupees USD Rupees USD Rupees USD Rupees USD
PPHI 4,983,400 58,628 2,220,010 26,118 7,203,410 84,746 720,341 8,475 32%
Govt.
B.H.U3,651,120 42,954 3,108,120 36,566 6,759,240 79,520 482,802 5,680 40%
Absenteesim
(%)
Pay of Officers Pay of Other staff Total Avg.Pay / facility
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Expenditure on Salaries:
Basic Health Unit and Rural Health Centre
42
Rupees USD Rupees USD Rupees USD Rupees USD
Govt. R.H.C 24,830,420 292,123 20,642,020 242,847 45,472,440 534,970 4,547,244 53,497 41%
Govt. B.H.U 3,651,120 42,954 3,108,120 36,566 6,759,240 79,520 482,802 5,680 39%
Absenteesim
(%)
Pay of Officers Pay of Other staff Total Avg.Pay / facility
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Conclusions
Absenteeism higher in far to reach rural areas.
Lack of basic facilities discourages doctors from serving in these areas.
Increase in pay scales or incentives un accompanied by monitoring does not ensure regularity.
Female doctors prefer to work in urban areas.
Absenteeism in urban areas was an issue as doctors tend to concentrate on private practice.
Unofficial arrangements b/w health personnel to exchange duties.
43
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Absenteeism rates higher in those HFs which lacked basic
infrastructure and facilities (medicines, equipment) and where
accessibility was an issue.
New initiatives, like the PPHI programme should have an inbuilt
monitoring system to make them work effectively.
Technicians substituting for doctors affect quality of services.
44
Conclusions
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Recommendations
Accommodation for the health personnel in the remote areas isimportant in ensuring regularity of the doctors.
In case of married medical couples, employment should beoffered to both husband and wife with family accommodations.
Policies in health should be designed to take into accountabsenteeism. Accountability should be strictly enforced both atthe local and provincial levels.
Refresher courses of Continuing Medical Education (CME) shouldbe frequently offered to the doctors so that they are in touch withthe recent advances in the medical field.
Health Facility Incharge should closely monitor the servicesprovided by the health workers.
45
HOPE & TAP STUDY ON ABSENTEEISM IN THE HEALTH SECTOR - PAKISTAN
Doctors should be carefully chosen to serve in the rural areasand a strict criteria for selection should be followed includingoriginal domicile ( where the doctor belongs), willingness toserve in rural areas.
Increase salary allocations as rural allowances should beaccompanied by strict monitoring measures. Simplyincreasing budgetary allocations does not ensure betterservice delivery.
Monitoring measures should not only ensure regularity of thedoctors but also the number of hours spent in the healthfacility, patient satisfaction, quality of care provided topatients. Outcome service indicators should be developed toassess the performance of the health personnel. Performancebelow the bench mark should result in disciplinary actionsand sanctions against the health personnel.
46
Recommendations