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.