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Volume 32, 12 Issues, 2022
  Letter to the Editor     August 2022  

Nursing Challenges in Karimabad Valley, Chitral, Pakistan

By Safia Islamuddin


  1. Department of Nursing, The Aga Khan University of Nursing and Midwifery, Karachi, Pakistan


We read with interest the editorial, “Challenges faced by Pakistani healthcare system: Clinician's perspective” published in your esteemed journal back in 2018 discussing the challenges faced in the rural health settings.1 The challenges faced by the nurses were specifically highlighted. The editorial rightly mentioned the inadequate nurse-to-patient ratio, the under allocation of gross domestic product (GDP) for the health sector, absenteeism of the staff due to the prolonged and hard duties, and lack of medical facilities in the rural areas of Pakistan. Heavy workload and continuous duties due to the limited healthcare facilities and staff lead to the frustration, fatigue, and resistance to work in the rural areas.2 Karimabad valley, located around 398 km far from the main town, Chitral, Pakistan, consists of around 30,000 population of 16 major villages. There is only one primary care hospital, the Aga Khan Health family health centre, for 16 villages. 3 There are only two nurses as per the facility requirement.

The most frequent procedure which they perform independently is the labor/delivery process. Due to the lack of knowledge, many women visit the hospital at the time of delivery. Hence, whenever peripartum complications occur, the nurses refer them to the secondary healthcare which is also the initiative of Aga Khan Health Service (two hours away) by car travel. During the travel, if the woman ends up with any complication, the nurse is blamed to be the culprit by the families.

Secondly, only two nurses deal with the thousands of patients of all the ages, i.e. neonates, children, adults, and elderly in 24/7 on-call duty. Being a primary health service providers, they may not manage all the cases thoroughly. However, they screen and facilitate every client visiting the centre anytime whether day or night. Consequently, they deal with each person visiting the centre by often sacrificing their sleep as well. This leads to both physical and mental exhaustion.

Thirdly, there is no proper access to the internet or advanced technology facilities to help them to enhance their knowledge by reading the updated literature. Though Government has initiated 4G network, but it is very expensive and frequently disturbed due to the extreme weather conditions. The Aga Khan Health Services do ongoing trainings, but the trainings cannot cover every single issue which is brought to the nurses by the patients. Moreover, the internet facility can also help in developing Tele-consultation clinics with physicians from the urban branches of the Aga Khan Health Services. The community expects from the nurses to solve every healthcare issue despite understanding the limitation of facilities. This creates low self esteem and guilt among the nurses for being unable to satisfy their clients.

The above scenario may be related to the Penchansky and Thomas’s “Theory of Access to Healthcare” which states that there are many characteristics of the healthcare access which increase patients’ satisfaction.4 These characteristics are accessibility (location), availability (supply and demand), acceptability (consumer perception), affordability (financial and incidental costs), adequacy (accommodation in organisation), and awareness (communication and information). “Access to health” is defined as the degree of fit between the user and the service; the better the services fit, the better the access.5 However, in this scenario the community is accessing the services as they know about its availability as per Penchansky and Thomas’s theory but the facility being the primary health service is not fit for all and cannot meet their demand resulting in decreased customers’ satisfaction and providers’ demotivation. Moreover, acceptability of the service is also lacking in the population. Being the only facility available in the whole valley, they perceive that it should cure all their problems and nurses should give them proper time which is not possible. Hence, they perceive it as an inadequate care. The affordability of the service is also an issue as private health services are not always affordable for every individual. Lastly, the said healthcare facility is accommodating the population which is far from its scope leading to the frustration and fatigue among the assigned nurses. In addition, communication and information are an integral component for the nurses to remain updated about the literature which is lacking because of the non-availability of proper communication channels, technology, and doctors’ facilitation.

 Hence, there is an intense need of the secondary government health facility in the valley to reduce the burden on this health centre and ultimately, on the nurses. This will help to increase community satisfaction, promote nurses’ retention in the rural areas, and decrease the workload on the only available health facility.

The author declared no competing interest.


  1. Khalid F, Abbasi AN. Challenges faced by Pakistani healthcare system: Clinician's perspective. J Coll Physicians Surg Pak 2018; 28(12):899-901 doi:10.29271/jcpsp. 2018.12.899.
  2. Andiwatir A, Betan Y. Letter to the editor: Evidence-based practice for nursing profession: Barriers and teaching strategies solutions. Int J Nurs Sci 2019; 6(1):123-4. doi:10.1016/j.ijnss.2018.11.009.
  3. Retrieved from 05/A-case-study-of-Karimabad-area-development-organisation.
  4. Penchansky R, Thomas JW. The concept of access: Definition and relationship to consumer satisfaction. Med Care 1981; 19(2):127-40. doi: 10.1097/00005650-19810 2000-00001.
  5. Saurman E. Improving access: Modifying Penchansky and Thomas’s theory of access. J Health Serv Res Policy 2016; 21(1): 36-9. doi: 10.1177/1355819615600001.

Authors Reply Section

By Ahmed Nadeem Abbasi


  1. Dr. Ahmed Nadeem Abbasi, Department of Radiation Oncology, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan




Thank you for seeking a reply from us to the Letter to Editor written as correspondence on our Editorial published in 2018.1 We wish to thank the authors of this letter in which they have acknowledged and commended the contents of our editorial which is cited by 39 manuscripts until now.2 Certainly, nursing staff serving in the rural areas of Pakistan is specifically facing great challenges. We agree with the authors in relating this situation with Penchansky and Thomas’s theory of access to healthcare.3

In reply to the points raised in this letter, we wish to emphasize and elaborate on two important factors which can bring a positive change in the healthcare system of any developing country like Pakistan. Firstly, the establishment of intra-disciplinary peer review processes at each level of healthcare delivery. This will definitely bring a meaningful improvement in our rural nursing-based healthcare services.4 Secondly, all the colleagues have to join hands in order to introduce and develop a multi-disciplinary culture at the primary, secondary, and tertiary levels of Pakistani healthcare system.5 Last but not the least, the issue of financial burden faced by our country’s population can also be resolved via enhancement of governmental funding in all the public sector medical services. Philanthropy plays pivotal role in filling this financial constraint which is being faced by almost every Pakistani patient going through illness. Nursing aspects of this financial burden are being documented in contemporary literature.6 A comprehensive national healthcare plan can ensure accessible and equitable healthcare to all the members of our population whether they belong to the rich or poor strata of society. We are witnessing a positive change in terms of multi-disciplinary working culture and we are hoping to address all the future challenges via well planned patient centred focused approach.


  1. Khalid F, Abbasi AN. Challenges faced by Pakistani healthcare system: Clinician's Perspective. J Coll Physicians Surg Pak 2018; 28(12):899-901. doi: 10.29271/jcpsp.2018. 12.899.
  2. Google Scholar Citations. Link accessed on 13th June 2022 User=WY85XRwAAAAJ&hl =en
  3. Penchansky R, Thomas JW. The concept of access: Definition and relationship to consumer satisfaction. Med Care 1981; 19(2):127-40. doi: 10.1097/00005650-1981 02000-00001.
  4. Qureshi BM, Mansha MA, Karim MU, Hafiz A, Ali N, Mirkhan B, et al. Impact of peer review in the radiation treatment planning process: Experience of a tertiary care University Hospital in Pakistan. J Glob Oncol 2019; 5:1-7. doi: 10.1200/ JGO.19.00039.
  5. Abbasi AN. Establishment and maintenance of quality of site-specific multidisciplinary tumor boards in Pakistan. J Coll Physicians Surg Pak 2016; 26(10):805-7.
  6. Thomas T, Hughes T, Mady L, Belcher SM. Financial toxicity: A review of the literature and nursing opportunities. Clin J Oncol Nurs 2019; 23(5):5-13. doi: 10.1188/19.CJON.S2. 5-13.