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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


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



Pakistan

4



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


Basic Indicators of Pakistan


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


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




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


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


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


Province of Sindh

13


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


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


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)


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



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


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



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


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


Absenteeism Rates

Doctors: 38.3%

Male Doctors: 33.5%

Female Doctors: 43.5%

Nurses: 27.8%

Technicians: 24.11%

24



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



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


Absenteeism Rate of Doctors in Government

and PPHI Facilities

29

Health Facility Number of Doctors Absenteeism Rate (%)

PPHI 15 32.2

Government 58 40


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



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




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


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


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


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


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


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


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


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


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


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


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




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To Assess the Extent of Absenteeism in the Health Sector ...siteresources.worldbank.org/EXTHDOFFICE/Resources/5485726... · To Assess the Extent of Absenteeism ... (PPHI) PPHI started