Opportunities and challenges in nursing sector (The Financial Express (Bangladesh))
A decision was taken at the Eighth WTO Ministerial held in December 2011 to grant preferential access in services to all least developed countries (LDCs) on an unconditional basis to facilitate their services exports. It invoked an enabling clause that permitted legal positive discrimination in favour of LDCs for the first time in the services sector under General Agreement on Trade in Services (GATS); previously only very narrow exceptions were permitted in the most favoured nation (MFN) clause. One highly promising outcome of this concession was the facilitation of services exports, especially in labour-based services through temporary movement of their nationals (‘natural persons’), under mode-4.
The gains from this preference can be enormous for Bangladesh, particularly from the facilitation of mode-4 exports. The country’s advantages include its vast pool of labour force as well as dependence on remittances and labour services exports. However, the realisation of benefits under this waiver still remains unclear as the sanction of preferential access is voluntary on the part of developed and developing countries. It also may not be granted for the sectors and modes of greatest interest to the LDCs. Under these circumstances, it is crucial for LDCs like Bangladesh to determine the services and modes having significance for exports and to formulate and implement proactive strategies cum action-plan for benefiting from this concession.
The highly promising services that Bangladesh could potentially target to benefit from this WTO waiver include Information Technology- Business Process Outsourcing and Labour Services in areas such as nursing. The present article provides a brief assessment of the market access opportunities and constraints to Bangladesh’s export of nursing services.
GLOBAL PICTURE: There is a huge global demand for nurses arising from demographic changes, ageing of populations, increase in chronic diseases, shortages of physicians in primary healthcare, demand for nurses as case managers and staffs in clinics (Siddiqui and Appiah, 2008). This demand is currently led by countries like the United States and the United Kingdom. Various studies, on the other hand, indicate a decline in the number of people enrolled in nursing programmes and graduate nurses in the developed countries (Aiken, 2007). For example, the United States had a shortage of 110,000 nurses (or 6 per cent) in 2000 and is expected to face a shortage of 29 per cent by 2020. It has been estimated that the United Kingdom admitted over 90,000 international nurses from many countries since 1997 and one in ten working nurses in the country was trained in foreign countries. Another study claims (Matsuno, 2009) that the entry of foreign-trained nurses in the US nursing workforce has risen faster than the US educated nurses. In this backdrop, nurse-exporting countries like the Philippines, India and China have taken proactive steps to train their nurses for working in overseas markets and meeting the future demand for professional nurses in North America, Europe, Australia, West Asia and Japan.
Countries like Bangladesh have huge potential to meet the future demands of developed countries in the nursing sector. However, nurse migration from Bangladesh has remained quite negligible until now. For example, a very small share (5.7 per cent) of the female workers who migrated from the country during the period 1991-2004 comprised nurses. The destination of most of these nurses were either the Middle-east or Southeast Asia, mainly Malaysia (Aminuzzaman, 2007). It was also found that there had been a steady decline in the number of Bangladeshi nurses going abroad since 2004 despite a growing overseas demand. This had been in sharp contrast to leading global suppliers like the Philippines which sent around 90,000 nurses abroad during the 1990s and early 2000s, accounting for 25 per cent of all overseas nurses and 83 per cent of foreign-origin nurses in the USA. It is, therefore, clear that Bangladesh has not been able to take advantage of the growing global demand for nurses. A variety of constraints can be pinpointed for this apparent failure.
BANGLADESH SCENARIO: As of January 2011, Bangladesh had 26,644 registered nurses with 17,605 posts in the public nursing services and institutions. Of these, 15,086 were filled up and 2,513 positions were vacant ((Mahmud, 2013). It is estimated that around 3,000 registered nurses are employed in the private sector and about 3,000 are working abroad. Studies suggest that 99 per cent nurses are employed in hospitals and about 95 per cent in urban hospitals and clinics. Bangladesh has a population-nurse ratio of 5000: 1, bed-nurse ratio of 13: 1, and doctor-nurse ratio of 2.5: 1. These ratios fall far short of the international standards.
At present, there are 38 nursing institutes in the public sector and only 5 in the private sector for grooming registered nurses. However, 7 new nursing institutes are being set up by the government at different districts and 5 new nursing institutes are awaiting approval of ECNEC (Website of Ministry of Health and Family Welfare, 2015). Around 1250 nurses graduate from public sector nursing institutes each year and 530 nurses from other nursing institutes. This rate of grooming nurses is undoubtedly inadequate to fulfil the demand for trained nurses in the immediate future.
MAJOR CONSTRAINTS: A major limiting factor in this area for Bangladesh has been the huge gap between domestic demand and supply. The country’s nurse-to-doctor ratio falls far short of the international standard of three nurses per doctor. There is currently an estimated shortage of 280,000 nurses along with 60,000 doctors and 483,000 health technicians. A proactive export policy for nurses may not, therefore, be immediately feasible or appropriate in the backdrop of such shortages. However, a long-term strategy for meeting both domestic and global demands will require Bangladesh to build capacity by involving the public and private sectors, private universities and institutions as well as the manpower exporting agencies. Several studies point to the need for massive investments in nursing education by both the public and private sectors of Bangladesh in order to expand capacity (World Bank, 2013).
Other constraints in the sector include both internal and external factors. Domestic constraints include the lack of proper training, dearth of appropriate skill sets, and the need to update and upgrade the curricula and teaching quality. For example, at present Master’s degree courses in nursing are not offered inside the country; nursing standards and midwifery standards have also not been introduced in most hospitals. External constraints include non-recognition of qualifications, language barriers and restrictive licensing requirements. Bangladesh’s export of nurses, therefore, will require a strategic and planned approach, where the focus should be on capacity creation in the domestic arena leading to spin-offs in the export market.
THE WAY FORWARD: In this backdrop, strategies for addressing both local and global constraints need to be formulated and implemented on an urgent basis for tapping the huge potential of our nursing sector. These include (World Bank, 2013):
1. The government should ease conditions that reduce the scope for private sector participation in nursing education. Emphasis should be placed on updating the curricula and teaching quality as well as enforcement of international standards in the nursing profession.
2. The government can focus on high-value skilled nurses by encouraging the establishment of international standard nursing colleges in partnership with European, American or Australian nursing institutes. Private universities may also be encouraged to set up top quality nursing institutes. These will not only bolster the supply of nurses for the overseas market, but would also raise the overall quality and standards of the nursing profession in Bangladesh.
3. The government can take initiative to learn and replicate from other successful countries like the Philippines, who pursued proactive policies for sending nurses abroad and built a good reputation in the global market as suppliers of nurses.
4. In view of the high demand for nurses in the target markets like Japan, Korea, UK, USA and West Asia, Bangladesh government may seek preferential market access in the form of quota for its nurses in selected countries. The quota sanctioned by Japan to Filipino nurses on bilateral basis under the Philippines-Japan Economic Partnership Agreement can serve as a good reference. As a future measure, Bangladesh can seek similar commitments on a multilateral basis under the WTO services waiver.
5. There is also a pressing need to discuss with other countries issues like equivalence of degrees and sign agreements in this regard. Bangladesh has already signed an agreement (along with other six countries) with Malaysia that allows its nurses to practise there, subject to meeting certain minimum requirements.
6. The government can also facilitate overseas access to its own health sector in areas such as entry of nursing researchers, educators and institutions to improve the educational standards and transfer of knowledge and thereby help build up domestic capacity in nursing.
CONCLUSION: Existing multilateral frameworks embody inherent challenges to granting preferential treatment to LDCs like Bangladesh by developed countries (World Bank, 2013). This is especially applicable in case of services export, where there are many behind-the-border barriers and vital regulatory issues, which make preferences harder to realise compared to trade in goods. Therefore, the systemic implication of WTO services waiver is that although it is apparently voluntary in nature, it is unlikely to operate as a one-way concession. The success of Bangladesh in exporting services like IT-BPO and Nursing will, therefore, hinge very much on the negotiating skills of GOB alongside building adequate capacity, institutional-cum-policy support in the prospective sectors inside Bangladesh.
Dr. Helal Uddin Ahmed is a senior civil servant and former editor of Bangladesh Quarterly.