analysis of health professionals migration: a two-country ... · analysis of health professionals...

Analysis of Health Professionals Migration:

A Two-Country Case Study for the United Arab Emirates and Lebanon

Draft for discussion

Fadi El-Jardali, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut Diana Jamal, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut Maha Jaafar, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut Zeinab Rahal, Department of Health Management & Policy, Faculty of Health Sciences, American University of Beirut

- October 2008 -

Table of Contents

Acronyms____________________________________________________ 5 I. Acknowledgements_________________________________________ 7 II. Executive summary_______________________________________ 8 III. Introduction ___________________________________________ 11

A. Human Resources for Health - International Context _______________ 11 Determinants of migration of health professionals__________________________ 13

B. HRH in the Eastern Mediterranean Region ______________________ 14 IV. Objectives _____________________________________________ 16 V. Methods ________________________________________________ 17 VI. Findings ______________________________________________ 17

A. Case of UAE – Destination Country_____________________17 1. Context of UAE ________________________________________________ 17

a) Geography and Demography ______________________________________ 17 b) Labor Market __________________________________________________ 19 c) Health System in UAE ___________________________________________ 22

2. Health workforce _______________________________________________ 26 3. Existing Stock of Health Workers __________________________________ 30

a) Obtaining Information on the Stock of Health Workers__________________ 30 b) Stock of Physicians _____________________________________________ 30 i. Data from MOH ________________________________________________ 31 ii. Data from HAAD _______________________________________________ 31 iii.Data from DOHMS _____________________________________________ 32 iv.Discrepancies in number of physicians ______________________________ 33 c) Stock of Nurses ________________________________________________ 34 i. Data from MOH ________________________________________________ 34 ii. Data from HAAD _______________________________________________ 38 iii.Data from DOHMS _____________________________________________ 38 iv.Discrepancy in number of nurses ___________________________________ 40 d) Data on Midwives ______________________________________________ 40

4. Yearly inflow of health workers____________________________________ 40 5. Shortage in UAE Health Workforce_________________________________ 41 6. Shortage of National Health Workers _______________________________ 43

a) Potential reasons for shortage of national Physicians____________________ 43 b) Potential reasons for shortage of national Nurses_______________________ 44

7. Reasons Expatriate Health Workers Come to Work in UAE ______________ 44 8. Graduates from Medical and Nursing Schools_________________________ 46

a) Medical Schools ________________________________________________ 47

El-Jardali, et al. 2008 1

b) Nursing Schools ________________________________________________ 48 c) Understanding nurse education programs in UAE ______________________ 51 i. UAE Nursing Education Programs _________________________________ 51 ii. Problems Related to Nursing Education Programs in the UAE____________ 51

9. Recruitment of Health Professionals in UAE__________________________ 53 10. Turnover among UAE Health Professionals ________________________ 55 11. Tawam Hospital Case Study ____________________________________ 57

a) Health workers in Tawam ________________________________________ 58 b) Staff satisfaction survey __________________________________________ 61

12. Training and Continuing Education of Health Professionals ____________ 62 a) MOH ________________________________________________________ 63 b) HAAD _______________________________________________________ 63 c) DOHMS ______________________________________________________ 64 d) The Army Directorate of Medical Services ___________________________ 64

13. Licensure and Continuing Education ______________________________ 65 14. Retention of Health Workers in UAE______________________________ 66

a) Retention Strategies for MOH Facilities _____________________________ 68 b) Strategies to Remedy Shortage of Nurses ____________________________ 70

15. Self sufficiency in UAE ________________________________________ 72 16. Bilateral Agreements __________________________________________ 74 17. Challenges, Successes and Recommendations in UAE ________________ 75

a) Challenges facing UAE __________________________________________ 75 b) Successes and Opportunities in UAE ________________________________ 77 c) Recommendations for UAE _______________________________________ 78

B. Case of Lebanon – Source Country ________________________ 80 1. Context of Lebanon _____________________________________________ 80

a) Geography and Demography ______________________________________ 80 b) Economic Profile _______________________________________________ 82 c) Migration Trends in Lebanon______________________________________ 83 d) Health System Profile____________________________________________ 84

2. Health Workforce in Lebanon _____________________________________ 85 a) Stock of Physicians in Lebanon ____________________________________ 86 b) Stock of Nurses in Lebanon _______________________________________ 90

3. Graduates from Medical and Nursing Schools_________________________ 92 a) Medical Schools ________________________________________________ 93 b) Nursing Schools ________________________________________________ 94 c) Midwifery Schools ______________________________________________ 97

4. HRH Migration from Lebanon_____________________________________ 97 a) Physician migration _____________________________________________ 98 b) Nurse migration _______________________________________________ 101

5. Recruitment agencies ___________________________________________ 102 6. Retention of health workers in Lebanon_____________________________ 103

a) Research on Nurse Retention in Lebanon ___________________________ 103 b) Research on Nurses’ Intent to Leave _______________________________ 105

7. Challenges, Successes and Recommendations for Lebanon______________ 106 a) Challenges facing Lebanon ______________________________________ 106


b) Successes and Opportunities in Lebanon ____________________________ 108 c) Recommendations for Lebanon ___________________________________ 109

VII. Limitations_____________________________________________________ 111

VIII. Conclusion___________________________________________________ 112

IX. References _____________________________________________________ 115

X. Appendices_______________________________________________________ 122

Appendix I: Methods_________________________________________ 122 Appendix II: Search Strategy ___________________________________ 128 Appendix III: Letter sent to schools and universities in UAE ____________ 133 Appendix IV: Data collection template for medical, nursing and midwifery schools in UAE ___________________________________________________ 134 Appendix V: Letter sent to Recruitment agencies in UAE_______________ 135 Appendix VI: Data collection template sent to Recruitment agencies in UAE _ 136 Appendix VII: Template for Key Informant Identification (UAE)_________ 137 Appendix VIII: UAE Key informants identified______________________ 138 Appendix IX: UAE Key informants interviewed _____________________ 140 Appendix X: Letter sent to schools and universities in Lebanon __________ 141 Appendix XI: Data collection template for medical, nursing and midwifery schools in Lebanon ________________________________________________ 142 Appendix XII: Letter sent to Recruitment agencies in Lebanon __________ 143 Appendix XIII: Data collection template sent to Recruitment agencies in Lebanon 144 Appendix XIV: Key informants interviewed in Lebanon _______________ 145 Appendix XV: Questions asked during phone interviews with Lebanese nurses working in UAE ____________________________________________ 146 Appendix XVI: Detailed distribution of physicians registered in DOHMS by nationality ________________________________________________ 147 Appendix XVII: Detailed distribution of nurses employed in MOH facilities across districts __________________________________________________ 148 Appendix XVIII: Detailed distribution of nurses registered in DOHMS by nationality ________________________________________________ 151 Appendix XIX: Detailed response from MOH ION and Institute of Applied Technology ________________________________________________ 152


Appendix XX: Detailed list of nationalities of physicians and nurses employed in Tawam hospital_____________________________________________ 153 Appendix XXI: Detailed distribution of 1st year students and graduates from three branches of the Lebanese University School of Nursing ________________ 155 Appendix XXII: Data received from Nursing Schools in Lebanon on program duration, number of students migrating and most preferable destination____ 156

List of Tables Table 1: National graduates of selected higher educational institutions _____________ 21 Table 2: Types of immigration policies in UAE and implementation status __________ 22 Table 3: Breakdown of Health Care Facilities in UAE __________________________ 23 Table 4: Breakdown of Health Workers in UAE Facilities _______________________ 28 Table 5: Number of physicians employed in public and private Hospitals in UAE (1996-2004) ________________________________________________________________ 31 Table 6: Physicians Working in MOH by Nationality in 2007_____________________ 31 Table 7: Physicians in DOHMS for the years 1997 to 2007 ______________________ 33 Table 8: Physicians in DOHMS distributed by nationality and gender (2007) ________ 33 Table 9: Distribution of Nurses across Health Authorities _______________________ 34 Table 10: Distribution of National Nurses working in MOH facilities only across different districts (December 2007) ________________________________________________ 35 Table 11: Distribution of nurses working in MOH facilities ______________________ 36 Table 12: Distribution of nurses in MOH facilities by gender_____________________ 36 Table 13: Distribution of nurses in MOH by nationality _________________________ 37 Table 14: Nurses registered in DOHMS for the years 1997 to 2007 ________________ 39 Table 15: Nurses registered in DOHMS distributed by nationality and gender (2007)__ 39 Table 16: Total number of recruited physicians and nurses in MOH facilities between 1998 and 2007 _________________________________________________________ 40 Table 17: Nurses in MOH Facilities (December 2007) __________________________ 42 Table 18: Performance of Applicants for Registration Examination (MOH 2007) _____ 43 Table 19: List of the educational institutions that were contacted in the UAE, whether they replied or not and whether they are public or private* __________________________ 46 Table 20: Information collected from Gulf Medical College ______________________ 47 Table 21: Number of 1st year students and graduates from nursing schools from 1998 to 2008 _________________________________________________________________ 49 Table 22: Contribution of nursing schools towards national supply according to sector 50 Table 23: Comparison between number of national and non-national graduates from MOH ION_____________________________________________________________ 50 Table 24: Degrees offered by the different nursing schools in UAE ________________ 52 Table 25: Nurse Recruitment and Resignation in MOH facilities by district (2006) ____ 57 Table 26: Nurse recruitment and resignation in MOH facilities by facility type (2007) _ 57 Table 27: Distribution of physicians and nurses in Tawam hospital by nationality ____ 58 Table 28: Physician trainees and physicians in rotation at Tawam hospital__________ 59


Table 29: Trends in recruitment and termination of medical and nursing staff in Tawam hospital between 2004 and 2007 ___________________________________________ 59 Table 30: Medical Termination summary for 2007 and 2008 _____________________ 60 Table 31: Reason for termination of medical and nursing staff from 2006 to 2008_____ 60 Table 32: Number of vacancies for physicians and nurses in Tawam _______________ 61 Table 33: Issues identified by staff satisfaction survey (Matarelli, 2008) ____________ 61 Table 34: DOHMS Continuing Education Department, Scholarship and Higher Education Department____________________________________________________________ 74 Table 35: Population and Health Indicators for Lebanon ________________________ 81 Table 36: Number of physicians inscribed/year________________________________ 87 Table 37: Physician numbers by Mohafazat 2005* _____________________________ 88 Table 38: Physician distribution by gender ___________________________________ 89 Table 39: Results of data retrieved from the Order of Nurses in Lebanon ___________ 91 Table 40: Number of training institutions by type and capacity of enrollment ________ 92 Table 41: Name, type, affiliation and reply status of medical and nursing schools in Lebanon ______________________________________________________________ 93 Table 42: Number of 1st year students and graduates at two medical schools in Lebanon94 Table 43: Number of 1st year students and graduates from nursing schools in Lebanon between 2000 and 2006 __________________________________________________ 96 Table 44: Number of 1st year students and graduates from two midwifery schools in Lebanon between 2000 and 2008___________________________________________ 97 Table 45: Push and pull factors as reported by medical students (Akl et al. 2007) _____ 98 Table 46: Data on Lebanese Nurses retrieved from four nursing schools ___________ 101

List of Figures Figure 1: Health Workers Save Lives (Adapted from World Health Report 2006) _____ 13 Figure 2: Major expatriate nationalities in UAE_______________________________ 18 Figure 3: Distribution of health workers across sectors by nationality______________ 28 Figure 4: Distribution of physicians across different facilities – HAAD (2007) _______ 32 Figure 5: Distribution of nurses working in UAE by nationality ___________________ 35 Figure 6: Distribution of nurses across different facilities – HAAD (2007) __________ 38 Figure 7: Distribution of physicians and nurses in the EMR______________________ 87 Figure 8: Top Retention Challenges as perceived by Lebanese Nursing Directors____ 104 Figure 9: Retention strategies adopted by hospitals ___________________________ 105


Acronyms

(In alphabetical order) AD CME Abu Dhabi Continuing Medical Education

AUB American University of Beirut

BSN Bachelors of Science in Nursing

BT Baccalaureate Technique

CCS Country Cooperation Strategy

CE Continuing Education

CME Continuing Medical Education

DHA Dubai Health Authority

DMS Directorate of Medical Services

DOHMS Department of Health and Medical Services

EMR Eastern-Mediterranean Region

EMRO Eastern Mediterranean Regional Office

FDON Federal Department of Nursing

GAHS General Authority for Health Services

GCC Gulf Cooperation Council

GDP Gross Domestic Product

GHQ Directorate of Defense Medical Services

HAAD Health Authority-Abu Dhabi

HIC High Income Countries

HRH Human Resources for Health

IBP International Best Practices

IMR Infant Mortality Rate

ION Institute of Nursing

KSA Kingdom of Saudi Arabia

LE Life Expectancy

LHS Lebanese Health Sector

LMG Lebanese Medical Graduates

LMIC Low-Middle Income Countries


MD Medical Doctor

MENA Middle East and North Africa

MHIC Middle-High Income Countries

MMR Maternal Mortality Rate

MOH Ministry of Health

MOH ION Ministry of Health Institutes of Nursing

MOPH Ministry of Public Health

NNMAC National Nursing and Midwifery Advisory Committee

PHC Primary Health Care

RAK Ras Al-Khaimah

ROV Rate of Variation

SEHA Abu Dhabi Health Services

TS Technique Superieur

U5MR Under-5 Mortality Rate

UAE United Arab Emirates

UAQ Umm al-Qaiwain

UK United Kingdom

US United States

USJ Université Saint Joseph

WHO World Health Organization


I. Acknowledgements

We would like to thank WHO Geneva for supporting and funding this project,

specifically Dr. Jean Yan, Dr. Jean-Marc Braichet and Dr. Pascal Zurn. We would also

like to thank WHO EMRO for facilitating this work, particularly Dr. Walid Abubaker and

Dr. Ghanim Alsheikh. Special thanks to Dr. Maryam Al Marri and Dr. Fatima Al Rifai for

helping us identify key informants in UAE. We would also like to extend our thanks and

gratitude to all key informants, educational institutions and recruiting agencies in both

countries that took the time to participate in this study.


II. Executive summary

A. Objective The objective of this paper is to analyze and discuss the context and the patterns of

health professionals’ (physicians, nurses and midwives) production, migration,

recruitment and retention in the United Arab Emirates (UAE) and in Lebanon.

B. Methods Quantitative and qualitative data was collected from several data sources including

literature and grey reports, surveys of universities and schools, surveys of recruiting

agencies and key informant interviews. Activities pertaining to data collection and

analysis spanned from June to August 2008.

C. Major findings and recommendations

1. United Arab Emirates The UAE is a fast growing country which is heavily reliant on foreign health care

professionals who come from different countries. In fact, a reported 82% of health

workers in UAE are expatriates whereas nationals only comprise around 18% of all health

workers. Despite excessive recruitment of foreign trained health professionals, the UAE

still faces severe health workforce shortages. Moreover, the country does not have

bilateral agreements for recruitment of foreign-trained health workers. UAE lacks accurate

estimates on the actual stock of physicians, nurses and midwives. However, the closest

estimates show that an estimated 5,000 physicians and close to 13,000 nurses are currently

employed in UAE, the majority of whom are expatriates. Data pertaining to estimates of

physicians and nurses in addition to number of graduates from medical and nursing

schools was obtained from different sources and are outlined in the findings section of the

report. In addition to heavy shortages, health facilities in UAE have high turnover rates

and poor staff retention. Our data collection and interviews in UAE showed that no

retention strategy exists at a country level. However, some retention initiatives have been


taken at the level of health care organizations. This is contributing to the high turnover in

UAE and may exacerbate current shortages. Key informants interviewed in UAE further

stated that UAE is not self-sufficient and may always have to depend on foreign trained

health workers to meet country demand. Several challenges pertaining to the health

workforce in UAE were documented, specifically the incomplete and sometimes outdated

data; the absence of a health workforce strategy; limited cooperation between health

authorities; no self sufficiency; recruitment and retention challenges for both nationals and

expatriates including high turnover rate; high number of expatriates; and cultural diversity

of health workforce. Some recommendations to remedy these challenges were also

outlined by key informants including a health workforce plan for UAE; a strategy for

recruitment and retention; better collaboration between health authorities; and engaging

the educational sector and improving medical and nursing education programs in UAE.

2. Lebanon Lebanon is characterized by and oversupply of physicians and under-supply of

nurses and paramedical personnel. It has the highest physician density in the Eastern

Mediterranean Region (EMR) and the 8th lowest nurse density in the region. Yet, Lebanon

lacks clear and accurate numbers on actual stock of physicians, nurses and midwives, and

annual supply of such health workers from medical and nursing schools. However,

available data shows that over 10,000 physicians and approximately 6,000 nurses exist in

Lebanon. More detailed findings are outlined within this report. Lebanon is considered as

a source country of health workers. Many physicians and nurses choose to migrate to

countries of the Gulf, Europe and North America in search of better job opportunities.

Lebanon has a culture of migration, this trend has actually become widely accepted by

society. Physicians typically migrate to complete specialty training but very often choose

to remain in their destination country. In fact, after adjusting for the country population

size, Lebanon ranks second among countries from where physicians in the US graduated.

Nurse migration, on the other hand, has reached alarming rates with recent estimates of 1

of every 5 nursing graduates migrating out of Lebanon within one to two years of

graduation. Furthermore, 67.5% of currently employed Lebanese nurses reported an intent

to leave within the next 1 to 3 years, 36.7% of which disclosed plans to leave the country.


Despite the many health workforce challenges in Lebanon, the country lacks a national

health workforce strategy. Limited research has been undertaken to understand health

workforce challenges and retention; findings are reported in subsequent sections of this

report. In light of the above, several key challenges related to the health workforce exist in

Lebanon. Key informants interviewed in Lebanon identified several challenges pertaining

to the health workforce including professional and geographic mal-distribution; migration

– brain drain; outdated curricula; lack of re-licensing of health professionals and

accreditation of educational curricula; limited opportunities for continuing medical

education programs and career development; and limited financial and non-financial

incentives. Key informants also identified several recommendations including developing

a system to manage out-migration; developing a national HRH plan; rectifying HRH

imbalances; revising educational curricula; implementing continuing education and career

advancement programs; and creating financial and non-financial incentives.

D. Conclusion As documented in this two-country case study, both UAE and Lebanon are facing

many challenges in recruiting and retaining their health workforce. This is due to the lack

of evidence-based HRH planning and a national strategy for health workforce in both

countries. Since the UAE is a dynamic and fast growing country, it will continue to

depend on foreign trained health workers to meet current and future needs. On the other

hand, Lebanon as a source country will probably continue to lose its health workforce if

nothing is done to address HRH challenges particularly push factors.

Prioritizing issues related to health workforce in both countries will require solid

leadership and a more efficient health sector. Health sector initiatives to improving the

health workforce requires strong management and leadership capacities. If the HRH

leadership gap continues to exist, both countries will face severe challenges that will

impact its health care systems. This two-country case study clearly shows the need for

immediate action to address HRH in both countries.


III. Introduction

A. Human Resources for Health - International Context

The early decades of the twenty-first century belong to Human Resources for

Health (HRH). HRH issues in several Middle Eastern countries have started to gain more

attention after the World Health Organization (WHO) launched in 2006 the health

workforce decade and set out strategies and recommendations to respond to urgent HRH

needs and challenges. The WHO report also suggested strategies for managing the

existing workforce and stressed on the need for each country to develop its own strategies

based on its contextual needs. As many developed and developing countries, several

Middle Eastern countries have come to realize that the most important asset to any heath

system, besides inputs including physical resources, capital and other consumables, is its

health workforce without which a health system cannot properly function (Kabene et al.,

2006). As detailed in the World Health Report (2006), the health care sector, which is both

labor-intensive and labor-reliant, would not function properly without the presence of a

well-trained health workforce that can meet population health needs and expectations

through delivery of quality health care services (WHO 2006). Furthermore, the quality of

services delivered by a system depends highly on the knowledge, skills and motivation of

health workers (WHO, 2000).

The Kampala declaration which emerged from the First Global Forum on Human

Resources for Health held in Uganda (March 2008) focused on the need for immediate

action to resolve the accelerating crises in the health workforce around the world,

particularly Low and Middle Income Countries (LMICs) which are already crippled by

poor health status and unstructured health systems (Global Health Workforce Alliance

2008). An agenda for global action emerged from this meeting and six interconnected

strategies were outlined:

1. Building coherent national and global leadership for health workforce

solutions

2. Ensuring capacity for an informed response based on evidence and joint

learning


3. Scaling up health worker education and training

4. Retaining an effective, responsive and equitably distributed health

workforce

5. Managing the pressures of the international health workforce market and its

impact on migration

6. Securing additional and more productive investment in the health

workforce

Currently, there are critical challenges facing the health workforce in developing

and developed countries alike. Health worker shortages, skill-mix imbalance, geographic

mal-distribution and poor work environments represent some of these challenges (Chen et

al., 2004 & Dussault & Dubois, 2003 as cited in El-Jardali et al., 2007). Yet, one of the

most significant of these challenges is the global shortage in the stock of HRH. In 2006,

the WHO estimated that there are 59 million health workers worldwide and a global

shortage of 4.3 million workers (WHO, 2006).

Health worker shortages are augmented by migration of health professionals.

While migration is not uncommon, health worker migration is one of the main reasons

behind the current shortages, particularly in LMICs which usually export health workers.

Recruiting foreign workers may help host countries in overcoming staff and skill

shortages. However, it deprives source countries from essential knowledge, skills and

expertise. These countries are losing their national human resources, usually those who are

better-educated, to wealthier countries (Stilwell et al., 2004). Such losses in LMICs,

particularly the loss of health workers, exacerbates challenges such as poor health

outcomes, rising death rates and decreasing life expectancies at birth (El-Jardali et al.,

2007). These highly skilled workers include physicians, nurses, midwives, dentists and

pharmacists among many other skilled professionals (Stilwell et al., 2004). This

association can be visually demonstrated by the figure below which is adapted from the

World Health Report (2006).


Figure 1: Health Workers Save Lives (Adapted from World Health Report 2006)

Determinants of migration of health professionals

Wars, deprivation and social unrest are some reasons behind the migration of

health professionals, particularly from LMICs (Stilwell et al., 2004). High unemployment

rates in source countries encourage professionals, especially from the Philippines and

African countries, to migrate to countries where job vacancies are available in abundance.

This has attracted health professionals to some developed countries such as Canada, the

United States (US) and the United Kingdom (UK) (Stilwell et al., 2004). Health workers

are attracted to these countries because of better wages and working conditions. Some

countries, such as the Philippines, actually encourage emigration (Stilwell et al., 2004).

That is not to say that other reasons for migration of health professionals do no exist. For

instance, migration of Arab health professionals is believed to be a result of the hampering

of individual prospects for social mobility at the level of institutional systems, hindering

professional advancement and rarely rewarding people according to their skills (Fargues,

2006).


B. HRH in the Eastern Mediterranean Region

The Eastern Mediterranean Region (EMR) has the second lowest HRH density

(per 1000 population) among the six administrative regions of the WHO, the lowest HRH

density is in Africa. Seven of the 21 countries in the EMR are believed to suffer from

HRH shortages. The shortage is estimated at 306,031 health workers in this region

whereas the total stock is 312,613, indicating that a 98% increase is required (WHO

2006). This is alarming since the stock of health workers, and consequently the density of

these workers, has been found to be directly correlated with population-based health

indicators such as Maternal Mortality Rate (MMR), Infant Mortality Rate (IMR) and

Under-5 Mortality Rate (U5MR) (Anand & Barnighausen, 2004; Robinson & Wharrad,

2001). The relationship between health worker density and health outcomes in LMICs and

Middle-High Income Countries (MHIC) of the EMR was recently investigated. The study

findings revealed that increasing physician density is associated with decreased mortality

rates. Higher nurse density was also significantly associated with lower MMR (El-Jardali

et al., 2007). This indicates that the presence of appropriate health workforce is essential

to prevent poor health outcomes.

Although the stock of health workers is important in achieving population health

goals, other factors influence the presence of a proper health workforce which delivers

best quality services in the most productive manner. These factors include properly

managing and directing health workers who are, in addition to being sufficient in

numbers, appropriately trained and equitably distributed (El-Jardali et al., 2007). Many

information gaps exist regarding HRH in the EMR especially regarding the planning and

management of human resources. Within HRH planning, limited data is available on the

supply and demand for HRH, types and skill-mix of health workers, and the distribution of

the health workforce. In terms of management, gaps exist in the areas of recruitment and

retention, working conditions, training and employment characteristics, performance,

migration and attrition and the scope of practice. However, these gaps need to be filled

especially in the EMR where most of its countries are either implementing health reform

plans or are in the process of doing so and thus are in need of a sufficient number of

qualified and skilled health workers (El-Jardali et al., 2007).


As a result of these knowledge gaps, there is a difficulty in planning and managing

the health workforce in the EMR. There is a need for evidence-based guidelines for

developing policies that tackle problems in areas where such challenges exist (EMRO,

2005 as cited in El-Jardali et al., 2008a). In addition to problems in the shortage, skill-mix,

underemployment and mal-distribution of workers, HRH in the EMR are plagued with

other challenges. For instance, health workforce migration is perceived to be a problem in

some countries, yet little evidence is available to assess its magnitude and impact.

Furthermore, the competence of the providers is questionable because of inadequate and

inappropriate health professional training. As a result of the current shortages, doctors

often end up doing nurses’ jobs and nurses end up doing nurse aides’ jobs. There is also a

lack of healthcare professionals with specific specialties. Other problems include lack of

recruitment and retention strategies, and the absence of an HRH database needed to help

policy makers make better decisions regarding their country’s health workforce (Chen et

al., 2004 as cited in the El-Jardali et al., 2008a).

Wide variations exist between countries in the EMR in terms of health indicators,

health workforce densities, financial indicators and other population health indicators. As

previously stated, 61% of the countries in the EMR are classified as LMICs. High Income

Counties (HIC) in the region are mainly the oil-rich countries which generally have better

financial indicators than the other countries in the region. For such reasons, many

professionals, including health workers, choose to migrate to the oil-rich HICs in search of

better job opportunities. Migration from the EMR also extends to other regions. A recent

study found Europe to be the most important destination of first-generation Arab

Emigrants. The region holds 59% of all such emigrants worldwide. The second most

important destination were the Gulf States, and Libya, while the rest of the world,

including the United States, were less important destinations (Fargues, 2006).

According to the UN databases in 2005, around 12.8 million non-nationals live in

the Gulf Cooperation Council (GCC) accounting for approximately 36% of their 36

million inhabitants. The Kingdom of Saudi Arabia (KSA) hosts half of these immigrants

while the United Arab Emirates (UAE) has the highest proportion of immigrants (71% of

its population). Limited data are available about the massive immigration to the GCC.

Population statistics released by GCC countries are very limited and when available are


rarely updated. In all GCC countries, Arabs currently constitute the minority of

immigrants (38% in KSA, 46% in Kuwait, 25% in Qatar, 10% in UAE and less than 10%

in Oman). Non-Arabs, on the other hand, account for 95.6% of the GCC immigrant labor

force in the private and public sectors combined, where Indians alone account for 60%

(Fargues, 2006).

Health professional migration in the region is also on the rise, and the direction of

this migration is generally from LMICs to HICs in the region. The booming economy of

the Gulf countries is creating an increasing demand for health professionals who are well

qualified to meet population needs. Production in countries of the Gulf is insufficient to

meet the growing demand and thus, these countries have grown dependant on importing

foreign trained health professionals from countries in the EMR (such as Lebanon, Jordan,

Egypt…) and beyond (such as India, Pakistan, Philippines…). Several countries in the

region act as source countries while many other countries can be referred to as destination

countries. An example of two such countries in the EMR are Lebanon and the UAE, the

former being an LMIC and a source country and the latter being an HIC and a destination

country. This case study will analyze the nature, context and patterns of health

professional migration, particularly migration of physicians and nurses, including

production, recruitment and retention, in UAE and Lebanon.

IV. Objectives

The objective of this work is to analyze and discuss the context and the patterns of

health professionals’ production, migration, recruitment and retention in the UAE and

Lebanon. This case study focused only on physicians, nurses and midwives. This is the

first of a series of case studies that will include other countries in the region with the aim

of generating evidence that will inform health policy makers in formulating evidence

based policies for the health workforce. For this case study, UAE was chosen since it is a

destination country in the EMR for foreign trained health workers from around the world.

As detailed in subsequent sections of this report, more than 80% of health workers in UAE

are expatriates and less than 20% are nationals. Lebanon was chosen given its position as

a source country for many other countries in the region, including UAE.


V. Methods

Several data sources were used in compiling data for this case study. These

included literature search and review, survey of medical and nursing schools and

universities, and interviews with key informants. The full description of methods used for

this study is detailed in Appendix I.

VI. Findings

A. Case of UAE – Destination Country

1. Context of UAE

a) Geography and Demography

The case of UAE is quite unique. Despite being a small country in the Gulf, it

boasts a multicultural society and is a meeting ground between traditional culture and

modern Western medicine (El-Zubeir et al., 2006). The country is highly dependant on oil

and gas revenues which have characterized the country as one of the wealthiest countries

in the world with a Gross Domestic Product (GDP) per capita of 37,000 U.S. dollars

(Younies et al., 2007). The country has two types of governments, federal and local. UAE

has seven emirates which vary in population and income. The seven emirates are: Abu

Dhabi, Dubai, Sharjah, Ras Al-Khaimah (RAK), Ajman, Al-Fujeira and Umm al-Qaiwain

(UAQ). Abu Dhabi is the largest emirate and is the major oil producer. It is divided into

three regions which are Abu Dhabi (the capital), Al-Ain (the main city in the eastern

region of the emirate) and the Western region. Dubai, on the other hand, is a major

commercial focal point and business center of the UAE and the region (Younies et al.,

2007).

In 1998, the Ministry of Planning estimated the population of UAE at

approximately 3,000,000 of which less than a quarter were composed of nationals

(Ministry of Planning, 1998 as cited in Wilkins, 2001). In fact, an estimated 2,488,000 of

the population was composed of expatriates, amounting to approximately 77.46% of the

UAE population. According to Figure 2, the majority of expatriates are from India (46%)


and Pakistan (21%). Expatriates coming from the Middle East account for approximately

15% of total foreign workers (Egypt 6%, Yemen 2%, Jordan/Palestine 5%, Iran 2%). The

Lebanese community was not evident in this estimate, but it is possible that they are

among the other nationalities (5%) in this figure.

Figure 2: Major expatriate nationalities in UAE

India44%

Egypt6%

Yemen2%

Bangladesh4%

Jordan/Palestine5%

Philippines5%

Sri Lanka7%

Other5%Iran

2%

Pakistan20%

Table 1 below also summarizes some demographic characteristics of the

population of UAE.


Table 1: Population and Health Indicators for UAE Lebanon

Total Population (2006) 4,248,000

Urban population as % of total (2006) 77%

Annual Growth Rate (1996-2006) 5%

In urban areas -

Life Expectancy (2006) 78

Males (2006) 77

Females (2006) 80

Under-5 mortality per 1000 (2006) 8

Males (2006) 9

Females (2006) 7

Infant Mortality (per 1000 live births) (2006) 8

Maternal Mortality Rate (per 100,000 live births) (2005) 37

Dependency Ratio -

Percentage of population aged under 15 (2006) 20%

Percentage of Population aged over 60 (2006) 2% Source: World Health Statistics 2008

b) Labor Market

Given that UAE has cities which are global centers of capitalism, businesses,

advanced services, trade and banking and economic and social interaction, the survival of

these cities depends on them having a viable labor market (Zlotnick, 2004 as cited in

Malecki & Ewers, 2007). In UAE, the labor force is approximately 1.3 million of which

90% are expatriates. Foreigners are mostly employed to perform manual and technical

jobs, yet many are recruited to perform specialized jobs in numerous sectors. There is an

incessant demand on workers from all nationalities to meet growing market demand.

Recruitment is mostly done through recruiting agencies although recruitment is also done

through government agencies, corporate recruitment centers and informal social channels

(families or social networks) (Zlotnick, 2004 as cited in Malecki & Ewers, 2007). The


UAE government is trying to reduce its reliance on expatriates especially because of high

unemployment among nationals, especially those who are young and educated. UAE

nationals represented only 8.3% of the labor force in 2003 (Nelson, 2004). No exact figure

on the degree of unemployment among nationals in UAE was found. However, the

government is aware that nationals will not perform such jobs, primarily because they lack

the motivation to do some jobs, but also because they lack experience, skills, and

qualifications for other jobs (Wilkins, 2001). Nationals reportedly complain of long

working hours and low salaries, especially in the private sector (Al Roumi, 1999 as cited

in Wilkins, 2001). In 1995, the percentage of nationals working in the private sector was

approximately 1% (Al Roumi, 1999 as cited in Wilkins, 2001).

The majority of expatriates in the UAE are men (accounting for two-thirds of the

working population (Wilkins, 2001). Female expatriates are mostly involved in domestic

work, entertainment and nursing. The significant inflow of female foreign workers was

necessary to replace national females who were not willing to join the labor force for a

number of reasons including wage and legal discrimination, job segregation, economic

reasons and a social image which limits the women’s work to taking care of her family

and home and being bound to household chores (Khalaf, 2004). However, the percentage

of national women in the UAE labor force has increased over the years since women have

started to attain higher educational achievements and as a result of changing attitudes

towards working women. This is also reflected in the increase in female enrollment in

higher education programs (El-Haddad, 2006). In fact, recent estimates show that

approximately 65% of those seeking education in the UAE are females. The number of

females graduating from colleges and universities and attaining higher degrees is greater

than males (El-Haddad, 2006) as observed in Table 2. It should be noted that the number

of graduates in the table below reflect only national graduates and are not necessarily

graduates of medical or nursing schools.


Table 2: National graduates of selected higher educational institutions

Males Females Total N % N % UAE University 395 15.0% 2236 85.0% 2631 Higher Colleges of Technology 111 7.2% 1422 92.8% 1533 Nursing Institutes 0 0.0% 21 100.0% 21 Dubai College for Medicine 0 0.0% 12 100.0% 12 Ajman University 24 13.4% 155 86.6% 179 Dubai University College 14 40.0% 21 60.0% 35 American University, Dubai 4 20.0% 16 80.0% 20 Institute for banking Studies 25 43.9% 32 56.1% 57 Total 573 12.8% 3915 87.2% 4488 Ministry of Planning as cited in Nelson, 2004 Estimates reflect 2000/2001

Yet, women are still restricted by geographic mobility and limited career options,

particularly nursing which is not considered appropriate for Emirati women (Nelson,

2004). In 2003 the percentage of national females in the labor force was only 2.1%

(Nelson, 2004). More than 90% of these women are employed in the government sector

(Sabban, 2003 as cited in Khalaf).

Market demand in UAE is shifting towards skilled employment rather than lower

technical positions (Zachariah et al., 2002). Current and future demand in the UAE is for

skilled workers including technicians, computer workers, heavy equipment operators and

electrical workers (Zachariah et al., 2002). UAE is also highly in need of professional

workers such as medical and paramedical staff including physicians, surgeons, nurses,

medical laboratory technologists (Zachariah et al., 2002). In 1996, the UAE introduced

strict restrictions on migrants especially those who are unskilled and who fall in low paid

job categories. Source countries, particularly India, have recognized the need to equip its

emigrants with skills that are needed in the UAE since remittances comprise a significant

proportion of their GDP (Zachariah et al., 2002). Several policies have been developed to

regulate migration to UAE and reduce unemployment among nationals (Fasano & Goyal,

2004). The immigration policies in UAE and their implementation status are summarized

in the table below. It is worth noting that no policies have been enacted regarding banning

the hiring of expatriates in certain industries, cash benefits and other incentives to employ

nationals, civil service retrenchment or unemployment benefits.


Table 3: Types of immigration policies in UAE and implementation status

Type of Policy Implementation in UAE

Substitution policies in the government sector

A 1992 regulation requires that ministries hire expatriates only if no national on the list of job seekers has the necessary qualifications

Quotas on expatriates Restrictions in the number of approved work visas for employers*

Quotas on nationals No formal targets except on the share of nationals employed in the public enterprises and the banking sector. Firms seeking work visas for female expatriate employees sponsored by their husband or father must employ an additional national to get the permit

Fees for use of expatriate labor Fees for issuing a work visa and visa renewal

Education and training School curricula have been revised to focus on vocational training. Local government and chambers of commerce provide training and internships financed by their own resources

Enhance private sector benefits A benefit pension scheme for nationals in the private sector was introduced in 1999. foreigners are subject to higher water and electricity tariff bills

Mobility, placement, support and information dissemination policies

In 1997, transfer of sponsorships between employers became possible after one year of service subject to the approval of all parties

Enforcements on legislations on visa requirements and work restrictions

Recent campaign to enforce immigration law including that expatriates should work only for their sponsor. Illegal workers are offered a grace period to legalize their stay or leave the country. Illegal workers can be subject to imprisonment for up to 3 years and fined up to Dh 30,000

* Authors did not specify any figures defining quotas or numbers for expatriate health workers Source: Adapted from Fasano & Goyal, 2004

c) Health System in UAE

UAE has a broad government health service which finances 81% of the costs of

health care and a private health sector which is currently on the rise (UAE Government-

Health). Therefore, health care is shared between the private and the public sector


(Younies et al., 2007). The annual healthcare budget in 2004 was U.S. $470 million up

from U.S. $313 million in 1995 (Younies et al., 2007). These investments have allowed

the UAE to make major progress in the health care sector thus greatly influencing the

ranking of the UAE as 43rd out of 174 industrial and developing countries in the latest UN

Human Development Report (UAE Government-Health).

One of the main reasons behind the success in delivering a high standard of health

care to the population is the sophisticated infrastructure in UAE. This includes well-

equipped hospitals, clinics and health care centers (UAE Yearbook, 2007). The health

care infrastructure is regularly updated and a central database project is being prepared

(UAE Government-Health). The government plans to double the bed capacity in its public

hospitals over the next ten years (UAE Government-Health). The government has focused

on the continuous development of primary health care centers especially those dealing

with maternal and child welfare, school health and health education. The public hospitals

also offer specialized services in addition to telemedicine links with many renowned

international associations (UAE Government-Health).

According to the 2002 annual statistics report, the UAE has 15 hospitals in urban

areas accounting for 57.7% of the total number of hospitals in the country. The other

42.3% represents the 11 hospitals located in rural areas (EMRO, 2006). A total of 106

primary healthcare centers are distributed between urban (33%, 35 centers) and rural areas

(67%, 71 centers) (EMRO, 2006). Please refer to the table below for a breakdown of

health care facilities in UAE.

Table 4: Breakdown of Health Care Facilities in UAE

Emirate Private Hospital

Private Clinics

Public Hospitals

Governmental hospitals*

Total

Abu Dhabi 11 432 12 7 462Dubai 13 485 2 6 506Sharjah 3 383 5 0 391Ajman 1 75 1 0 77Umm al-Qaiwain 0 13 1 0 14Ras Al Khaima 1 71 4 0 76Al-Fujeira 0 21 2 0 23Total 29 1480 27 13 1549*government hospitals besides MOH Source: Younies et al., 2007


Health services in the UAE are provided by six different authorities, five of which

are governmental and one is private. Each of these authorities has its own staff, policies,

procedures and operating systems (EMRO, 2006). The governmental authorities are

(Abdul Ra’ouf, 2008):

1. Ministry of Health (MOH): is the largest health care provider in the UAE

employing more than 17,000 people who come from different educational and

cultural backgrounds (El-Haddad, 2006). The MOH provides health care

services for the population through its 14 hospitals and 70 outpatient clinics. It

is also responsible for providing health care for the northern emirates. In

addition to delivering health services, the MOH is involved in (1) licensing and

renewal of licensing for health institutions, doctors, nurses and technicians; (2)

investigating complaints and medical malpractice; (3) inspecting health

institutions; (4) certifying medical reports and sick leaves; (5) licensing of

health advertisements; and (6) coordinating with health institutions regarding

continuing medical education (UAE Ministry of Health Website).

2. Health Authority-Abu Dhabi (HAAD): previously known as the General

Authority for Health Services (GAHS) which was established in 2001 through

a royal decree (Canadian Chamber of Commerce Website, 2005). Since 2003,

it started to be known as the Health Authority-Abu Dhabi (HAAD). SEHA

(Abu Dhabi Health Services) is the management arm of this authority.

However, there is an overlap between this arm and the operation arm. This has

created confusion for health care organizations and the professionals who are

employed within them. The decree which led to the establishment of this

authority mandated that the authority should manage all MOH hospitals and

Primary Health Care (PHC) centers within the Emirate of Abu Dhabi. The

purpose was to upgrade hospitals in Abu Dhabi and adopt international

standards (specifically Joint Commission for International Accreditation) in

their operation. The authority also aims at establishing centers of excellence by

transforming its general hospitals into reference centers for specific specialties

such as surgery, oncology and in-vitro fertilization. Its open budget in 2005


was expected to exceed 800 million dollars. Recently, the authority has

announced its intention to move from publicly managed monopolies into

models of public/private partnership (Canadian Chamber of Commerce

Website, 2005).

3. Dubai Health Authority (DHA): previously known as the Department of

Health and Medical Services (DOHMS) in the government of Dubai. DOHMS

has existed for more than 30 years (since 1972) (EMRO, 2006). DOHMS has

focused on the development of primary healthcare centers which are

considered as the cornerstone of all other health services (DOHMS, 2008).

These centers provide preventive and therapeutic health services such a

maternal and child healthcare and a wide variety of services in school health,

community services, mental health, and rehabilitation (DOHMS, 2008). The

PHC network in Dubai consists of 20 health centers and peripheral clinics

distributed throughout the Emirate. These centers and clinics are located in

areas that are accessible to all residents and equipped with high quality

physical and human resources who are trained specifically to serve in this field

(DOHMS, 2008). In Dubai, there is 1 health center or clinic for every 30,000

individuals (DHMS, 2008). DOHMS hospitals provide specialized healthcare

in areas of obstetrics, gynecology, pediatrics and genetics (Canadian Chamber

of Commerce Website, 2005). A recent initiative has been launched to create a

new body, the Dubai Health Authority (DHA). Currently, Dubai is passing

through a transitional phase until it reaches the completion of the DHA by

2012 (Eye of Dubai, 2008). In the meantime, DOHMS continues to provide

day to day services. After completion, the DHA will be separated from all

health service delivery (Eye of Dubai, 2008). It will not be directly delivering

services since this will be done by government owned public corporations

separate from the Dubai Health Authority (Eye of Dubai, 2008).

4. Health Services-Ministry of Internal Affairs: no information found

5. Health Services-Armed Forces: runs 3 hospitals and several field clinics

which provide services to military personnel and their family members (The

Canadian Chamber of Commerce Website, 2005).


6. Private Sector: The majority of the private health care systems are located in

the more affluent emirates such as Abu Dhabi, Dubai and Sharjah (Younies et

al., 2007). Yet the quality of public health care systems in UAE outscored that

of the private sector (Younies et al., 2007). With the exception of a few private

hospitals in Abu Dhabi and Dubai, patients with critical and major health

conditions and issues are usually transferred to public hospitals (Younies et al.,

2007). Private hospitals are usually for-profit family owned businesses which

target rich patients from the UAE and the gulf region (Younies et al., 2007).

The private sector has been developing throughout the past years in UAE until

it became an important partner in the delivery of healthcare services (Canadian

Chamber of Commerce Website, 2005). There are 22 privately owned hospitals

with 827 beds that have state of the art equipment and the latest diagnostic

facilities (Canadian Chamber of Commerce Website, 2005). This sector is

likely to expand and play a bigger role in the healthcare industry (Canadian

Chamber of Commerce Website, 2005).

There is no formal structure for coordination between the 6 authorities which has

implications on the health workforce. Due to the political reform underway in the country,

a comprehensive health strategy is being developed but it needs to be revised and updated

(EMRO, 2006). Perhaps the most significant change in policy has been the withdrawal of

the MOH from direct healthcare delivery (EMRO, 2006). Therefore, the relationship

between the different providers of health services and the MOH requires greater

clarification and reorganization.

2. Health workforce

Similarly to the overall labor market in UAE, the great majority of health workers,

mainly physicians and nurses are expatriates (El-Zubeir et al., 2006). The country is

heavily reliant on foreign health care professionals who come from different countries

(Younies et al., 2007) such as South East Asia, Arab countries, North America and the

U.K. to fill gaps in the medical and nursing workforce (El-Zubeir et al., 2006). These

workers usually follow a wage system that is different than that of UAE nationals and


have an annually renewable contract (Younies et al., 2007). Moreover, the majority of

healthcare workers are employed in the public sector. Public sector hospitals are divided

into federal hospitals which are managed and operated by the MOH and the non-federal

hospitals which are managed and operated by the local government of the emirate in

which the hospital is located (Younies et al., 2007).

UAE has a total of 27,475 health workers, this includes administrators, physicians,

laboratory staff, nurses, technicians and others (See Table 5 below) distributed over 1,549

public and private facilities (this does not include ambulatory services) (See Table 4 in

previous section) most of whom are concentrated in Abu Dhabi and Dubai (Younies et al.,

2007). Approximately 82% of health workers in UAE are expatriates whereas nationals

only comprise around 18% of all health workers (Younies et al., 2007). Most health

workers (69.7%) in the UAE are employed in the public sector while health workers in the

private sector make up 30.3% of the whole workforce. National health workers are

employed solely within the public sector whereas expatriates are employed in both the

public and private sector (69.2% and 37.1% respectively). Countries that have a low

number of national health workers tend to provide employment opportunities within the

public sector. This phenomenon is common among all the Arab Gulf States where

nationals represent a small proportion of the labor force. In these countries, nationals

compete with expatriates for many positions. Through employing national workers in the

public sector, the government decreases this competition and ensures the employment of

its national workers. Figure 3 below shows the distribution of health workers across the

public and private sectors with respect to nationality (Younies et al., 2007).


Table 5: Breakdown of Health Workers in UAE Facilities*

Emirate Private Hospitals

Private Clinics

Public Hospitals

Government hospitals**

Total

Abu Dhabi 1543 1812 7821 612 11788Dubai 2254 1702 1563 1767 7286Sharjah 402 996 2557 0 3955Ajman 65 162 791 0 1018Umm al-Qaiwain 0 18 571 0 589Ras Al Khaima 17 133 1671 0 1821Al-Fujeira 0 76 942 0 1018

Total 4281 (15.6%)

4899 (17.8%)

15916 (57.9%)

2379 (8.7%)

27,475

* Density of health workers per district is not included since the total population density was not available. Distribution of national and non-national health workers was also not available from this source. ** Government hospitals besides MOH Source: Younies et al., 2007 Figure 3: Distribution of health workers across sectors by nationality

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

Nationals Expatriates All health workers

Public Sector Private Sector

Source: MOH 2007

Reports about the labor market estimate that 10,000 UAE nationals should be

absorbed by the market annually (Al Roumi, 1999 as cited in Wilkins, 2001). This is part


of a recent trend referred to as “Emiratization.” This policy was developed to deal with the

rising levels of national unemployment (Wilkins, 2001). Yet despite “Emiratization,” the

flow of foreign health workers to UAE has not decreased and the country continues to

recruit health workers to work in different medical fields. Moreover, the proportion of

national health workers in the UAE remains low compared to expatriates. According to

key informants, since the UAE is suffering from severe shortages in the total number of

health workers, it is recruiting as many health workers as possible, possibly more than any

other country in the GCC. The country is placing extreme efforts on recruiting both

nationals and expatriates to remedy its health worker shortage, particularly nurses.

Early in the 1960s, and before the establishment of the federation, foreign nurses

started arriving in UAE, mostly from the Indian subcontinent (El-Haddad, 2006). During

that period and specifically in 1961, basic healthcare services were being provided to

people residing in Sharjah, Ras Al-Khaimah and Dubai. In 1966, following a Canadian

Mission in Al-Ain, the first hospital was set up in UAE, the Oasis Hospital. In 1967, the

first public hospital was built in Abu Dhabi (El-Haddad, 2006). Foreign female labor was

needed since female nationals were discouraged from entering the workforce, particularly

after the oil boom in the 1970s when the need for male migrants was replaced by the need

for female migrants, specifically nurses (Zlotnick, 2004 as cited in Malecki & Ewers,

2007). Nursing became the primary skilled occupation for female migrants in the Gulf,

including UAE.

Many countries responded to the increasing demand for nurses in UAE and the

Gulf region. One such country was the Philippines which actively responded to the

demand for nurses (Zlotnick, 2004 as cited in Malecki & Ewers, 2007). Other source

countries included other countries in North America and Europe in addition to countries in

South East Asia and some Arab countries. Filipino and Egyptian nurses are usually given

middle status registered nurse positions. Sri Lankan and Pakistani workers usually fill

unskilled orderly and janitorial positions in the health care facilities (Ball, 2004 and

Zlotnick, 2004 as cited in Malecki & Ewers, 2007). American and European health

workers were given higher positions such as administrators and head nurses (Ball, 2004

Zlotnick, 2004 as cited in Malecki & Ewers, 2007).


3. Existing Stock of Health Workers

In order to further understand the dependence of the UAE on immigrant healthcare

workers, it is necessary to divide the stock of health worker migrants by type and country

of origin.

a) Obtaining Information on the Stock of Health Workers

As previously indicated, several health authorities exist in UAE; these authorities

rarely communicate and collaborate with each other. They also have no unified national

data about health workers. Therefore, it was very difficult to obtain information about the

health workers in the UAE as a whole and thus information had to be obtained

individually from each health authority. In addition, information about health workers in

the private sector could not be obtained because an authority responsible for the private

sector as a whole could not be identified.

b) Stock of Physicians

According to the World Health Statistics (2008), the UAE has a total number of

4,960 physicians with a density of 17 per a 1000 population (World Health Statistics,

2008). Only 10% of doctors practicing in the UAE are nationals (UAE Yearbook, 2007).

Data on the number of physicians in the UAE was obtained from many sources. Table 6

displays the number of physicians working in public and private hospitals. The numbers in

the table below show that the number of physicians in both public and private hospitals

has increased since 1996. However, the increase in the number of physicians in private

hospitals is worth some attention. In 1996, the number of physicians in the private sector

was 356 and it has increased to 1,157 in 2004. In 2004, the total number of doctors in both

public and private hospitals is 4,300. This number does not include the doctors who

practice in facilities other than hospitals such as clinics and primary healthcare centers.

But this estimate is close to the one provided by the World Health Statistics (2008). We

were unable to calculate the density of physicians in each district or across types of

hospitals since the total population under each category is not available.


Table 6: Number of physicians employed in public and private Hospitals in UAE (1996-2004) Year Public Hospitals Private Hospitals Total 1996 2,227 356 2,583 1997 2,354 469 2,823 1998 2,444 567 3,011 1999 2,641 578 3,219 2000 2,569 654 3,223 2001 2,917 917 3,834 2002 3,096 1,077 4,173 2003 3,042 1,166 4,208 2004 3,143 1,157 4,300 Source: http://library.gcc-sg.org/health

i. Data from MOH

The total stock of physicians working in MOH as estimated in 2007 is 1,475. Most

of these physicians come from UAE (23.7%), followed by Egypt (20.3%), Iraq (15.6%)

and India (13.4%) (See Table 7 below). This is not surprising since the public sector is the

largest employer of nationals.

Table 7: Physicians Working in MOH by Nationality in 2007

Country # of physicians %UAE 349 23.7%Egypt 300 20.3%Iraq 230 15.6%India 198 13.4%Sudan 129 8.7%Pakistan 93 6.3%Palestine 51 3.5%Jordan 41 2.8%Syria 33 2.2%Yemen 27 1.8%UK 9 0.6%Iran 8 0.5%Canada 7 0.5%Total 1,475 100%Source: Obtained from UAE MOH HR Department

ii. Data from HAAD

A total of 3,394 physicians are registered in the HAAD. As observed in the figure

below, approximately 70% work in hospitals affiliated with the authority, 21.2% are

employed within PHC centers and 8.9% in clinics.


Figure 4: Distribution of physicians across different facilities – HAAD (2007)

Hospital69.9%

Primary Health Care Center21.2%

Clinic8.9%

Data obtained from Health Facility Licensing Database, Department of Planning and Economy, HAAD assumptions and analysis as cited in Statistical Highlights 2007 Health Statistics 2007: Health Authority Abu Dhabi Reliable Excellence in Health Care

Information on nationality of physicians in HAAD was not made available.

iii. Data from DOHMS

Data obtained from DOHMS show that 1,292 were registered with the referenced

authority in 2007. As observed in the table below, physicians comprise approximately

13% of all health workers (year 2007) in Dubai. The average Rate of Variation (ROV) for

2007 is 6.3 indicating an increase in the number of physicians between 2006 and 2007.


Table 8: Physicians in DOHMS for the years 1997 to 2007 # of physicians % Physicians 1997 757 10.1% 1998 777 10.2% 1999 808 10.4% 2000 855 10.5% 2001 842 10.4% 2002 848 10.4% 2003 885 10.8% 2004 893 11.1% 2005 1,009 11.6% 2006 1,215 12.7% 2007 1,292 13.7% ROV* 6.3

* Rate of variation for physicians between 2006 and 2007 is {(number of physicians in 2007 – number of physicians in 2006) / number of physicians in 2006} x 100. Source: DOHMS, 2008

The number of national physicians in DOHMS is 486 (37.6%) as compared to 806

(62.4%) non-nationals (estimates for the year 2007). While the distribution of male vs.

female physicians is equal when adding the number of national and non-national

physicians together; it is worth noting that among nationals, male physicians comprise a

minority (31.7%) compared to non-nationals where males are a majority (61%) (See Table

9).

Table 9: Physicians in DOHMS distributed by nationality and gender (2007) Nationals Non-Nationals N (%) N (%) Males 154 (31.7%) 492 (61.0%) Females 332 (68.3%) 314 (39.0%) Total 486 806

Source: DOHMS, 2008

For further information on detailed distribution of physicians registered with

DOHMS by nationality, please refer to Appendix XVI.

iv. Discrepancies in number of physicians

It is worth noting that there is a wide discrepancy between the numbers of

physicians reported by the different sources available. This indicates that there is an urgent


need for the six health authorities to update and collate the number of physicians

registered within their health centers to come up with an accurate national estimate.

c) Stock of Nurses

According to WHO (2006) the total number of nurses in UAE for 2001 is 12,045

and the density is 4.18 per 1000 population. However, this estimate dates back to 2001.

More updated data on nurses registered with each of the MOH, HAAD and DOHMS is

detailed below.

i. Data from MOH

We were able to obtain national nursing workforce data from MOH. According to

this data obtained from MOH (2007), approximately 18,000 nurses from more than 100

countries currently work in UAE (See Table 10). More than 3,000 of these nurses

currently work in the MOH and the rest either work in the private sector or in other health

authorities. Since data on population covered under each health authority is unavailable,

we were unable to produce density of nurses across the authorities.

Table 10: Distribution of Nurses across Health Authorities 2006 2007MOH 3,115 3,157Abu Dhabi Health Authority 3,624 5,211Dubai Health Authority 2,786 3,500Health Services-Abu Dhabi Police 184 337Health Services-Defense 1,051 1,126Private-MOH 2,000 4,652Total 12,760 17,983Source: MOH 2007

Emirati nationals constitute 7% of the total number of nurses working in UAE

(FDON, 2007) (See Figure 5 below). Evidence dating back to 2003 showed that 3% of

nurses in UAE are nationals (FDON, 2003 as cited in El-Haddad et al., 2006), indicating

that efforts to increase the stock of nationals have been slightly successful.


Figure 5: Distribution of nurses working in UAE by nationality

Arabs, 28%

East Asia, 63%

Others, 2% Nationals, 7%

Source: MOH 2007

The table below indicates the distribution of national nurses across MOH facilities

as per estimates dating to December 2007.

Table 11: Distribution of National Nurses working in MOH facilities only across different districts (December 2007) District NumberDubai 21Sharjah 76Ajman 7UAQ 6Fujeirah 65RAK 65Federal Department of Nursing 4Total 244Source: FDON Annual Report 2007

To further explore the distribution of all nurses employed in MOH facilities across

districts, please refer to the table below. It is worth noting that the majority of nurses are


working in Sharjah, RAK, Fujeirah and Dubai. (For further information on detailed

distribution of nurses in MOH facilities among districts, please see Appendix XVII).

Table 12: Distribution of nurses working in MOH facilities

District N %Sharjah Medical District 1168 37.1%RAK Medical District 623 19.8%Fujeirah Medical District 420 13.3%Dubai Medical District 406 12.9%Ajman Medical District 315 10.0%UAQ Medical District 211 6.7%Total 3159 100.0%Source: FDON Annual Report, 2007

In Table 13 below, the distribution of MOH nurses is detailed according to gender.

The proportion of female nurses is consistently higher than male nurses across all districts.

Table 13: Distribution of nurses in MOH facilities by gender Female Male N (%) N (%) Total

Dubai Medical District 319 (83.7%) 62 (16.3%) 381 Sharjah Medical District 738 (89.9%) 83 (10.1%) 821 Ajman Medical District 236 (83.7%) 46 (16.3%) 282 UAQ Medical District 217 (92.7%) 17 (7.3%) 234 RAK Medical District 494 (88.4%) 65 (11.6%) 559 Fujeirah Medical District 162 (88.0%) 22 (12.0%) 184 Total 2,166 (88.0%) 295 (12.0%) 2,461

Source: FDON Annual Report, 2007

Despite the increase in the number of national nurses employed in MOH facilities,

the country highly is still highly dependant on foreign nurses to fill the gaps in the nursing

workforce (El-Zubeir et al., 2006). In fact, about 90% of nurses in the UAE are

expatriates. This is further evidenced in the figure above (Figure 5) which indicates that

63% of nurses come from South East Asian countries such as from India, Pakistan, the

Philippines whereas 28% come from Arab countries such as Palestine, Jordan, Oman,

Syria, Egypt, Sudan and Somalia. The table below details the distribution of nurses

working in MOH facilities by country of origin. It is worth noting that the majority of


nurses are from India (31.4%), followed by UAE (24%), Egypt (8.5%) and the Philippines

(7.9%).

Table 14: Distribution of nurses in MOH by nationality Country N %India 1,097 31.4%UAE 839 24.0%Egypt 296 8.5%Philippines 276 7.9%Sudan 177 5.1%Jordan 142 4.1%Palestine 141 4.0%Oman 106 3.0%Somalia 82 2.3%Syria 66 1.9%Yemen 55 1.6%Lebanon 45 1.3%Pakistan 43 1.2%Tunisia 35 1.0%Indonesia 20 0.6%Iran 13 0.4%Iraq 12 0.3%Algeria 7 0.2%Others 40 1.1%Total 3,492 100.0%

Source: data from MOH HR department (2007)

It is worth noting here that the proportion of nationals working in MOH facilities

(24% in Table 14) is much higher than the number of nationals working across UAE (7%

as in Figure 5). This may be due to the fact that the government is trying to employ as

many national nurses as possible within the public sector. It should be noted that data in

Table 14 might underestimate the distribution of nurses by nationality at the level of all

UAE. The table only provides data on MOH facilities which constitute only some of all

health providers in UAE.


ii. Data from HAAD

A total of 6345 nurses are registered in the Abu Dhabi Health Authority. As

detailed in Figure 6 below, the majority of nurses work in hospitals (89.2%) while the rest

work in PHC centers (8.8%) and clinics (1.9%).

Figure 6: Distribution of nurses across different facilities – HAAD (2007)

Hospital89.2%

Clinic1.9%Primary Health Care

Center8.8%

Data obtained from Health Facility Licensing Database, Department of Planning and Economy, HAAD assumptions and analysis as cited in Statistical Highlights 2007 Health Statistics 2007: Health Authority Abu Dhabi Reliable Excellence in Health Care

iii. Data from DOHMS

Data obtained from the Dubai Health Authority show that 3,571 nurses registered

in 2007. As observed in Table 15 below, in 2007, nurses constituted approximately 38%

of all health workers registered in DOHMS. The average ROV of 3.7 indicates that the

number of nurses increased between 2006 and 2007.


Table 15: Nurses registered in DOHMS for the years 1997 to 2007 # of Nurses % Nurses 1997 2,331 31.2% 1998 2,380 31.3% 1999 2,456 31.6% 2000 2,602 32.1% 2001 2,617 32.2% 2002 2,741 33.7% 2003 2,834 34.5% 2004 2,793 34.7% 2005 3,006 34.6% 2006 3,444 36.1% 2007 3,571 37.9% ROV* 3.7

* Rate of variation for nurses between 2006 and 2007 is {(number of nurses in 2007 – number of nurses in 2006) / number of nurses in 2006} x 100. Source: DOHMS, 2008

The number of national nurses in DOHMS is 102 comprising less than 3% of all

nurses (estimates for the year 2007). As detailed in Table 16, non-national female nurses

outnumber non-national male nurses in DOHMS (3,035 (87.8%) females compared to 434

(12.2%) males). This observation is consistent among nationals and non-nationals.

Furthermore, national male nurses are much fewer in proportion (2.9%) as compared to

non-national male nurses (12.5%) (See Table 16).

Table 16: Nurses registered in DOHMS distributed by nationality and gender (2007) Nationals Non-Nationals N (%) N (%) Males 154 (31.7%) 492 (61.0%) Females 332 (68.3%) 314 (39.0) Total 486 806 Nationals Non-Nationals N (%) N (%) Males 3 (2.9%) 434(12.5%) Females 99 (97.1%) 3,035 (87.5%) Total 102 3,469

Source: DOHMS, 2008

For further information on detailed distribution of nurses registered with DOHMS

by nationality, please refer to Appendix XVIII.


iv. Discrepancy in number of nurses

There is some discrepancy in the number of nurses reported by different

authorities. However, this discrepancy is much less pronounced for nurses than

physicians. But this further ascertains the need for the different authorities to collaborate

and try to provide accurate numbers on health workers registered in their facilities.

d) Data on Midwives

The UAE lacks information about midwives. In fact, we found no reference to any

midwifery schools or educational programs in UAE. Yet, we were able to find out that

there are currently 20 midwives employed in the MOH (18 westerners and 2 nationals).

These midwives were described as highly qualified.

4. Yearly inflow of health workers

As detailed above, UAE is continuously recruiting additional health workers to

practice in different authorities in the country. Since the demand for health workers has

been increasing, one would only assume that the annual inflow would also increase. To

this end, information on health workers recruited in MOH facilities between 1998 and

2007 was obtained. Information pertaining to the total number of physicians and nurses

recruited only to MOH facilities between 1998 and 2007 is detailed in the table below.

Table 17: Total number of recruited physicians and nurses in MOH facilities between 1998 and 2007* Nationals Non-Nationals TotalPhysicians 287 971 1,258Nurses 573 2,926 3,499

* The discrepancy between the cumulative number of health workers in Figure 7 and the total number of non-national physicians and nurses in Table 17 reflects the extent of internal migration and movement across health authorities

Information on yearly inflow of physicians and nurses in other health authorities

was not available.


5. Shortage in UAE Health Workforce

UAE, as is the case in many countries, faces a shortage in its health workforce as a

whole, including nurses. The nursing shortage is being exacerbated by diminished supply

and increasing demand. The decreased supply of nurses is a result of the inability to retain

the current nursing workforce and the inability of nursing schools to produce enough

nurses to meet the growing demands of the population. Enrollment rates in nursing

programs are critically low especially since the profession has a poor social image in

many places around the world (AbuAlRub, 2007). Nurses always come across multiple

opportunities for them to practice in different settings away from the bedside or in

different professions all together. Slow salary increases, unattractive working conditions,

fewer numbers of students choosing nursing as a profession and a decrease in the number

of nursing faculty are other factors contributing to this shortage. Working conditions and

the work environment are often unsatisfactory and are characterized by high workloads,

limited clinical autonomy, conflicts with physicians and non-supportive working

conditions (AbuAlRub, 2007). In Arab countries, although the social image of nursing has

improved, it is still being seen as a woman’s job which involves non professional duties.

In addition, families disapprove of their daughters becoming nurses since it may involve

working night shifts, which decreases their chances of getting married.

The nursing shortage often has impact on patient care. One hospital in Al Baraha

area in UAE has a ratio of 1 nurse to 10 patients in general and 1 nurse to 4 patients in the

ICU. These are alarming statistics because recommended nurse to patient ratios in

hospitals are 1 nurse to 5 patients in general and 1 nurse to 1 patient or at most 1 nurse to

2 patients in the ICU (Zain & Libo, 2008). Nurses in the EMR region have been moving

to the US or European countries that may sometimes offer them family and immigrant

visas. These nurses spend on average 3 years in the UAE but end up leaving to the West

especially because of the high living expenses and the high cost of living (Zain & Libo,

2008). One nurse in Al Baraha Hospital reported that on first arriving to UAE, the

government provided her with many benefits including housing and even a food

allowance. But after she got married, she lost those benefits and as a result could no longer

afford the high cost of living particularly after having children (Zain & Libo, 2008).


The table below details the extent of the nursing shortage in UAE. As evident in

the table below, approximately 743 additional nurses (20%) are needed to fill the gap in

MOH facilities alone. But this number could be much higher if information on the gaps

was found for the rest of health authorities in UAE.

Table 18: Nurses in MOH Facilities (December 2007) Type of Facility Current Required* % ShortageHospital 2307 2639 12.6%Out Patient Clinics 208 263 20.9%New Wards in Hospital, School Health and Preventive Medicine 120 100.0%

Health Centers 303 450 32.7%School Health 281 347 19.0%Preventive Medicine 58 81 28.4%Total 3157 3900 19.1%* This is estimated based on standards adopted by MOH in UAE. These standards were not specified by the key informants during the interview.

The shortage of nurses in UAE has been exacerbated by the compulsory insurance

recently implemented. Patients are seeking care more often since they know they are

insured (Zain & Libo, 2008) which has increased the demand for medical services and put

further pressures on the current workforce. This problem is expected to increase in the

coming years. This created the need to recruit additional nurses. The ministry has taken

steps to tackle this issue including allowing foreign nurses in UAE on visit visas to work,

allowing nurses who take the MOH exam to take up work in the private sector, and

reducing the number of mandatory years of service in the public institutions after

graduation (Zain & Libo, 2008). In regard to reducing mandatory years of service in the

public sector, the authors did not elaborate further on this issue (Zain and Libo 2008) to

include the duration of this period, number of health workers this policy applies to, former

mandatory duration of practice and efficiency of this strategy. Still, according to the

MOH, the problem is not in the number of applicants but it is in the qualifications of these

applicants. Key informants reported that most applicants are assistant nurses and not

registered or licensed nurses who have a minimum of 3 years of professional education.

As evident in the table below, many nurses are applying for positions in the MOH, yet

more than half have failed their registration exam which delays their entry to practice or

eliminates this possibility entirely.


Table 19: Performance of Applicants for Registration Examination (MOH 2007)* Professional Category Total applicants Passed Failed Missed Registered Nurse 1571 754 803 14 Practical Nurse 182 77 105 0 Registered Midwife 1 1 0 0 Practical Midwife 11 4 7 0 Total 1765 836 915 14 * Registration examination is only for non-nationals

6. Shortage of National Health Workers

Although UAE is not primarily dependant on its nationals to provide the majority

of the labor force in the country, it is always aiming to increase its national stock of health

workers. While our findings show that there is no accurate quantitative data on existing

shortages of physicians and nurses, key informants acknowledged extreme shortage of

national health workers as compared to expatriates; some of the reasons for this shortage

are detailed below:

a) Potential reasons for shortage of national Physicians

In UAE, like many Arab countries, being a physician is considered to be much

more prestigious than being a nurse. Yet, UAE has a severe shortage in the number of

national physicians. Key informants reported that nationals in UAE lack the interest and

motivation to enter the medical profession and are not very attracted to it. Becoming a

physician required many years of study and preparation and does not offer sufficient

financial rewards for UAE nationals who prefer the business sector which allows them to

make money sooner and faster than the health sector. Key informants stated that the

problem does not lie in the attraction of national to the medical profession but the simple

fact that the overall proportion of UAE nationals to expatriates in the country’s population

is low. Moreover, problems exist in the number and quality of medical education

programs. The number of graduates is not sufficient to meet national demands and

medical schools have minimal programs that offer training for some specialties that are

critically needed in the UAE. According to key informants, since the type and

qualifications of graduates in UAE is not really compatible with the need of the labor


market, the government has requested that each emirate communicate with universities

and define the professions that are highly needed by the labor market.

b) Potential reasons for shortage of national Nurses

To begin with, nursing has a low profile and a poor social image among UAE

nationals. They repel from the nature of the profession which involves physical contact

with patients. In addition, the long working hours, multiple shifts and night shifts work

against attracting nationals to the nursing profession. These factors may be overcome if

incentives and benefits are provided to national. However, according efforts in this area

have been limited. Key informants reported that nursing salaries are still too low and the

working conditions in many facilities are unsatisfactory. Perhaps, the major reason behind

the shortage in the number of national nurses lies in the nursing educational programs

which are few in number, diverse and lack training in different nursing specialties.

Due to the severe shortages in health workers in UAE and the inability of the

national health workforce to meet market demands, the country is heavily dependant on

recruiting foreign trained health workers to remedy existing shortages and meet market

demand.

7. Reasons Expatriate Health Workers Come to Work in UAE

Due to the lack of literature on pull factors that encourage health workers to

emigrate to UAE, we asked many of the key informants to provide their insight into this

matter. The reasons reported by key informants differed. For instance, one key informant

stated that financial incentives are the main reason why all workers, and not only health

workers, seek employment in the UAE. It should be noted, however, that salaries for

nationals much exceed salaries for non-nationals. The key informant went on to say that

“unless we were born and raised here, we are here for the money.” In addition to the high

salaries, health workers are attracted by better living conditions and better health

standards. Other key informants reported that there is a great probability that many

workers, not only health workers, currently employed in the UAE previously worked in

other Gulf countries, but preferred to come to the UAE not because of higher salaries but

because of other benefits. These include the ability of workers to bring their families with


them, the lack of a time limit on the duration expatriates can stay in the country

(depending on the renewal of their licensure), and the lack of discrimination between UAE

nationals and expatriates when it comes to access to many facilities in the country which

makes expatriates feel more welcome and less confined.

Stability and religious freedom were also identified as incentives for workers to

work in UAE. Recently, the UAE has witnessed a rise in the number of foreign doctors

coming from Iraq due to the situation in there which offers no security or stability. Some

key informants reported that expatriates are able to raise their children in a traditional

Muslim, yet open society; this luxury is not available to the same extent in other Gulf

States. All these incentives are actually part of the government’s strategy to encourage

immigration and investment in the UAE. This was actually the main reason behind

creating the new universal insurance scheme. Moreover, the country has been witnessing

an increase in the number of hospitals and health care centers. If the UAE wants to

compete with developed countries in the West, all people living in the country should

have access to health care.

In addition to the above, key informants reported that the experience and

professional development opportunities available in UAE are also some of the reasons

why health professionals choose it as a destination. Some hospitals have begun to

understand this and have initiated training programs as part of in-house retention

strategies. Foreign trained health workers who go to UAE are exposed to state-of-the-art

technology possibly not available in their own country. They also have the chance to

engage in continuing medical education programs and have the opportunity to work with

some of the best health professionals in the region.

According to some key informants, strategies to encourage expatriates to come to

the UAE are not only seen in the health care field (universal insurance plan) but also in the

country’s infrastructure. Airports are being built to accommodate more travelers. As for

health care workers, they are attracted to the state-of-the-art health and medical

infrastructure of the country and the advanced technologies present in health care facilities

keeping them always up to date with issues related to the medical and health field.


8. Graduates from Medical and Nursing Schools

One common strategy to increase the national stock of health workers is through

investing in educational programs. The shortage in UAE merits investing in educational

programs in effort to increase national supply and decrease reliance on expatriates. It is

therefore essential to examine the contribution of medical and nursing educational in

increasing the national supply of health workers, specifically physicians and nurses. Major

educational institutions that have medical and nursing programs were contacted by the

research team and were asked to fill a survey (See Appendices II and III). The survey

requested information on the number of graduates and first year students between the

years 2000 and 2008. We also asked schools to specify the number of national graduates

so we can deduce the number of expatriate students. We also requested information on

whether graduates were emigrating within three years of practice, their number and reason

for emigration.

A list of medical and nursing schools that were contacted in UAE is enclosed in

the Table below. We also reported whether the institutions are public or private to identify

the contribution of each sector in HRH production. As evident in the table, not all schools

responded to our request.

Table 20: List of the educational institutions that were contacted in the UAE, whether they replied or not and whether they are public or private* Name of Institution Type Status Affiliation Gulf Medical College Medical Replied Private UAE University Medical Did not reply Public Dubai Medical College for Girls Medical Replied Private University of Sharjah Medical School Medical Did not reply Private University of Sharjah School of Nursing Nursing Replied Private Institutes of Nursing (3 branches) Sharjah Nursing Replied Public Fujairah Nursing Replied Public Ras Al-Khaimah Nursing Replied Public Institute of Applied Technology (2 branches) Abu Dhabi Nursing Replied Public Al-Ain Nursing Replied Public *No Schools of Midwifery were identified in the UAE


Responses received from institutions were accumulated and the results (number of

first year students and number of graduates) are subsequently reported.

a) Medical Schools

Since only 2 medical schools in the UAE replied, the information was limited.

Dubai Medical College for girls did not report the number of graduates on an annual basis

and only provided the total number of graduates for all years. The total number of

graduates from Dubai Medical College for Girls between 1998 and 2008 was reported as

600. Responses for the Gulf Medical College are summarized in Table 21 below. It should

be noted that nationalities of non-national graduates was not requested from universities

and schools. As observed, a total of 129 medical students graduated in 2000 and 2001.

Since the program at Gulf Medical College, like most medical schools, is a six-year

program, students admitted between 2002 and 2008 have not yet graduated.

Table 21: Information collected from Gulf Medical College

Number of 1st year students

Number of Graduates

National Graduates

2000 96 75 82001 73 54 82002 80 - -2003 59 - -2004 73 - -2005 63 - -2006 65 - -2007 60 - -2008 - - -Total 569 129 16

Based on the data provided by both medical schools, the total number of medical

graduates is an estimated 728. It should be noted that this number is widely

underestimated since it does not include data from other medical schools in UAE. The two

institutions that responded to the survey are private institutions, and therefore admit both

national and non-national students. Public institutions, on the other hand, typically restrict

admission to nationals who are usually exempted from paying tuition fees. Still, some

public institutions allow admission to non-nationals provided that they pay tuition fees.


One of the universities that did not reply to the survey was UAE University which

is the only public school of medicine. Admission to this faculty is restricted to UAE

nationals and the 6 year program it provides is in English, problem-based, student-oriented

and problem centered (El-Zubeir et al., 2006). The University of Sharjah School of

Medicine also did not respond to our survey, it is a private medical school.

It is also noteworthy that one medical school was not contacted. This school is in

Ras Al-Khaimah and is also private. Therefore, although we did not receive information

from all medical schools, it is clear that the private sector is contributing the most to

supplying physicians trained in UAE. Still, many key informants interviewed in UAE

reported that the production of medical graduates is very low and insufficient to meet local

demand.

b) Nursing Schools

As evident in Table 19, all three nursing schools responded to our survey. One

additional school, DOHMS in Dubai Government Institute of Nursing, was not included

since it closed down in 2004 due to insufficient admission. But results from this school

were obtained and are reported in Table 22. As reported in Table 22, a total of 1,837

nurses graduated from the four nursing schools. The number of 1st year students may not

be very accurate since the Institute of Applied Technology and DOHMS in Dubai

Government Institute of Nursing did not provide any data in that regard and some of the

other schools did not provide data for all requested years.


Table 22: Number of 1st year students and graduates from nursing schools from 1998 to 2008

Ministry of Health Institute of Nursing

DOHMS in Dubai Government Institute

of Nursing*

Institute of Applied Technology

University of Sharjah School of Nursing Total

1st year Graduates 1st year Graduates 1st year Graduates 1st year Graduates 1st year Graduates1998 72 22 15 42 72 791999 74 19 39 0 74 582000 80 36 19 53 80 1082001 135 69 24 93 17 15 152 2012002 146 59 24 88 18 13 164 1842003 161 81 27 87 15 6 176 2012004 184 119 44 120 21 13 205 2962005 203 109 101 29 12 232 2222006 233 104 82 19 6 252 1922007 217 88 93 17 7 234 1882008 108 0 108

Total 1,501 814 192 759 136 72 1,637 1,837*Institute was shut down in 2004 due to poor admission from nationals in the institute


As evident in the table below, public nursing schools are producing 96% of the

country’s national supply (See Table 23 below). This is because only one of the four

nursing schools, University of Sharjah School of Nursing, is a private institution.

Table 23: Contribution of nursing schools towards national supply according to sector Graduates N (%)

Affiliation Contribution

Ministry of Health Institute of Nursing 814 (44.3%) Public DOHMS in Dubai Government Institute of Nursing 192 (10.5%) Public Institute of Applied Technology 759 (41.3%) Public

96.1%

University of Sharjah School of Nursing 72 (3.9%) Private 3.9%

It is worth noting that as opposed to public medical schools, public nursing schools

allow admission for nationals and non-nationals. Table 24 shows that 46.2% of nurses

who graduated from the 3 branches of the MOH Institutes of Nursing (ION) were

nationals compared to 53.8% non-nationals. This may have contributed to the survival of

these institutes because without the non-national students, the number of those enrolled

and the number of graduates would have been much lower. In fact, the Institute of Nursing

(similar to the MOH ION) that was under the authority of DOHMS, Government of Dubai

only allowed admission to nationals and was forced to shut down in 2004 due to poor

admission.

Table 24: Comparison between number of national and non-national graduates from

MOH ION

Nationals Non-NationalsInstitute N (%) N (%) Total

ION Sharjah 1 (3.2%) 30 (96.8%) 31 ION RAK 25 (73.5%) 9 (26.5%) 34 ION Fujeirah 16 (61.5%) 10 (38.5%) 26 Total from three branches 42 (46.2%) 49 (53.8%) 91 FDON Annual Report, 2007

Since the MOH Institute of Nursing has three branches and the Institute of Applied

Technology has two branches, their detailed responses are detailed in Appendix XIX.


c) Understanding nurse education programs in UAE

i. UAE Nursing Education Programs

Given that the MOH ION was the major producer of nurse graduates in the UAE,

it may be useful to learn more about it. The ION currently has five branches located in

Abu Dhabi (1972), Sharjah (1987), Fujeirah (1992), Al-Ain (1993) and Ras Al-Khaimah

(2001) (MOH ION, 2007). The branch in Abu Dhabi was founded in 1972 after issuing a

presidential decree. It was one of the first schools of nursing in the Arab Gulf Region. The

initial one and a half year program aimed at preparing post-elementary students to be

assistant nurses. In 1976, the program was extended to three years and required students

who wanted to enroll in the program to have completed 9 years of school. At the time, the

program included many separate courses covering the different medical specializations. In

1982, the MOH collaborated with the American University of Beirut to set new standards

in the nursing education program by introducing the Basic Nursing Program which also

required enrollees to have completed 9 years of school education (MOH ION, 2007). In

1986, this Basic Program was replaced by a 3 year Diploma Program in Abu Dhabi

requiring enrollees to have completed secondary school. The ION institute has undergone

many changes which have affected its curricula and clinical training. One of these changes

is the newly introduced case-based process-oriented curriculum where teacher acts as a

facilitator of the teaching-learning process allowing students to develop problem solving

and analytical skills (El-Zubeir et al., 2006). Admission to the institute is open to both

nationals and non-nationals; however most students are non-nationals (El-Zubeir et al.,

2006). In 2005, Abu Dhabi and Al-Ain branches were embedded into the Abu Dhabi

General Authority for Health Services thus leaving the other three branches under the

authority of the MOH (MOH ION, 2007).

ii. Problems Related to Nursing Education

Programs in the UAE

– Diversity of Programs: The nursing profession naturally has to respond to radical

changes in the medical profession such as technological advances and ever-changing

healthcare needs (MOH ION, 2007). Adapting to these changes requires a


commitment to continuing education and the development of expertise in the theory

and practice of professional nursing (MOH ION, 2007). The UAE has witnessed

many demographics changes, changes in morbidity and mortality patterns, advances

in medical services and responses to complexities of health sector reforms (FDON,

2002). These changes had to go in parallel with changes in the nursing education

that were required to cope with the newly developed systems. Although several

nursing education programs have been created since the early 1970s (FDON 2002)

there is a great variation in these basic nursing programs (El-Haddad, 2006). Each of

these nursing institutes and colleges offers a diverse set of degrees which are

summarized in the following table.

Table 25: Degrees offered by the different nursing schools in UAE Institution Degree

– Assistant Nurse Program – Technical Nursing Program – Basic Nursing Program

MOH ION (formerly known as the school of nursing)

– Diploma nursing program – Assistant Nurse Program – Practical Nurse Program – Bridging Practical Nursing program

for Assistant Nurses – Registered Nurse Program

Directorate of Defense Medical Services (GHQ)

– Higher Diploma in Nursing – Diploma in General Nursing Program– Assistant Nurse Program – Nursing Aid Program

Dubai Department of Health, ION

– Post Basic Program in Maternal and Newborn Nursing

Higher Colleges of Technology – Higher Diploma in Nursing Program Sharjah University – The Bachelor of Science in Nursing

Program Source: FDON, 2002

The variation in these programs within the UAE may lead to multiple standards thus

adversely affecting the delivery of the nursing services (El-Haddad, 2006). In

September 1995, the EMR Advisory Panel on Nursing suggested that over the

period of 15 years, member states should combine all their nursing programs into

one standard 4-year Bachelor of Science program (WHO-EMRO, 1998 as cited in

El-Haddad, 2006). In 2002, and in support of these recommendations, the Secretary


General of the Scientific Association of Arab Nursing urged Arab countries to

develop Bachelors of Science in Nursing (BSN) programs in order to produce

qualified nurses capable of dealing with new technologies and changes in the health

care industry (Gulf News, 2002 as cited in El-Haddad, 2006). As a result, Emirati

nurses with Diplomas in nursing are now encouraged and supported by the UAE to

enroll in BSN bridging programs whether in the country or abroad.

– Lack of Educational Programs and Resources in Arabic: Having proper English

language skills is a requirement for joining any of the three MOH ION branches.

Although, this requirement has been criticized and accused of worsening the nursing

shortage. The undersecretary of the MOH, Dr. Shaker, said that solving the problem

of the nursing shortage will not be achieved by pushing aside this requirement

(Muslim, 2007). Applicants are not required to satisfy international English

language proficiency tests, instead, they have to pass a written and oral exam set by

the MOH. This is important because Continuing Education (CE) activities (medical

conferences and lectures) which are becoming mandatory for all UAE health

professionals are administered in English (Muslim, 2007). Shaker added that new

conditions would soon be required of applicants such as proper time management

abilities, decisiveness and computer proficiency (Muslim, 2007). Educational

programs also lack educational resources in Arabic (El-Haddad, 2006). Educational

resources such as evidence-based scientific medical and nursing books, journals and

research papers are not available in Arabic (El-Haddad, 2006). Even though the

official language in most health care institutions in UAE is English, nurses currently

employed in the UAE, particularly nationals, have poor command of the language

(El-Haddad, 2006). Therefore this is a significant problem given the critical

shortages in MOH facilities (Key Informant, MOH). The MOH currently needs

more than 1000 nurses for its hospitals and centers (Muslim, 2007).

9. Recruitment of Health Professionals in UAE

The public sector in the UAE mainly relies on private recruitment agencies for

assisting them in the recruitment process. Key informants reported that the private sector


does not rely as much on private recruitment agencies. Instead they often engaged in

recruitment trips whereby they actually send a recruitment group to some source countries

and conduct recruitment presentations. Key informants stated that in order to maintain the

standards of ethical recruitment, there is no active recruitment from African countries

which suffer from the greatest shortages of health professionals. However, African health

professionals who voluntarily come to the country are allowed to be employed.

Public hospitals or health care facilities under the authority of the MOH request

the help of recruitment agencies for recruiting international health care professionals. This

is because the MOH does not want to spend a lot of money on the recruitment process

especially when it comes to interviewing applicants. It costs the MOH much less to hire

recruitment agencies than to engage in recruitment trips like private hospitals. These

agencies make up for this decrease in costs by charging applicants for a fee for their

service. This switches the burden from the MOH to the applicants. During the process of

recruitment, a delegate from the MOH travels to the source country at the expense of the

recruitment agency in order to recruit health professionals.

a) Issues Related to Contracting Health Professionals

Health professionals seeking employment in the UAE have to get a license in order

to be able to practice in the country. This license is given to professionals if they meet

eligibility criteria and pass an exam administered by the different authorities (each

authority might have a different exam). According to key informants, re-licensure occurs

on an annual basis and therefore, the contract is renewed annually. There is no limit on the

number of years that workers can spend in the country and therefore the contract does not

have any time limitations. If physicians choose to practice for a limited time, they are

referred to a “Visiting Professors” and their contract is renewed every two years. The

renewal of the contract depends on re-licensure which in turn depends on completing a

certain number of Continuing Medical Education (CME) hours. Key informants reported

that a performance appraisal is conducted on an annual basis and the CME credit hours

accumulated by the health professional in question are assessed to evaluate whether or not

they meet requirements. In public institutions, if the required credit hours required are not

met, there is no immediate termination of the contract or license. In such cases, the


employee may receive a warning, a lower grade on his/her performance appraisal or a

penalty.

b) Data on Vacancies

Because several health authorities are present in UAE, and because little

coordination exists between these authorities, the exact number in vacancies in medical

and nursing professions is unknown. However, many vacancies are available in the MOH

facilities because it is expanding and building more facilities. Specifically, the MOH

reported 462 vacancies for nurses and midwives and 150 vacancies for physicians. These

numbers should be interpreted with caution since they only reflect the MOH. Another

example about vacancies comes from one of the main hospitals in Abu Dhabi, Tawam

hospital, which currently has approximately 200 physicians, nurses and midwives. Official

data on vacancies from other health authorities was not available.

c) Recruitment Agencies

Two main agencies were identified by key informants. These are RITCH and

Horizon. Both these agencies were contacted but Horizon Agency was the only one to

reply. The reply came as follows:

Since 2000, the agency has been recruiting nurses and paramedical staff to all

major hospitals in the MOH, DOHMS and the Dubai Police (ambulance

department/clinics). In 2004, 300 expatriate physicians, nurses and midwives were

recruited to the UAE. The agency identified several reasons behind why expatriates

emigrate to the UAE including good salaries and benefits, good working conditions,

international standards at the workplace, safety and stability, the availability of modern

amenities and the presence of a multi-cultural environment. Benefits package includes

world standard living arrangements, technical allowance, cost of living allowance, family

status and transportation allowance. The agency recruits health workers mainly from India

and the Philippines.

10. Turnover among UAE Health Professionals

High turnover rates exert both direct and indirect costs on health systems. Direct

costs include the expenses that will be spent on the advertisement and recruitment process.


As for indirect costs, they include expenses for termination, decreased productivity and

the effect of the decrease in the nursing staff on the quality of patient care (Alotaibi,

2007). Key informants reported high turnover rates in UAE health facilities. Reasons for

the high turnover include low salaries (particularly in MOH as compared to private sector)

and no salary increases, high cost of living, inability to pay the high cost of CME courses

and workshops, high workload and poor work environments, to name a few.

A survey on “Duty hours-Nurses working shifts in clinical settings” conducted in

December 2001 was administered to nurses in MOH facilities (FDON, 2001b). Results of

this survey showed that 87% of sampled nurses were not willing to work 12-hour shifts

because of stress, harmful effects on their physical well-being, quality of care and quality

of life at home. A total of 79% of sampled nurses indicated that an increase in their

mandatory working hours may affect their decision to remain employed in the facility. It

was stated more than 873 times that longer duty hours would have detrimental effects on

family and social life. In addition, it was stated that more than 439 times that long duty

hours affect the physical and mental well-being and more than 41 times that it adds to the

already stressful nature of the work (FDON, 2001b).

Many health workers in the UAE often view it as a transit country, a stepping

stone to countries like the US, Canada or European countries. Many health workers

choose to work in the UAE to gain experience needed to make them eligible for better

positions in more developed countries. Positions in more developed of the west not only

offer better salaries and benefits, but there is also the lure of attaining a foreign

nationality, such as US green card or citizenship in other countries; this is not possible in

UAE.

Some information was obtained on trends in recruitment and resignation in MOH

but not actual turnover rates. This data is presented in the tables below. As observed in

Table 26, recruitment in 2007 decreased as compared to 2006, yet at the same time,

resignations increased in 2007 as compared to 2006.


Table 26: Nurse Recruitment and Resignation in MOH facilities by district (2006)

Current Nurses Recruitment Resignations 2006 2007 2006 2007 2006 2007 Dubai 409 406 36 37 10 40 Sharjah 1,160 1,168 147 73 57 55 Ajman 307 315 23 23 6 9 UAQ 209 211 13 14 7 11 RAK 601 623 63 48 18 31 Fujeiira 415 420 71 22 8 18 FDON 14 16 4 1 1 0 Total 3,115 3,159 357 218 107 164

As detailed in Table 27, recruitment and resignation in 2007 was highest for

hospitals affiliated with the MOH as compared to PHC, school health and preventive

medicine.

Table 27: Nurse recruitment and resignation in MOH facilities by facility type (2007)

Facility Existing staff Recruitment Resignation Hospitals 2514 197 131 PHC 290 14 22 School Health 280 5 9 Preventive Medicine 59 1 2 Total 3143 217 164

Information on turnover from other health authorities was not found. However,

additional data on turnover will be reported under the section related to Tawam hospital.

11. Tawam Hospital Case Study

As a case study about the recruitment of health workers in hospitals in UAE,

Tawam hospital was selected. This hospital can provide some insight into how a typical

hospital in UAE recruits and retains its health workers. Below we briefly summarize the

context of Tawam hospital, its existing stock of health workers, vacancies and turnover, in

addition to its activities in staff retention.

Tawam hospital, a tertiary care facility in the city of Al Ain, is managed and

operated in partnership with Johns Hopkins since March 2006. This affiliation has helped

Tawam Hospital to benefit from the medical expertise of one of the top medical


institutions in the US (UAE Yearbook, 2007). John Hopkins Medicine will supervise the

management and operation of the hospital until the year 2016. It will also supervise the

building of the Middle East’s largest cancer treatment center by the year 2010: The

Tawam and Johns Hopkins Cancer Centre based at Al-Ain Hospital (UAE Yearbook,

2007).

Tawam Hospital started operating in 1979 with a capacity of 265 beds and was

managed at that time by the MOH. In 2001, the General Authority for Health Services

(GAHS) took over the management of the hospital. Today, Tawam hospital operates with

a capacity of more than 400 beds (SEHA, 2008). The unique status of Tawam hospital is

associated with its geographic proximity to the UAE University medical college. Sharing

knowledge and expertise between the university and the hospital has greatly helped both

interns and patients at the hospital.

a) Health workers in Tawam

Tawam hospital has a total of 462 physicians and 1282 nurses from 52

nationalities. National physicians comprise only 5.4% and national nurses are only 2.8%

of the entire staff body. A detailed list of the nationalities of physicians and nurses in

Tawam in enclosed in Appendix XX.

Table 28: Distribution of physicians and nurses in Tawam hospital by nationality

Physicians Nurses N % N %National 25 5.4% 36 2.8%Non-National 437 94.6% 1246 97.2%Total 462 100.0% 1282 100.0%

Tawam, as a teaching hospital, hosts 68 physician trainees (See Table 29), 17.6%

of them are interns and 82.4% are residents. Tawam hosts an additional 131 physicians in

rotation.


Table 29: Physician trainees and physicians in rotation at Tawam hospital

Physician Trainees N %UAE Interns 12 17.6%UAE Residents 56 82.4%Total trainees 68 100.0%Physicians in rotation 131

As shown in Table 30 below, turnover of medical and nursing staff decreased from

11.8% and 45.3% in 2004 to 29.7% and 26.8% in 2007. Tawam hospital has been

engaging in staff retention strategies to reduce the high turnover rates observed in 2004.

According to key informants in Tawam, the main incentives for health workers in the

hospital include continuing education opportunities and affiliation with Johns Hopkins;

specific strategies undertaken were not specified. However, the decrease on overall

turnover demonstrates the success of those strategies.

Table 30: Trends in recruitment and termination of medical and nursing staff in

Tawam hospital between 2004 and 2007

Medical Nursing Recruited Terminated Turnover Recruited Terminated Turnover 2004* 127 142 111.8 223 101 45.32005 143 48 33.6 262 79 30.22006 123 44 35.8 146 85 58.22007 128 38 29.7 205 55 26.8* GAHS Policy changes shows high turnover in year 2004

Table 31 details the type of medical employees terminated between 2007 and

2008. If we compare the number of terminations between January and June for 2007 and

2008, we find that the total number of terminated medical staff decreased from 21 in 2007

to 14 in 2008 indicating further the success of retention strategies adopted by Tawam

hospital.


Table 31: Medical Termination summary for 2007 and 2008

Special Grade

Sr. Consultant Consultant Specialist MO/ GP Total

2007 2008 2007 2008 2007 2008 2007 2008 2007 2008 2007 2008January - - - 1 - 1 1 0 1 1 2 3 February - - - - - - 1 0 2 1 3 1 March - - - - - - 1 1 - 1 1 2 April - - 1 1 1 1 - 2 - - 2 4 May - - - - 2 1 6 0 1 0 9 1 June - - 2 1 1 0 1 0 2 4 3 July - 1 - - - 1 0 August 2 1 - 4 1 8 0 September - - - - 1 1 0 October - 2 1 3 0 November - - - - - 0 0 December - 1 - 1 1 3 0 Total 2 0 8 3 4 3 15 3 8 5 37 14

Reasons for staff termination are summarized in Table 32 below. The most

common reason for termination in 2006 was resignation for better opportunity in another

health organization. Tawam was successfully able to decrease the number of resignations

for this reason in 2007 and 2008. The second most common reason for termination 2006

was in fact, termination. The decrease in number of terminations for this reason decreased

in 2007 and decreased even further in 2008. Two problematic reasons for termination

appear to be end of contract and resignation without eligibility for re-hire. But these

reasons are out of the control of the hospital and are in fact caused by the staff themselves.

Table 32: Reason for termination of medical and nursing staff from 2006 to 2008

Reason for termination 2006 2007 2008Resignation (eligible for rehire at different organization) 46 24 19Termination 19 14 1End of contract 8 1 7Resignation-not eligible for rehire 7 12 6Deceased 3 0 1Absconded 0 10 6Transferred 0 4 0Total 83 65 40


Tawam reported a total of 197 vacancies for nurses (178 technical and 19

administrative) and 76 physicians (45 consultants, 16 specialists and 15 MO) (See Table

33). The total number of vacancies as reported by Tawam is 273.

Table 33: Number of vacancies for physicians and nurses in Tawam

Type NumberPhysicians Vacancies Consultants 45 Specialists 16 MO 15 Total physician vacancies 76Nurse Vacancies Technical 178 Administrative 19 Total nurse vacancies 197All vacancies 273

b) Staff satisfaction survey

A staff satisfaction survey was conducted in Tawam hospital. All hospital staff

was included in this survey which was conduced by International Best Practices (IBP),

Australia. The Chief Nursing Officer in Tawam provided us with the outcome of the

survey which is detailed in the table below.

Table 34: Issues identified by staff satisfaction survey (Matarelli, 2008)

Question Survey outcome Reasons why they believe that Tawam Hospital is a 'truly great place to work'

Pay 13% Improvement 10% Service to Clients 9% The People 8% Benefits + Incentives 7%

Barriers that are stopping Tawam Hospital from becoming a 'truly great place to work'

Lack of Fairness 18% Job Security 12% Upper Management 11% Benefits + incentives 10% Lack of Pay 10%

Identify the 3 most important things they expect from Tawam Hospital

Salary 51% (40% satisfied) Allowances and Benefits 45% (40% satisfied) Fairness 26% (40% satisfied) Education 23% (52% satisfied) Support 14% (46% satisfied)


Question Survey outcome Identify the reason they were initially attracted to work in Tawam Hospital

Money – The Pay 31% Entitlements 17% Money – Good Pay 16% Location 15% Experience – Development 14%

Identify the types of issues that might affect any decision to stay working in Tawam Hospital in the future

Money – The Pay 31% Experience + Development 23% Influence of Family and Friends 19% Entitlements 14% Colleagues 14%

Identify the types of issues that might affect any decision to leave Tawam Hospital in the future

Better Pay Elsewhere 33% Lack of Fairness 22% Lack of Entitlements 17% Inadequate Accommodation 13% Family Influences 13%

Identify the things (if any) that have IMPROVED over the last year in Tawam Hospital

Facilities 24% Training + Education 18% Pay 17% Quality of Service 14% Systems + Procedures 11%

Identify the things (if any) that have DETERIORATED over the last year in Tawam Hospital.

Benefits + Incentives 20% Quality of Service 13% Pay 11% Systems + Procedures 9% Staffing Levels 8%

12. Training and Continuing Education of Health Professionals

Training and education of health professionals has gained importance throughout

the years and it is currently being linked to the re-licensure of health professionals. The

developments in the healthcare infrastructure, the recruitment and training of healthcare

professionals necessitated training and continuing education (MOH Website). The UAE

council for medical specialists is being developed in order to assist in upgrading the

training of UAE medical personnel. In addition, training programs are being conducted in

combination with international universities (UAE Yearbook, 2007). Each of the health

authorities in UAE has different rules and regulations regarding training and continuing

education for health workers employed within their facilities. They are detailed below.


a) MOH

The MOH trains health professionals employed within its facilities. The ministry is

involved in hosting, participating in and attending international and regional scientific

conferences and workshops. This helps professionals gain international experience and

remain up to date when it comes to health care services and new medical technology

(Canadian Chamber of Commerce Website, 2005). The MOH requires a minimum of 50

credit hours on an annual basis. The MOH and the department of Continuing Education

(CE) pays for CME activities if the event is sponsored by the MOH, otherwise nurses have

to pay a registration fee. According to key informants, the priority for attending CME

conferences is usually for nationals. Fees for such conference may cost as much as

1000US$ for a workshop or a conference lasting 2-3 days.

b) HAAD

The Abu Dhabi Health Authority established the Abu Dhabi Continuing Medical

Education Unit to assist and support physicians and other health professionals within the

Emirate of Abu Dhabi in their continuing professional development through organizing

CME events. Another reason behind creating this unit was to promote cooperation

between hospitals in the Emirate of Abu Dhabi. Information communicated to health

professional informs them about state-of-the-art medical practices and potential for

developing new skills (AD CME, 2008). In addition, the unit informs professionals about

changes that have recently occurred in medical practices as a result of research and

developments at major universities around the world. Similarly to the MOH, the HAAD

requires a minimum of 50 CME hours on an annual basis.

The Abu Dhabi Continuing Medical Education Unit focuses on promoting CME in

the following institutions: Central Hospital, Mafraq Hospital, Shaikh Khalifa Medical

City, Al Ain Hospital, Tawam Hospital, Al Rahba Hospital and the Western Region. In

addition to promoting cooperation between these hospitals, CME aims at allowing patients

to benefit fully from the services available before having to look elsewhere or even

abroad. It also encourages the dissemination of information such as services provided in

these hospitals, expertise available, the presence of visiting professors or doctors coming

from abroad, availability of new equipments or investigations, and new techniques being

performed. The CME unit is responsible for disseminating this information by fax, email


and the internet. In addition, the unit lists all CME Time Tables of all hospitals and

national and international conferences on the website. Physicians from all hospitals are

encouraged to attend the CME activity of their specialty. The unit also aims to make CME

compulsory for all personnel preferably through participating in events occurring in Abu

Dhabi. In addition, the unit aims at inviting speakers from the rest of the Emirates and

abroad to run lectures and workshops or even from outside the UAE via latest

technologies such as satellite and internet broadcasting. The unit also helps in organizing

conferences, meetings and workshops in Abu Dhabi Emirate through the provision of

equipment, finding sponsors, finding venues and advertising the event. In addition, the

unit sets learning objectives, course syllabi and certificates of attendance and also

oversees evaluation and feedback during the event. The unit sometimes videotapes the

event for personnel who are unable to attend. The unit is involved in improving the

training of health personnel in addition to providing advice and help regarding research

projects in conjunction with the Emirates Research Center at Mafraq Hospital (AD CME,

2008).

c) DOHMS

The Dubai health authority is starting its own requirements for CME that are not

linked to or affected by MOH and HAAD standards (AME Info, December 13, 2006).

Irrespective whether national or expatriate, CME is provided by the CME department in

DOHMS. Physicians can attend unlimited numbers of conferences and courses within the

country. However, key informants reported that DOHMS sponsors only 1 international

conference annually.

d) The Army Directorate of Medical Services

The Army Directorate of Medical Services (DMS) has a CME program which

offers full scholarships for short term and long term education and training opportunities

to health personnel. These personnel are from the different domains of the health

profession and they include local physicians, nurses, technicians and administrators, all in

an effort to nationalize the workforce (Canadian Chamber of Commerce Website, 2005).

This authority does not have an official “International Doctors Visit Program” but it

contracts with some recognized institutions from the US, UK and Germany to provide


services. According to the authority, offers by physicians to provide such services are

welcome (Canadian Chamber of Commerce Website, 2005).

Key informants disclosed information about a plan to send national doctors abroad

to train indifferent specialties; this is an ongoing program that has been planned for years.

These programs are fully funded and the physicians come back to practice in the UAE in a

position that is reserved for them. Also during their education they receive an ongoing

salary. Physicians are followed up by program directors to make sure that training

complements their needs.

13. Licensure and Continuing Education

Government licensure is mandatory for physicians and nurses to be able to practice

in a health organization affiliated with any of the health authorities in UAE. Obtaining

licensure involves conducting an interview after submitting an application, sitting for an

exam (questions include areas of nursing, medicine, surgery, maternity and pediatrics) for

which the passing grade is 50%. The exam can be taken up to 3 times.

Healthcare professionals in public facilities are often sponsored when pursuing

continued education (higher studies). However, they are required to work at the health

organization that sponsored their education for a duration that is equal to the time spent in

completing their education.

According to key informants, health professionals who practice in the private

sector renew their license on annual basis. Continuing education is a pre-requisite for

renewing a license. If nationals fail in obtaining a license for any given reason, the

government is forced to train the health workers within hospitals for a period of time to

provide them with experience and better opportunity at passing the exam and obtaining

licensure. This is also applicable for expatriate professionals (physicians) who sometimes

train within hospitals without financial remuneration for a period of time after which they

can apply for licensure. However, there is a certain limit on the number of these

expatriates allowed to engage in this process. Licensing is based on certain standards, but

the standards are flexible since it pertains to health workers coming from different

countries implying differences in educational background and culture.


14. Retention of Health Workers in UAE

Our findings point out to the lack of a formal and comprehensive retention strategy

for retaining health workers in UAE. However, some small scale attempts have been made

at the organizational level and some action has been taken in some health authorities.

One of the major challenges facing health organizations in UAE is high turnover

of health personnel. This is partly due to the lack of retention strategies and lack of

incentives for national health workers. Key informants stated that salaries and benefits

used to be more attractive than they currently are and foreign health workers used to earn

much more than they do today. Such salaries and benefits have become less which is a

dis-incentive for health workers to remain employed. As mentioned earlier, foreign health

workers, particularly nurses come to UAE seeking to gain experience needed to make

them eligible for positions in North America or Europe. According to key informants,

during the early 2000’s, the climax of the global nursing shortage in UAE, Western

Countries sent representatives to the UAE in an effort to recruit experienced foreign-

trained nurses. Western countries attract foreign nurses for many reasons. One of the

major reasons is higher salary and better benefits than those provided to these nurses in

the UAE. Another reason is the stability of those countries and the lure of immigration and

citizenship which allows them to also bring their families. This comes to show that

retaining the health workforce, whether national or non-national, is imperative if UAE is

to decrease the current shortages. Concurrently, there is a need to also encourage nationals

to enter the medical and nursing field to decrease the shortage in national health workers.

One key informant suggested creating a national campaign which involves visiting

schools and addressing students and teaching them about the importance of health

professionals, specifically nurses, and their roles in the community. In light of this,

financial incentives can play a major role in attracting nationals and retaining non-

nationals. For instance, salaries received by national nurses (even though they are higher

than the salaries of non nationals) are low as compared to other professions. One should

also consider the working conditions in the health field. In fact, nursing is not a well-

respected profession in Arab countries specifically because of the intimate physical nature

it involves (Marrone, 2004 as cited in El-Haddad, 2006). This applies to the UAE as well

(El-Haddad, 2006) where the society views nursing as an unattractive profession. Nurses

are sometimes viewed as inferior members of the healthcare team and are given fewer


financial incentives as compared to physicians and other health professionals (El-Zubeir et

al., 2006). However, one key informant mentioned that nationals are willing to overcome

the image of nursing, the hard work it involves and the poor working conditions, if their

efforts are rewarded in the form of better remuneration. This also applies to non-nationals.

Although the salaries they receive in UAE are higher than in their home countries, they

are still lower than other professions and also much lower than they used to be. Given the

higher living expenses in the UAE, financial compensation poses serious concerns to both

nationals and non-nationals. Therefore, financial incentives can play an important and

significant role when considering retaining the already existing staff. This is further

supported by Younies and colleagues (2007) who stated that financial incentives attract all

kinds of health workers in both the public and private sector and across the different

nationalities. In fact, Younies et al. (2007) identified both financial and non-financial

incentives that attract and motivate health workers. The three most desirable material

rewards and recognition schemes were financial rewards, paid vacations and health

insurance. The most favorable non-material incentives included linking pay to

performance, training and educational opportunities, opportunities to use new technology,

flexibility of working hours and organizational power. Female health workers were more

concerned with incentives such as health insurance and the flexibility in working hours

whereas male health workers were more concerned with organizational power. The desire

for power and autonomy was generally more common among Arabs and the Arabic

speaking population. Physicians were found to be more interested in receiving training

and education and less interested in using new technologies or gaining more flexibility.

They were concerned with linking performance to rewards. When creating a system of

reward and recognition, it is necessary to consider the diversity of the workforce

especially in a multi-cultural society like the UAE. The UAE health workforce was found

to prefer financial rewards probably because of the continuous economic development and

the increasing inflation rates that occurred in the country.

In regards to the nursing profession, the Federal Department of Nursing (2001),

proposed many recommendations to improve the conditions of nurses working in UAE

and specifically in MOH facilities. These recommendations were related to nurse positions

and staffing levels, salary scale, contractual and other benefits, shift and overtime pay,

non-nursing duties, status of nursing within the healthcare system, staff development and


shared accommodations. They were also related to recruitment, appointment, transfer,

promotion and exit of nurses. Today, and after 7 years of issuing the report, key

informants stated that nurses are still facing the same problems in these areas. This further

proves the need to create a national health workforce plan in the UAE, develop a national

strategy for recruitment and retention, ensure better collaboration between health

authorities and engaging the educational sector and improve the medical and nursing

education programs in UAE.

a) Retention Strategies for MOH Facilities

As a result of the critical shortage in the nursing workforce and its detrimental

effects on patient safety, the Federal Department of Nursing (FDON) formed an urgent

task force to address the issue. After situational analysis, literature reviews and surveys,

the taskforce collected data on nurse resignation, nurse job satisfaction, sick and

emergency leave patterns, shared accommodations and the daily reality of nurses. The task

force reviewed potential consequences and implications of the current situation (FDON,

2001a). In addition, recommendations and activities to effectively address the critical

situation were proposed by the task force. The results of the investigation showed an

increase in the number of resignations. Findings also showed that 60% of nurses working

in specialized areas, such as primary health care and intensive care, stated that the main

reason for leaving was because of better opportunities (FDON, 2001a). Findings also

showed that 75% of the sampled nurses indicated low or very low job satisfaction rates.

The main reason for dissatisfaction was low salaries followed by the lack of promotion

opportunities. The absence of medical coverage, lack of recognition and poor housing

were also factors affecting nurse satisfaction (FDON, 2001a). The daily reality of nurses

was not found to be any better. Non-nursing duties were taking the nurse away from direct

patient care. Moreover, satisfaction with co-workers was poor, nurses reported inequity in

working hours and cited lack of nursing management autonomy (FDON, 2001a).

After analyzing the results, the department characterized the situation as serious

and suggested immediate action to prevent deterioration in quality of care, nurse-patient

distrust and even scaling down or closing vital types of services (FDON, 2001a). As a


result, several recommendations were suggested, ten of which were considered as urgent.

These recommendations include (FDON, 2001a):

– Nurse Positions and Staffing Levels: It is necessary to separate nursing positions

from other technicians, ensure advancements and adequate staffing in MOH

facilities.

– Salary Scale: Review salary scales to reflect the cost of living in UAE in order to

retain current nurses and attract nurses for recruitment.

– Contractual and Other Benefits: Review and improve the contractual status of all

nurses of merit who were appointed on the Inclusive Contract.

– Health Care: It is necessary to provide free health care to nurses and their

immediate family members through a free annual medical card. In addition, it is

important to investigate the provision of a staff clinic at the major health care

facilities.

– Shift and Overtime Pay: Initiate shift differential and overtime pay.

– Shared Accommodation: Improve and standardize shared accommodation

benefits, conditions and rules across facilities specifically through allowing each

nurse her/his own room while paying attention to cultural differences of nurses

sharing apartments.

– Recruitment, Appointment, Transfer, Promotion & Exit: Optimize recruitment

and appointment process (including tracking and auditing of progress), simplify the

exit process for nurses wanting to leave legally, broaden special grade nurse

recruitment criteria in order to recruit nurses from different required specialties,

support the appointment of talented nurse professionals to be role models and

support national initiatives.

– Non-Nursing Duties: Free nurses from non-nursing duties through providing

auxiliary staff like clerks.

– Status of Nursing within the Health Care System: Enhance management status of

nurse executives within districts and facilities.

– Staff Development: Enhance quality of staff development efforts at MOH, district

and facility level through designating a budget, allocating skilled educators and

allocating material resources.


b) Strategies to Remedy Shortage of Nurses

Through our literature search and data collection in UAE, we were able to

document some strategies to remedy the nursing shortage. It is worth noting, however, that

similar documentation for physicians was not found.

i. Strategies to Remedy Overall Nurse Shortage

In addition to the above listed retention strategies, detailed below are some of the

strategies proposed to remedy the overall nursing shortage in UAE. The strategies listed

below have not necessarily been implemented and are a combination of recommendations

from key informants and the literature.

– Allowing non-nationals to enroll in MOH ION (MOH ION, 2007)

– Allowing nurses on visit visas to take the licensure exams required by MOH and

apply for nursing jobs in the UAE

– Decreasing mandatory years of experience required to be eligible to work in the

public sector to two years (Zain & Libo, 2008)

– Increasing the frequency of licensing tests to increase the pool of applicants and

decrease the shortage in hospitals and private medical centers.

– Decreasing waiting time from licensure to practice; applicants who passed licensure

test were previously forced to wait for 4 months before being able to practice. This

policy has been abolished (Nazzal, 2007).

– Encouraging private universities to invest in diverse nursing and medical curricula

– Providing employment opportunities for nationals in the public sector after

receiving numerous complains from graduates about the lack of job opportunities

and competition for these positions with expatriates (AME Info, June 7, 2008)

ii. Strategies to Remedy Shortage of National

Nurses

Some strategies to remedy the shortage of national nurses in UAE are detailed

below.

– Extra Benefits: According to key informants, UAE nationals have more benefits

aimed at encouraging them to seek education in medicine and nursing. By law,

national UAE nurses receive better salaries and benefits than expatriates. Even


before graduating, national nursing students who study at the MOH Institutes of

Nursing receive a monthly allowance from the ministry. Since these benefits were

still not enough to encourage nationals to enter the profession, nursing salaries are

now under review (UAE Yearbook, 2007).

– Establishing the Emirates Nursing Association in 2001 in order to support UAE

national nurses (El-Haddad, 2006)

– In 1992, the MOH established the Federal Department of Nursing by a ministerial

decree to be able to better manage the delivery of nursing services in the country

(El-Haddad, 2006). The FDON considers the management of human resources as

complex and multi dimensional (FDON, 2001b). It involves creating a relevant

staffing model through the optimization of recruitment, appointment, retention,

promotion and exit processes (FDON, 2001b) which can be reached more easily

when quality skills and work well done is awarded through benefits and incentives.

This department has been trying to improve the conditions of nurses.

– Launching the first nursing journal by the General Authority for the development of

Health services (GAHS) (UAE Yearbook, 2007) in an effort to give more

importance and weight to the nursing profession.

– Role of National Nursing and Midwifery Advisory Committee (NNMAC): In 2006,

the 59th World Health Assembly adopted a resolution to strengthen nursing and

midwifery through involving these health professionals in the development that the

health systems all over the world have been witnessing. Leaders and senior

executives from the different public and private sectors including government,

police, armed forces, nursing education institutions, and professional associations

(Emirati Nursing Association) worked together to develop a proposal which

identified the critical steps to strengthen nursing and midwifery services in the UAE.

This committee, known as the National Nursing and Midwifery Advisory

Committee (NNMAC) developed several objectives. The objectives include setting

a vision statement for nursing and midwifery in the UAE, recommend strategic

directions to decision makers and foster the quality of nursing and midwifery care

with the help of relevant authorities. The committee also aimed at setting standards

in line with international standards for the practice, education and professional

conduct of nursing and midwifery practice in the UAE (FDON, 2007b).


– Initiatives by private institutions: Welcare World Health Systems signed a deal to

establish the first “Emiratisation Training Program” in the UAE’s healthcare sector.

This was the first private establishment to do such a program where UAE nationals

will be recruited to work in the system’s hospital clinics and centers (AME Info,

September 11, 2007).

15. Self sufficiency in UAE

While medical schools and nursing schools in the UAE are not producing enough

graduates, specifically national graduates, to meet market demand, this is not the only

reason why UAE is highly dependant on expatriates. Key stakeholders in UAE identified

many other reasons why UAE is not self-sufficient and will probably never be self-

sufficient when it comes to producing health workers in sufficient numbers.

Firstly, the country has witnessed a great increase in the population in a relatively

short period of time. UAE nationals represent a little more than a quarter of the population

while the rest of the population is composed of foreigners and expatriates. Therefore, it is

nearly impossible for this small proportion to produce enough health professionals for the

whole population. It is also noteworthy to mention that a quarter of the population is under

the age of 15 which further exacerbates the problem (Wilkins, 2001).

Second, health facilities in UAE are consistently obtaining newer technologies in

health care, therefore it is necessary to recruit people who know how to operate this

equipment as the country may lack the capacity to train its nationals for this task.

Thirdly, an insufficient number of nationals enter the medical and nursing fields.

In 1998, 72% of UAE University graduates held an art degree indicating that national

students are not inclined towards a career in the medical or nursing field (Wilkins, 2001).

Moreover, nationals are often not proficient in English language and sometimes lack

computer skills that may allow them to enter medical and nursing schools. This also

hinders nationals from the health care field which is highly dependant on proficiency in

English and demands good computer skills.

Perhaps, one of the most significant reasons behind why the UAE highly relies on

an expatriate health workforce is the lack of important specialties in the medical field.

Thirty seven private and public special needs centers are present in UAE. However, they


are not enough to meet the needs of the population (AME Info, January 21, 2007). This

problem is exacerbated by the lack of specialized personnel thus causing people to miss

out on necessary services (AME Info, January 21, 2007). Key informants reported that

specialties are limited but are in high demand in UAE and include endocrinology,

genetics, surgery and liver and pancreatic specialties. Shortages also exist in the fields of

gynecology, pediatrics, and internal medicine among others (AME Info, April 8, 2007).

According to key informants, shortages are mainly due to the lack of school programs for

these particular specialties, especially for midwifery, pediatrics, mental health and

neonatal medicine. However some action has been taken to increase the number of

specialists thus decreasing the shortage in critically needed specialties. After the

establishment of trauma centers in Dubai, there was a need for pediatric skills which the

nursing staff lacked. Therefore, an in-house training was performed and it aimed at

providing 50 to 100 nurses with the skills needed for the delivery of proper midwifery and

neonatal nursing in order to meet required standards and increase the quality of health care

delivery. In Dubai, nurses who are specialized in certain fields are sometimes to train

locally employed nurses, mainly in neonatal and screening services. A third strategy taken

by the DOHMS was to sponsor physician education (specialization) abroad but only if

these physicians are willing to work in the DOHMS facilities without monetary

compensation for the same number of years they spent attaining their degree upon

returning to UAE. Data obtained from the DOHMS showed that four administrative

personnel were sponsored to study Human Resources Management overseas. Furthermore,

a total of 53 medical personnel were sponsored to study overseas; the fields of specialty

were ophthalmology, psychiatry, neurology, pediatrics, cardiology, obstetrics &

gynecology, allergy & immunology, endocrinology, cardiology, internal medicine,

emergency medicine, respiratory, physical medicine & rehabilitation, trauma, general

surgery, radiology and oncology. The 53 medical personnel were sponsored to study in

Canada (N=19), Germany (N=15), USA (N=8), UK (N=4), Sweden (N=3), Ireland (N=1),

Italy (N=1), Jordan (N=1) and KSA (N=1). Further detailed in the table below is the

annual number of graduates who were sponsored to study abroad between the years 2004

and 2008.


Table 35: DOHMS Continuing Education Department, Scholarship and Higher

Education Department

Year Number of sponsored graduates 2004 16 2005 17 2006 8 2007 7 2008 4 Total 52 DOHMS, 2008

16. Bilateral Agreements

Bilateral agreements allow for the recognition of the qualifications of health

professionals between governments thus making it easier for health professionals to move

between countries having such agreements and maintaining a position in their same field

of work (Stilwell et al., 2004). There are no bilateral agreements between the UAE and

other countries when it comes to health workers. This is because bilateral agreements

necessitate agreements between two governments. According to key informants, the UAE

is currently recruiting health professionals on an individual basis. This enhances

competition since individuals will be chosen according to their skills and qualifications

and it also gives more power to the country over the individual. However, there are mutual

agreements between UAE and other countries for services which involve sharing

experience, knowledge, staffing and educational information. These agreements are with

many countries including the US, Canada, UK, Singapore, Germany and Australia

depending on the health needs of the UAE (ex. Harvard University - Medicine). These

agreements pertain to exchange of expertise in various areas and do not include medical

staff exchange. Collaboration also exists between GCC states and UAE. Nurses coming

from a GCC state are exempt from registration and licensure exams as a result of these

agreements.


17. Challenges, Successes and Recommendations in UAE

a) Challenges facing UAE

The major HRH challenges in the UAE include:

i. Lack of accurate data

As detailed in the above sections, there is a lack of accurate data on health

workforce in UAE. Health authorities have different reporting systems and as a result,

differences in reported numbers were observed. The lack of a unified database translates

into limited ability to assess available stock, production, gaps and needs.

ii. Absence of a health workforce strategy

Findings show that there is no national health workforce strategy to assist planners

in mapping out the health workforce requirements in UAE. This translates into poor

ability of the government and the individual health authorities to estimate actual supply,

deduce shortages and haps, and forecast future demand.

iii. Limited coordination between authorities

The lack of coordination between health authorities, i.e. the MOH, HAAD,

DOHMS, Health Services for the Ministry of Internal Affairs, Health Services for Armed

Forces and the Private sector which has created challenges. One of the outcomes of the

lack of coordination is the lack of a unified database on the numbers and types of health

workers in UAE. In fact, each health authority reported different and non-matching figures

on number and type of health workers affiliated with their organizations. Furthermore, key

informants reported that there is no collaboration with the Ministry of Education in trying

to determine national production. Some key informants stated that the health authorities

fear that unifying standards of practice may eliminate their independence. But it should be

noted that the lack of unification in standards among authorities has created many

challenges in retaining health workers. For instance, due to low salaries in MOH facilities,

many health workers opted to apply to health facilities affiliated with other authorities

such as HAAD or DOHMS since their offer much higher salaries. This dramatically

increased turnover at MOH facilities and resulted in much criticism by FDON (AME Info,

June 27, 2008).


iv. Recruitment and retention challenges for both nationals

and expatriates including high turnover rate

UAE is facing some challenges in recruiting a sufficient number of health workers

and is also struggling with poor retention and high turnover. Recruitment of health

workers in UAE is insufficient, particularly due to the poor supply of national health

workers. In spite of increasing recruitment of foreign-trained health workers, the existing

stock is not sufficient to meet the ever rising demand. Despite all efforts to retain health

workers, turnover remains high since many health professionals view UAE as a transit

country to other countries in North America or Europe. According to key informants,

countries like the US, UK and Canada are engaging in active recruitment of health

workers from UAE since those workers have attained work experience in settings

characterized by advanced infrastructure and medical technology. Such countries are

mostly recruiting nurses and using incentives such as family sponsorship and visas. These

countries engaged in active recruitment of nurses in 2002 at the peak of the nursing

shortage in UAE (FDON, 2001a).

v. No self sufficiency

Perhaps the biggest challenge facing UAE is its inability to ever become self-

sufficient. This is due to a multitude of reasons, mainly low proportion of nationals to

expatriates, poor entry into medical and nursing schools and active recruitment of non-

nationals to UAE. But, according to some key informants, the situation is even further

exacerbated by the lack of a national health workforce strategy.

vi. High number of expatriates

Most health workers in UAE are non-nationals (over 80% of all health workers)

which creates high competition for available positions. UAE nationals who work in the

health domain are involved in administrative jobs and positions (EMRO, 2006). Still,

nationals often complain that expatriates are flooding the labor market and many positions

that should have been primarily available for nationals are being offered to expatriates.

The impact of workforce diversity on the health sector is also a challenge in UAE. In fact,

healthcare settings in the UAE lack culturally congruent care due to the cultural diversity

of its health providers, particularly physicians and nurses (Winslow & Honein, 2007).


Many health professionals in the UAE may not have any understanding of culturally based

care. When this problem intersects with language barriers, client dissatisfaction,

misdiagnosis and poor health outcomes result (Winslow & Honein, 2007). This diversity

has also created a need to constantly have translators and interpreters on staff in healthcare

facilities to help patients and health care providers communicate.

b) Successes and Opportunities in UAE

Informants in the UAE all agreed on the fact that the new insurance plan and the

advances in facilities and medical technologies are two factors which are retaining

professionals in UAE health Facilities. The creating of the FDON has also helped better

retain nurses and also improve selection of best available health professionals and

facilitate the registration and licensing process. The presence of the FDON offers a unique

opportunity to improve nurse retention UAE. Moreover, investment in CME for both

national and non-nationals by all health authorities has also helped better retain the

existing health workforce.

Many key informants reported that splitting health care delivery arm from the

regulatory, funding and strategic planning arm of health authorities has improved

competition. One example of improve competition is the creation of the DOHMS. The

DOHMS will lay down workforce requirements for the health care sector of Dubai as a

whole in public, private and free zone areas (Eye of Dubai, 2008). Within the authority,

there will be different interlinked components which will check available services,

required services, and optimal number of health workers needed (Eye of Dubai, 2008).

This will provide DOHMS with the ability to independently manage the wider health

sector thus removing any conflict of interest which results when the government both

regulates and delivers health services. DOHMS will also be responsible for its own health

service planning and delivery and will consequently have a better opportunity to operate

its facilities with more efficiently. This will also create equal opportunities between the

public and the private sector (Eye of Dubai, 2008).

In addition to the above, in 2005, HRH took a major part of the government’s 3

year strategic plan. Moreover, the MOH strategic plan for the years 2008-2010

represented, through some of the themes it contained, the importance of developing


human resources specifically those working in MOH facilities. This strategic plan focuses

mostly on national health workers in health organizations and methods to train and

develop their skills.

An opportunity to further improve the health workforce is through the recently

established Health Council which will coordinate between federal and local bodies in

UAE, including the private sector. This decision by Sheikh Mohammed Bin Rashed Al

Maktoum, Vice President and prime Minister of UAE, came as a first step to ensure the

integration and improvement in health service delivery. The goals of this council are to

upgrade health services through the consolidation of health services and the adoption of

global standards and practices which will be applied by all the health authorities. The

council will also support the role of the private sector to advance the state of medical

health services and adapt to the growing needs of the expanding UAE population. This

newly established Health Council can also play a role in addressing HRH challenges in

UAE.

c) Recommendations for UAE

Some of the major recommendations for addressing HRH challenges in the UAE

are outlined below. Recommendations focus on HRH planning, management and

education.

i. Health workforce plan for UAE

A national health workforce plan in UAE should include production, needs and

gaps. UAE currently has an opportunity to initiate such a strategy in light of the recent

Country Cooperation Strategy (CCS) with the WHO. Several areas of collaboration in all

aspects of health management, including HRH was proposed in the CCS document. One

of the areas of cooperation included improving human resource development functions in

the MOH planning department with particular emphasis on nursing care and public health

professionals (EMRO, 2006). The presence of the FDON is another opportunity the UAE

can take advantage of for creating a national strategy for nurses and midwives (FDON,

2002). The national strategy should also take into consideration the means to increase the

entry of nationals into the profession. If the UAE is to achieve its goal of “Emiritization,”

there is a need to encourage the entry of nationals into the health field. In this context,


there is also a role to be played by the Ministry of Education and medical and nursing

schools. Scholarships and bursaries to aid students, particularly in private institutions, can

increase admission rates.

ii. Strategy for recruitment and retention

Our findings show that UAE lacks a national health workforce retention strategy,

not even within individual heath authorities. While some health facilities, such as Tawam

hospital, have adopted some in-house retention strategies for their employees, the impact

of these strategies would be small given the extent of the shortage and high turnover rates

in UAE. Therefore, there is an urgent need for a national health workforce retention

strategy to better manage the existing workforce and reduce high turnover rates. Such

retention strategies should also include foreign-trained health workers. Some key

informants reported that improving incentives, both financial and non-financial, can

decrease the impact of these burdens. Financial incentives can include competitive salaries

and benefits. Furthermore, key informants also reported that benefits packages are not as

attractive as they used to be which has also discouraged some health workers. It should be

noted that developing a national health workforce recruitment and retention strategy

would not be possible without the collaboration of all health authorities. It is therefore

essential that health authorities collaborate on this issue and that each provides its insight

into potential methods to improve health workforce management and reduce turnover.

iii. Better collaboration between health authorities

Key informants reported that there is no effective collaboration and little

communication between heath authorities in UAE. This has resulted in multiple standards

of training and practice among health facilities. Collaboration should also include the

private sector which has become a key player in the UAE health system. Some key

informants cited a fear of collaboration and standardization since they may reduce the

independence of each health authority. However, if health authorities are to collaborate on

anything, it should be on a centralized health workforce database so that better estimates

can be made and more accurate prediction of future demand and shortages can be

deduced. The newly established Health Council also has an opportune role to play in this

effort.


iv. Engage educational sector and improve medical and

nursing education programs in UAE

There is also a need to engage the health sector and improve educational programs

in UAE. Although much has been done to create solid programs for future health

professionals, there are still some areas of weakness particularly within the nursing

educational programs. Key informants reported that the role of the Ministry of Education

in this effort has been invisible. To this end, schools can strive to develop more advanced

degree programs (executive or masters degrees) to create incentives for students and help

students map out a career path. Creating educational programs for health profession,

particularly specialized areas, may create interest among the national population and

encourage entry into the profession. Moreover, improving standards and applying for

accreditation by international associations can also make the profession seem more

attractive to prospective students.

B. Case of Lebanon – Source Country

1. Context of Lebanon

a) Geography and Demography

Lebanon is a small country located east of the Mediterranean Sea. It spreads over

10,452 squared kilometers and is bordered on the North and East by the Syrian Arab

Republic, the Occupied Palestinian Territories to the South, and the Mediterranean Sea to

the West (Mohammad-Ali et al. 2005; CCS 2004). The country is divided into six

administrative regions, they are: Beirut, Mount Lebanon, North, South, Nabatiyeh, and

Bekaa (CCS 2004).

As per a government survey conducted in 1997, Lebanon has a population of 4

million; however, the WHO estimates that the population in Lebanon is 3.577 million

(WHO 2007), 80% of which reside in urban areas (CAS 1997 as cited in CCS 2004, and

Mohammad-Ali et al. 2005). The annual population growth rate is estimated at 1.2%, 87%

of which is in urban areas (See Table 36) (WHO 2007). The dependency ratio is close to

60%, 6.2% of the population is under 15 years of age, wile 10.2% is over 60 indicating

that the Lebanese population is fairly young (See Table 36).


Lebanon’s health status indicators are considered poor compared to Global

averages, but it fares better than many other countries in the region. Still, some regional

discrepancies exist whereby rural areas have poor health status indicators compared to

urban areas (CCS 2004). The country’s average life expectancy is estimated at 70 (68 for

males and 72 for females), Under-5 Mortality is estimated at 31 per 1000 (35 for males

and 26 for females), Infant Mortality Rate is 24.5 per 1000 and Maternal Mortality Rate is

150 per 100,000 (See Table 36).

Table 36: Population and Health Indicators for Lebanon Lebanon Total Population (2005) 1 3,577,000 Urban population as % of total (2002) 2 87.2% Annual Growth Rate (1995-2005) 1 1.2% In urban areas (2005) 1 87% Life Expectancy (2004) 1 70 Males (2004) 1 68 Females (2004) 1 72 Under-5 mortality per 1000 (2004) 1 31 Males (2004) 1 35 Females (2004) 1 26 Infant Mortality (per 1000 live births) (2005) 3 24.5 Maternal Mortality Rate (per 100,000 live births) (2000) 4 150 Dependency Ratio (2004) 5 57% Percentage of population aged under 15 (2002) 2 6.2% Percentage of Population aged over 60 (2004) 5 10.2% 1. WHO 2007 2. UNDP 2004 as cited in Mohammad-Ali et al. 2005 3. World Fact Book 2005 4. World Health Report 2005 5. WHR 2006

Lebanon is going through a major epidemiological transition, making the country

subject to many chronic diseases. The National Household Health Expenditure and

Utilization survey in 1999 and the Beirut: Health Profiles in 1984 to 1994 both found that

there has been a shift from acute infectious diseases to chronic, noninfectious, and

degenerative diseases. Still, the actual burden of disease is unknown and there is no

national study to prioritize these diseases and determine national health priorities. But still,

people of low income groups are still known to suffer from infectious diseases in addition


to the emerging non-communicable diseases, heart diseases, cancer and other emerging

diseases and infections (Mohammad-Ali et al. 2005).

b) Economic Profile

Before the break-out of the Civil War in 1975, Lebanon was prosperous and was a

center for regional and international trade, commerce and services. The war destroyed the

country’s physical and economic infrastructure, reduced national output and led to a

devaluation of its national currency resulting in an overwhelming rise in the national

poverty level (Mohammad-Ali et al. 2005). After the civil war came to an end in 1989

upon the declaration of the “Taef Agreement,” several health, education and economic

reform strategies were developed. The reform strategies required money the government

did not have (Mohammad-Ali et al. 2005). Therefore, the government held several donor

conferences to raise money to fund the reform strategies (bilateral donors offered 55% of

financial assistance while multilateral donors offered 32%). As a result, Lebanon’s net

debt increased by 646% between 1993 and 2001, half of that debt is in external currencies

(CCS 2004).

As an outcome of the national debt crisis and poor performance of several sectors

in the country, the government is continuously being criticized for being socially inactive

as it is pre-occupied with its grave economic crisis. The fiscal budget of 1999 revealed

that most of the country’s expenditures (83.8%) went to servicing the country’s debt or

paying salaries of government employees (21.9%, which does not include retirement and

pension funds). The budget deficit (estimated at 180%) crippled the governments’ ability

to address the social needs of its citizens. Several measures have been taken since to try to

alleviate the poor economic and financial situation of Lebanon and its citizens

(Mohammad-Ali et al. 2005). But the level of success of those strategies was slow. The

exchange rate of the local currency against the USD decreased from 1,741 in 1993 to

1507.5 in 1999 and has been stable to date (i.e. August 2008). The annual inflation rate

also decreased from 100% to almost 0% in 1999. While the country’s GDP also continued

to grow, it was at a decreasing rate, declining from 8% in 1994, to 1.2% in 1998. GDP

decreased even more to become negative in 1999 (-1.6%) and 0.6% in 2000 but then

began to grow positively in 2001 (0.8%) and reached 3% in 2003 (Mohammad-Ali et al.

2005). The per capita GDP in Lebanon as estimated between 1975 and 2002 is $4,520.


Given that the highest value of the per capita GDP was in 1997, this indicates that it has

probably declined since that time. In fact, some believe that the feared economic crisis in

Lebanon has become a reality (CCS 2004).

c) Migration Trends in Lebanon

A recent report showed that around four million (4,319,598) first-generation Arab

emigrants were residing in several destination countries. Of these, around 10% (363,357)

were Lebanese (Fargues, 2006). These emigrants reside in various countries and regions

such as North America (179,281), Western Europe (148,272), Arab countries (123,966)

and other countries (75,720) making up 606,812 post-1975 emigrants (Kasparian, 2003 as

cited in Fargues, 2006). A total of 51.8% of these Lebanese migrants have university

education (Fargues, 2006).

Saint Joseph University was involved in a survey which studied the trends in the

migration of Lebanese from 1975 up until 2001 (Khalaf, 2004). The results showed that

46.2% of the Lebanese households that participated in the survey had one of their family

members residing abroad (Khalaf, 2004). Demographic characteristics of the migrants

showed that they were mostly men, women who migrate are younger than the men who do

and the majority of those who migrate are married (75.4%). Although men migrated more

than women, the proportion of women migrants was also significant (10% of Lebanese

women vs. 16.4% for men) (Khalaf, 2004).

What was mostly alarming about the USJ survey results was the fact that the rate

of economic activity among the migrants aged between 15 and 64 was found to be higher

than that of the residents. In addition, 28% of migrant men and 20.8% of migrant women

were university degree holders. A total of 54.4% of the migrants left the country during

the period of 1975 and 2000 representing an average of 18% for every 5 year period

(Khalaf, 2004). Professionals have a greater global mobility than unskilled workers

(Zlotnick, 2004 as cited in Malecki & Ewers, 2007).

Therefore, Lebanon is considered as a source country for professionals who

usually migrate to different areas in the world. According to the USJ survey on Lebanese

immigration, several reasons behind the out-migration of individuals were identified.

These included the availability of better job opportunities abroad (with better working

conditions) and moving away from the political and social instability in the country


especially because the period of the study accompanied the period of the Lebanese Civil

War. The reasons behind leaving for men and those for women were different. Men left

the country for (in order of most common to least common): finding a job, the economic

situation in the country, acquiring an education and escaping the war in the country at the

time. As for women, their priorities for leaving the country were (also in order of most

common to least common) family reunification, moving away from the prevailing

situation, finding a job, the economic situation in the country, running away from war,

reasons related to marriage and finally moving in order to attain an education (Khalaf,

2004).

d) Health System Profile

The current structure of the Lebanese Health Sector (LHS) is a direct consequence

of the damage and corruption that resulted from the Civil war. The fragmentation and

pluralism of the LHS is due to the existence of several key players in both health financing

and provision of services (Mohammad-Ali et al. 2005). As a result of the Civil War, the

role of the government declined giving way to the expansion of the private sector. The

private sector is highly dependant on funding from the public sector including the

Ministry of Public Health (MOPH), Ministry of Labor, Ministry of Social Affairs, the

Army, and other Civil Servants (Mohammad-Ali et al. 2005). Coupled with the erosion of

the governance role of the MOPH, this has lead to (Mohammad-Ali et al. 2005):

i. A weakened MOPH

ii. Inflation of the medical bill

iii. Uncontrolled growth of the private sector, which lead to:

a. Oversupply in health facilities

b. Emphasis on expensive curative and tertiary care

c. High reliance on expensive and widely available medical

technology (adding to the health bill)

d. Weak PHC system

One positive outcome resulting from the oversupply of health resources (hospitals,

health centers and other health facilities) is the positive and improving health status

indicators (Mohammad-Ali et al. 2005). Moreover, there are no reported problems in


accessibility to health care or availability of a hospital bed or physician. Yet, quality may

vary considerably as Lebanon lacks a national health strategy (Mohammad-Ali et al.

2005). Moreover, due to the lack of a national health information system, accurate data on

the number and distribution of available resources is unknown to stakeholders. The

sources of such information (MOPH and registration information available through orders

and syndicates) are in many instances incomplete and inaccurate. The MOPH has recently

initiate the Geographic Information System to determine the country’s health map and

provide reliable information on the exact number and distribution of hospitals, beds,

health workforce, medical technology and other issues relating to health resources

(Mohammad-Ali et al. 2005).

2. Health Workforce in Lebanon

Lebanon has an incomplete and unstructured policy regarding its health workforce.

While a policy regarding education, training and licensure exists, there is no such policy

for distribution and recruitment of the Lebanese health workforce (Mohammad-Ali et al.

2005; Lebanon EMRO, 2006). The production of HRH is limited to private educational

institutions and is not under the control of the government (Mohammad-Ali et al. 2005).

The public healthcare sector in Lebanon offers healthcare workers wages and

benefits which are considered very poor and minimal when compared to the private sector.

As a result, dual employment is common among medical and paramedical personnel who

end up working in both sectors to supplement their salaries and retain the benefits

provided by the private sector. However, all health workers in the private sector face more

challenges regarding workload and working hours. On the other hand, personnel in the

public sector are subject to the law of employment of the government as stated by the

Civil Service Board (Lebanon EMRO, 2006).

All medical and paramedical staff should be granted a License of Practice from the

MOPH before registering in their Orders of specialty. However, after they register in the

MOPH, the ministry loses track of these health workers thus making it hard to determine

the stock of the national health workforce. In addition, professional orders only (and not

always) have information on members who pay the annual membership fees.

Consequently policies on staffing needs and deployment are hard to develop.


In Lebanon, there is a lack of accurate information on the number and distribution

of different categories of HRH. The MOPH does not have accurate data in this regard.

This issue is further complicated by some additional factors:

– Two Orders of Physicians exists in Lebanon; one in Beirut and another in

Tripoli. Many physicians are registered in both, many are registered in only

one, and many others are registered in neither one (Mohammad-Ali et al.

2005). The databases of both sources are not continuously updated making

the task of estimating the number of physicians available in Lebanon hard.

– The Lebanese Order of Nurses and the Lebanese law require that all

Lebanese nurses register in the order before they can practice. While the

Order has an exhaustive database on its nurses, it is not continuously updated

and also suffers from missing data and data entry errors (El-Jardali et al.

2007 – Nurse Retention). This makes the number of nurses in Lebanon also

hard to estimate.

a) Stock of Physicians in Lebanon

The most critical issue facing HRH in Lebanon is the oversupply of physicians and

under-supply of nurses and paramedical personnel. According to data from the World

Health Organization (2006), physician density in Lebanon is the highest in the EMR (3.25

per 1000 compared to a regional average of 1.14 per 1000) (WHO, 2006). Figure 7 below

shows that the physician density is almost thrice the nurse density in Lebanon indicating a

major professional mal-distribution (El-Jardali et al 2007).


Figure 7: Distribution of physicians and nurses in the EMR

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Low Income Low Middle Income Upper MiddleIncome

High Income

Low and Middle Income Middle to High Income Averages

Physician Density Nurse Density

Although some policies regarding HRH have been created at the organizational

and institutional level, Lebanon still lacks a national policy to manage and control the

supply, geographic distribution and specialty distribution of physicians.. The supply of

physicians in Lebanon has been growing since 1993. The rate of increase in supply of

physicians is approximately 9% which much exceeds the average rate of population

growth (1.9% per year). However, this growth in supply slowed in 1999 as shown in

Table 37. The rapid growth in physician supply occurred for two main reasons. First,

grants and scholarships were provided to Lebanese students during the war period to

continue their studies abroad, especially in the Soviet Union, Arab countries, and France.

After the war, physicians returned to their country of origin seeking work opportunities

and thereby saturated the market. To compound the situation further, the number of

medical schools in the country increased as well (Mohammad-Ali et al. 2005).

Table 37: Number of physicians inscribed/year

Year Order of physicians of Beirut

Order of physicians of North Lebanon Total


Year Order of physicians of Beirut

Order of physicians of North Lebanon Total

1999 504 75 579 2000 415 28 443 2001 400 70 470 2002 279 43 322 2003 276 29 305 2004 268 56 324 Total 2,142 301 2,443

Source: Order of Physicians of Beirut and Order of Physicians of North Lebanon as cited in Mohammad-Ali et al. 2005

According to the two orders the total number of physicians in mid 2005 was

estimated at approximately 1,0454, indicating that physician density is 27 physicians per

10,000 population. Evidence shows an over supply of physicians in Lebanon, particularly

as compare to nurse density (Mohammad-Ali et al. 2005). Physician density in Beirut was

found to be 6 physicians per 1000 compared to only 2 physicians per 1000 in Bekaa. This

raises concerns about geographic mal-distribution of physicians across different

Mohafazat (See Table 38) (Mohammad-Ali et al. 2005). This observation is further

exacerbated by the lack of incentives to encourage physicians to practice in rural areas

(Lebanon EMRO, 2006). The major negative consequence of this over supply is

increasing physician unemployment and switching of careers.

Table 38: Physician numbers by Mohafazat 2005*

Mohafazat N % Beirut 4159 39% Beirut inscribed at North Lebanon 33 0.3% Mount Lebanon 2800 27% Mount Lebanon (Jbail) inscribed at North Lebanon 3 0.03% North Lebanon 1157 11% North Lebanon inscribed at Beirut 185 2% South Lebanon 1316 13% Bekaa 796 8% Bekaa inscribed at North Lebanon 5 0.05% Total 10,454 100% * Density for each region is not calculated since population for the Mohafazat is not available Source: Order of Physicians of Beirut and Order of Physicians of North Lebanon as cited in Mohammad-Ali et al. 2005


During the Civil War, Lebanese medical students were offered numerous

opportunities to continue their studies abroad. The impact of this trend is reflected in the

diversity of specialties among physicians in Lebanon today. There are over 74 specialties

in the Lebanese medical labor market and Lebanese physicians have been trained in more

than 51 different countries. The majority of physicians in Lebanon (70%) are specialized

and there is a shortage in general practitioners (Mohammad-Ali et al. 2005).

Consistent with the worldwide trend of increase in employment opportunities

among women, the proportion of female physicians in Lebanon has been steadily

increasing. However, according to the recent data offered by both orders of medicine, the

ratio of female to male physicians is 2:8 (Mohammad-Ali et al. 2005).

Table 39: Physician distribution by gender

Female Male N (%) N (%)

Total

Order of Physicians of Beirut 1766 (19.1%) 7490 (80.9%) 9256 Order of Physicians of North 191 (16.3%) 983 (83.7%) 1174 Total 1857 (17.8%) 8473 (81.2%) 10430 Source: Order of Physicians of Beirut and Order of Physicians of North Lebanon as cited in Mohammad-Ali et al. 2005

Very little information is available on physicians’ practice and reimbursement

schemes. Only one such study investigated physician reimbursement and payment

mechanisms (study conducted by Department of Health Management and Policy at the

Faculty of Health Sciences at the American University of Beirut). Study results showed

that 99% of physicians reported multiple job holdings. The majority of physicians also

maintain private clinics in addition to working at one or more health centers (including

those who were employed by the public sector). Physicians were paid according to three

different payment modalities; fee-for-service (25%), hourly rate (45%), and salary (30%)

(mainly those working at the MOPH health centers). Only 44% reported being satisfied

with the type and amount of compensation. Physicians working in the public sector make

much less compared to physicians working in the private sector. As such, 60% of

physicians in Lebanon also work in the private sector.


b) Stock of Nurses in Lebanon

Lebanon suffers a severe nursing shortage. Nurse density in Lebanon is one of the

lowest in the world; the World Health Organization (2006) reported that nurse density in

Lebanon is 1.17 per 1000 population compared to an EMR average of 2.20 per 1000 (See

Figure 8). The shortage results from an unattractive professional status, and high turnover

(Lebanon EMRO, 2006), in addition to poor job satisfaction, poor work environment and

excessive emigration (El Jardali et al., 2008(a)).

The nurse density in Lebanon is one for every 1600 people which is considered to

be one tenth the ratio in developing countries. The ratio of nurses to hospital beds in

Lebanon (1 nurse /4.5 beds), this is much less than the ratios in European countries (1

nurse/ 2.5 beds). This shortage in nursing personnel can be attributed to two main reasons.

First, there are an increasing number of inactive nurses who leave their job for other

careers. Second, many nursing personnel emigrate seeking better job opportunities outside

Lebanon, mainly in the Gulf.

The nursing profession in Lebanon is regulated by the Lebanese Order of Nurses.

The Order was established in 2003 and is located in Beirut. Membership covers all nurses

in Lebanon. Data from the Lebanese Order of Nurses indicates that a total of 6,026 nurses

are registered in their database. According to the Order, an additional 2,000 nurses have

yet to register. As evident in Table 40 below, 85.3% of nurses are females and 51.5% are

below 30 years of age, (mean age is 32.1 ± 8.9, ranging from 18 to 87). This is of

particular importance since evidence shows that nurses in this younger age group are more

likely to leave the profession or migrate. Over 90% of nurses are employed and the

majority (75%) holds either a Bachelors’ of Science (BSN) or a Technique Superior (TS)

(46.4% and 28.6% respectively) (See Table 40). There is also a geographic mal-

distribution of nurses since the majority prefers working in urban areas such as Beirut

(35.8%) and Mount Lebanon (25.7%) (See Table 40). Moreover, approximately 10% of

nurses are currently unemployed and 61.6% of them are under the age of 30. This

indicates the need to investigate this particular group of nurses to determine reasons for

unemployment, particularly since there is a perceived shortage of qualified nurses in

Lebanon.

Data from the Order indicates that less than 2% of Lebanese nurses are working

abroad. But this number should be interpreted with caution since:


– Many nurses may have migrated before the establishment of the Lebanese

Order of Nurses in 2003 and may not have registered.

– According to the Order, nurses do not regularly update their personal

information. Therefore, many nurses who are apparently registered as

employed in Lebanon may in fact be working abroad.

Table 40: Results of data retrieved from the Order of Nurses in Lebanon* N (%)Sex Female 5143 (85.3) Male 883 (14.7)Age < 30 years of age 3105 (51.5) 30 – 45 years of age 2402 (39.9) 46 – 55 years of age 374 (6.2) > 55 years of age 145 (2.4) Mean (SD) 32.1 (8.9)Marital Status Single 3750 (62.2) Married 2091 (34.7) Nun 100 (1.7) Divorced 63 (1.0) Widowed 16 (0.3) Deceased 6 (0.1)Employment Status Employed 5446 (90.4) Non-employed 578 (9.6) Retired 2 (0.0)Degree Bachelors of Science 2794 (46.4) Technique Superieur 1726 (28.6) Baccalaureate Technique 1506 (25.0)Location/Area Beirut 1914 (35.8) Mount Lebanon 1375 (25.7) North 1001 (18.7) South 597 (11.2) Bekaa 368 (6.1) Abroad 96 (1.8)

* Density for each region is not calculated since population for the each of the geogrpahic areas is not available


3. Graduates from Medical and Nursing Schools

Most universities that offer degrees in medical, nursing and health sciences follow

either the American or the French educational system and sometimes certified by

international universities with which they are affiliated. As evident in Table 41 below,

Lebanon has four medical schools, three schools of dentistry, four schools in pharmacy

and ten nursing schools (Mohammad-Ali et al. 2005). Universities granting degrees in

higher education are subject to the laws and regulations of the Ministry of Higher

Education. All degrees granted by private institutions have to be accredited by the

Committee of Accreditation for Higher Education (Ministry of Higher Education). Only

graduates of the Lebanese University (a public university) are exempted from this process

(Mohammad-Ali et al. 2005).

Table 41: Number of training institutions by type and capacity of enrollment Type of institution Number of institutions Capacity Medical Schools* 4 1500 Schools of Dentistry 3 500 Schools of Pharmacy 4 1000 Nursing and Midwifery Schools 10 1500 * Data from this source indicates that 4 medical schools exist in Lebanon. This data reflect estimates dating to before the year 2001 when the medical school at Balamand University was established. Source: Centre de Recherche et Development Pedagogique (CRDP) website: http//: www.crdp.gov.lb

Many medical and nursing curricula in Lebanon are outdated and not context-

specific. This issue is raising questions about the quality about health professionals

graduating from Lebanon. In addition, Lebanon lacks a re-licensing process which forces

health professionals, especially nurses and physicians, to stay up to date. The qualification

of health professionals and consequently the quality of care provided to patients is further

jeopardized by the lack of a formal continuing education program in healthcare

institutions (Lebanon EMRO, 2006).

There are currently eight university-level nursing programs which prepare nurses

at the BSN level. Three of those eight programs offer a Masters degree. Some of these

schools of nursing are the American University of Beirut which is the oldest dating back

to 1905, St. Joseph University (since 1943), The Lebanese Cross School of Nursing

(1945) and the Makassed School of Nursing (1954).


All medical and nursing schools (university level) in Lebanon were contacted.

Two medical schools and five nursing and midwifery schools replied to our request (See

Table 42 below).

Table 42: Name, type, affiliation and reply status of medical and nursing schools in Lebanon Name of Institution Type Replied Affiliation AUB Medical School Medical Yes Private

Beirut Arab University Medical School Medical No Private

University of Balamand Medicine and Medical Sciences*

Medical Yes Private

Lebanese University Medicine Medical No Public

USJ School of Medicine Medical No Private

Beirut Arab University School of Nursing** Nursing Yes Private

USJ School of Nursing Nursing Yes Private

University of Balamand Nursing Nursing No Private

AUB School of Nursing Nursing Yes Private

Lebanese University Health Sciences (Nursing/Midwifery)

Nursing and Midwifery

Yes Public

USJ School of Midwifery Midwifery Yes Private

*established recently, student admission began in 2001 ** established recently, student admission began in 2006

Responses received from the above institutions were accumulated and the results

are reported in the sections below.

a) Medical Schools

Physicians in Lebanon do no only include those who graduated from Lebanese

universities. Lebanese medical graduates also come from different medical schools all

over the world. Some of them have returned to Lebanon after the Civil War ended. The

study by Kassak et al. (2006) revealed that 18.3% of the sampled physicians graduated

from Eastern Europe, 31.5% from Western Europe, 2.6% from North America, 29.6%


from Lebanon, 2.9% from countries in the Middle East and North Africa (MENA) Region

and 1.3% from other countries (the remaining 13.8% did not answer this question).

Two of the five contacted medical schools responded to our survey. The duration

of the educational program at both universities is 4 years. As per the table below, the total

number of graduates at these two medical schools was 736. The total number of 1st year

students was 980 indicating a high drop out rate (attrition).

Table 43: Number of 1st year students and graduates at two medical schools in

Lebanon

AUB Balamand University Total 1st year Graduates 1st year Graduates 1st year Graduates 2000 75 74 75 74 2001 75 71 26 101 71 2002 76 76 31 107 76 2003 77 72 35 112 72 2004 81 79 36 25 117 104 2005 79 74 40 30 119 104 2006 82 80 41 36 123 116 2007 84 84 55 35 139 119 2008 87 87

Total 716 610 264 126 980 736

It should be noted that the above number is a gross underestimate of the actual

number of medical graduates in Lebanon.

b) Nursing Schools

Two types of nursing programs exist in Lebanon: the university programs leading

to BSN or a licensure in nursing and a technical program leading to Baccalaureate

Technique (BT) or TS. There are also a number of vocational programs that exist which

offer varying levels of technical training in nursing.

Different leading universities are offering nursing education programs including

the Lebanese University, the American University of Beirut (AUB), Universite St. Joseph

(USJ), Beirut Arab University and Balamand University. Other training institutions that

are widely spread all over Lebanon offer technical degrees and are attracting a large

number of students. Admission requirements into a BSN program is a secondary degree or

at least a BT. The length of a BSN program can range from 3 to 4 years. Admission into a


BT program is completion of intermediate education; the length of the program is 3 years.

A TS degree requires three years of study following completion of BT.

A total of five nursing schools offering a BSN program were contacted for this

study. Four of the contacted schools replied. Data from the four schools is detailed in the

table below.


Table 44: Number of 1st year students and graduates from nursing schools in Lebanon between 2000 and 2006 USJ Beirut Arab University AUB Lebanese University Total 1st year Graduates 1st year Graduates 1st year Graduates 1st year Graduates 1st year Graduates2000 58 66 35 19 97 51 190 1362001 62 59 46 17 106 86 214 1622002 79 50 39 36 116 87 234 1732003 89 63 55 32 116 85 260 1802004 77 68 41 34 118 85 236 1872005 60 71 42 32 117 95 219 1982006 78 68 26 45 43 116 91 265 2022007 58 61 36 47 32 106 99 247 1922008 47 36 45 25 136 94 264 119Total 608 506 98 395 245 1028 773 2129 1524

As observed in Table 44 above, a total of 1524 nurses graduated from the four nursing schools between the years 2000 and 2006.

It should be noted that the Beirut Arab University has only recently been established and began student admission in 2006 and has not yet

graduated any nurses. Only the Lebanese University is a public institution and graduated approximately half the total number of

graduates. The Lebanese University has five branches across Lebanon. All the branches were contacted, only three responded and each

provided information pertaining to its own branch. This information is summarized in Appendix XXI. In Appendix XXII, a summary of

the data colleted from each nursing school on program duration, number of graduates migrating within 3 years and most preferable

destinations is enclosed.


c) Midwifery Schools

Two schools of midwifery were contacted, one within USJ and another within the

Lebanese University. Both schools responded to our survey. The table below summarizes

number of 1st year students and graduates from the two midwifery schools between 2000

and 2008.

Table 45: Number of 1st year students and graduates from two midwifery schools in Lebanon between 2000 and 2008 USJ Lebanese University Total 1st year Graduates 1st year Graduates 1st year Graduates 2000 11 10 9 7 20 17 2001 5 5 16 13 21 18 2002 3 2 17 14 20 16 2003 4 4 10 8 14 12 2004 7 14 12 21 12 2005 7 14 5 21 5 2006 9 17 11 26 11 2007 9 7 13 5 22 12 2008 6 4 15 21 4 Total 61 28 125 75 186 103

As per the data summarized in Table 45 above, a total of 103 midwives graduated

from the above referenced schools between 2000 and 2008. Both programs require 4 years

of training. The Lebanese University further reported that 7 of its graduates emigrated

within 3 years of practice. USJ did not report the number of graduates that emigrated out

but reported their most preferable destinations (in order of preference) as the Gulf, Europe

and North America. The Lebanese University cited Gulf countries as a primary destination

for its graduates as well.

4. HRH Migration from Lebanon

Lebanon is considered as a source country of health workers. Many physicians and

nurses choose to migrate to countries of the Gulf, Europe and North America in search of

better job opportunities. Lebanon has a culture of migration; this trend has actually

become widely accepted by society (Akl et al. 2006). Decision to emigrate is often

enhanced by the presence of family, friends and communities abroad, and possibility of


attaining a dual citizenship (Akl et al., 2006). Yet, the actual reasons for migration may

differ according to the category of health professionals, therefore migration patterns and

reasons for migration pertaining to each of physicians and nurses are listed in detail

below.

a) Physician migration

Since the late 1970s, there has been an increase in the trend of Lebanese medical

graduates (LMG) in the US. Currently, 41.1% (2004) of LMGs since 25 years work as

active physicians in the US representing 1.3% of all international medical graduates in the

country. Although this appears to be a small percentage, after adjusting for the country

population size, Lebanon ranks second among countries from where physicians in the US

graduated. These statistics were retrieved from a study by Akl et al. (2007) which focused

on understanding issues around LMG in the United States. The study also found that these

graduates are board certified and that they are more likely to work in medical research as

compared to other American and international medical graduates. Another study by Akl et

al. (2006) performed a qualitative study on pre-final and final year medical students in

Lebanese universities aiming at identifying intents of these students to immigrate to other

countries after they graduate. In addition, the study identified the push and pull factors that

influence the intent of students to leave the country (Akl et al., 2007). The push and pull

factors that were identified were segregated into different areas and dimensions including

residency training, professional career, financial area, political area, social areas. These

are summarized in the table below.

Table 46: Push and pull factors as reported by medical students (Adapted from Akl et al. 2007) Push factors in source country Specific area Pull factor in recipient

countries Unavailability of desired specialty, intense competition for few training positions, unfair competition for training positions

Training opportunities

Availability of desired specialty, availability of a large number of training positions, fair competition for training positions based on competences

Insufficient exposure or the lack of a variety of cases, insufficient training in procedural skills, insufficient

Clinical training Better exposure, focusing more on procedural skills, giving trainees more responsibilities, conformity to standards of care


Push factors in source country Specific area Pull factor in recipient countries

autonomy, inability to practice theoretical concepts

and thus the ability to practice theoretical concepts

Lack of financial resources, lack of human resources, dissatisfactory mentorship, weak research culture

Research training More resources, more opportunities, better mentorship, better chances to publish in a culture where research is highly appreciated

Weak institutional commitment to teaching, attending physicians not committed enough to teaching, absence of explicit curriculum, no governmental accreditation or supervisions

Teaching Higher commitment to teaching in well defined curricula, respect and appreciation for trainees as opposed to considering them as cheap labor

No explicit delineation of duty, high and unregulated workload, distressing relationship with trainers and nurses, deficient or unfair rewarding and evaluation systems

Residency working conditions

Well defined duties, regulated workload, collegial relationship with trainers, better reward systems and the support for extra-curricular activities

Training systems which are imported and not totally adequate for local practice, inability to enter in foreign job markets, competitive disadvantage in the local job market, poor chances of academic careers

Impact on career Ability to enter foreign job markets, ability to compete in the local job market, having a chance at entering an academic career

Fierce unfair competition, very limited career opportunities in academia and major health centers, no attractive job opportunities in remote areas, risk of not working in trained in specialty

Job opportunities Competence based competition and more job opportunities, ability to work in the trained-in specialty

High workload, dysfunctional health care system, poor professional standards in dealing with colleagues and patients, inequitable rules of academic and professional advancement, incompetent supporting staff, no organized or required continuous medical education

Working conditions

Lighter workload in a functional health system better professional standards, basing academic advancement on research and teaching, continuous medical education and stable jobs


Push factors in source country Specific area Pull factor in recipient countries

Low un-guaranteed income, high expenses, inability to start a family, financial dependency, poor prospects of national economy

Financial

Higher income thus leading to financial independency, ability to start a family and financially assist parent in home country

National/regional instability/frustration with political situation and system, inability to affect change and unforeseen change, worry about personal security, lack of political ethics and transparency and civil instability

Political Political stability, opportunity to acquire foreign citizenship thus ensuring further security and social justice

Discontent with social norms (interdependency of individual with family), sectarian social system affecting social rights and finally social inequalities

Social Independency, self responsibility, reunion with a network of friends and family abroad, traveling and meeting people abroad

Among the push factors listed above, the over-saturation of the local job market

was the factor common among most students. In Lebanon there is abundance in medical

schools and an influx of medical graduates from foreign schools which is leading to a high

density of physicians thus reducing employment opportunities (Ghossain et al., 2003 as

cited in Akl et al., 2008). Fierce competition has resulted among Lebanese physicians.

Lebanese medical students believed that training abroad will provide them with local,

regional and international competitive advantage. In fact, the students stated that training

abroad was actually becoming a need rather than a choice and has become a minimum

requirement since so many Lebanese physicians are training abroad today. In addition

there is a societal belief that physicians who train abroad are much more competent than

those who are trained locally (Akl et al., 2006). A second survey conducted by Akl et al.

(2008) found that 96% of medical students intend to emigrate from Lebanon in order to

attain their specialty (77.6%) and subspecialty training (17.9%) (Akl et al., 2008). The

countries that were reported as most attractive for training were US (74.1%), France

(12.1%), UK (7.6%) and Canada (4.2%). Only 25.1% of the sampled students intended to

return home after completing their training, whereas 63.8% intend to return after working

abroad for a number of years after the completion of their training and 10.6% of these

students intended never to return back to Lebanon. These numbers are alarming because


despite the high density of physicians in Lebanon, the country is facing a loss in its

intellectual capital and educational investment because those who decide to migrate and

never come back may be the best among their peers.

b) Nurse migration

Migration of nurses in Lebanon is perceived to be significant but very little

information exists about this issue. Only one study has been conducted to assess the

magnitude and predictors of nurse migration out of Lebanon. Study results showed that

one out of every five nurses that receive a BSN leave within one to two years of

graduation (El-Jardali et al. 2008c). Data for this study was collected from five nursing

schools. Data pertained to the total number of graduates in addition to the numbers of

those working in Lebanon and abroad. Only four of the five sampled schools provided full

information at the time of the study. The data is summarized in the table below.

Table 47: Data on Lebanese Nurses retrieved from four nursing schools

In Lebanon Abroad Total N (%) N (%) NGraduates of 2000 76 (67.3) 37 (37.2) 113Graduates of 2001 81 (71.1) 33 (28.9) 114Graduates of 2002 92 (75.4) 30 (24.6) 122Graduates of 2003 115 (79.3) 30 (20.7) 145Graduates of 2004 113 (81.3) 26 (18.7) 139Graduates of 2005 137 (90.1) 15 (9.9) 152Graduates of 2006 147 (96.1) 6 (3.9) 153Total 761 (81.1) 177 (18.9) 938

According to the 5 schools, a total of 2,024 received a BSN between the years

2000 and 2006. The migration rate was calculated based solely on the information

provided by the 4 schools that provided full information on their graduates working in

Lebanon and abroad. The overall percentage of nurses working abroad was found to be

18.9% (See Table 47). It should be noted that nurses are required to have at least 1 year of

work experience before being recruited for a position abroad. This explains the lower

migration rates for graduates of 2005 and 2006 since some of those graduates might

migrate in 2007 and 2008 (El-Jardali et al. 2008c).


To assess reasons for migration, a second study was conducted targeting migrating

nurses in their destination countries. Identified reasons for leaving included was the lack

of career development opportunities, followed by poor salaries, no equality with other

health professionals, and not being treated as a valued health professional. Reasons for

leaving differed among nurses working the Gulf and those working in North America or

Europe. For instance, financial reasons were the main reasons for leaving for nurses

practicing in the Gulf whereas continuing education was a primary reason for leaving for

nurses in North America and Europe. Although most nurses did not express an intent to

return to Lebanon, some reported that a combination of financial and non-financial

incentives can encourage them to return to practice in Lebanon. The most recurring

incentives (pull factors) to encourage nurses to return to practice in Lebanon salaries and

improved benefits, managerial support and appreciation, improved work environment

(from blaming to shaming), improved social image of nurses and increasing the

effectiveness of the Lebanese Order of Nursing (El Jardali et al., 2008 (a)).

5. Recruitment agencies

Several recruitment agencies in Lebanon were contacted to assess reasons for

physician and nurse migration. Only three agencies replied. Only one agency reported

actively recruiting physicians and nurses to practice in UAE, another reported currently

reviewing applications for candidates who want to go to UAE. The third agency reported

that they only recruit health professionals to the KSA. All agencies reported that Gulf

countries were the most preferable destination for applicants, mainly KSA followed by

UAE, Kuwait and Qatar. The primary reason for emigration as reported by the three

agencies was better salaries. Only one other reason was reported which was exposure to

international experience which would make it easier for candidates to apply for positions

in North America. It should be noted that two of the three agencies reported that

physicians and nurses emigrating to countries of the Gulf often hold a lower occupational

position than the one they held in Lebanon. Benefits packages in the gulf countries often

include housing, health insurance, one month vacation and cost of ticket to Lebanon.


6. Retention of health workers in Lebanon

Despite the many health workforce challenges in Lebanon, our findings point out

to a lack of a health workforce strategy that encompasses planning and management of the

Lebanese health workforce. Some initiatives have been taken at the organizational level,

particularly when it comes to nurse retention. Yet, little has been done on a national level

to understand health workforce challenges and retention. No documentation of such

strategies was found for physicians, however, some research and activities on nurse

retention was found and is documented below.

a) Research on Nurse Retention in Lebanon

A recent national study undertaken by Dr. Fadi El-Jardali and colleagues aimed to

better understand the challenges around nurse retention and hospital specific activities in

this regard. One part of this study targeted nursing directors at all hospitals in Lebanon.

The purpose of this activity was to assess nurse retention challenges and strategies as

perceived by Nursing Directors in Lebanese hospitals. This national study included all

hospitals in Lebanon (teaching/non teaching, urban/rural, large/small) with at least 20

beds. A two-page questionnaire targeting nursing directors was developed based on an

extensive literature review on nurse retention challenges in addition to discussions with

Nursing Directors of major Lebanese hospitals and the Lebanese Order of Nurses.

Hospitals were asked to report their most common retention challenges and retention

strategies.

The majority of the sampled hospitals (88.2%) reported facing challenges in

retaining their nurses. The main reasons for leaving as perceived by the nursing directors

included, but were not limited to: unsatisfactory salary and benefits (80.8%); unsuitable

shifts and working hours (38.4%); presence of better opportunities abroad (30.1%); better

opportunities in other hospitals within the country (30.1%); workload (27.4%); instability

of the country (16.4%); marriage (16.4%), in addition to the geographical location of

hospital (12.3%) (See Figure 8). Other less frequent reasons for leaving included the lack

of incentives, shortage in qualified staff and nurses, and work related stress (El-Jardali et

al. unpublished study).


Figure 8: Top Retention Challenges as perceived by Lebanese Nursing Directors

Location of the hospital, 12.3%

Marriage, 16.4%

Instability of the country, 16.4%

Work load, 27.4%

Better opportunities in other hospitals, 30.1%

Better opportunities abroad, 30.1%

Shifts and working hours, 38.4%

Salaries and benefits, 80.8%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

A total of 88.2% of sampled hospitals reported employing nurse retention

strategies to mitigate the reported challenges, retain their nurses and decrease their

turnover rates. The most common retention strategies adopted by these hospitals included:

offering financial rewards and benefits (62.7%); implementing a salary scale (47.8%);

flexible schedules (31.3%); staff development (29.9%); offering praise, incentives and

motivation (19.4%); improving the relationship between nurses and management (19.4%);

improving work environment (14.9%); and promotion opportunities (11.9%). Other

methods such as staffing, educational opportunities within and outside the hospital were

also indicated among others as methods of retention by some of the hospitals (E-Jardali et

al. unpublished study). Figure 9 shows the distribution of some of the strategies adopted

by the sampled hospitals.


Figure 9: Retention strategies adopted by hospitals

Promotion, 11.9%

Healthy work environment, 14.9%

Good management and nurses relationship, 19.4%

Praise, incentives and motivation, 19.4%

Staff development, 29.9%

Flexibility of schedule, 31.3%

Salary scale, 47.8%

Financial rewards and benefits, 62.7%

0% 10% 20% 30% 40% 50% 60% 70%

b) Research on Nurses’ Intent to Leave

To better understand predictors of nurses’ intent to leave their job and their

country, a national study targeting all nurses in Lebanon was further conducted. The

purpose of this study was to determine the perceived intent to leave of Lebanese nurses

and explore its relationship with job satisfaction. Job satisfaction was assessed using the

McLoskey Mueller Satisfaction Scale. A total of 1,793 nurses were included in this

survey. Results showed that 67.5% of nurses reported an intent to leave within the next 1

to 3 years, 36.7% of which disclosed plans to leave the country. Of the remaining 63.3%

of nurses who reported an intent to leave the hospital but stay in Lebanon, 22.1% plan to

move to a different health organization in Lebanon, 29.4% plan to leave the nursing

profession and 48.5% had other plans such as taking care of their children and other

dependants, or continuing their education. Lebanese nurses were found to be least satisfied

with extrinsic rewards (financial rewards). Nurses reporting an intent to leave has lower

scores on all aspects of job satisfaction (El-Jardali et al. unpublished study).


7. Challenges, Successes and Recommendations for Lebanon

Focus groups and key informant interview conducted with key stakeholders in

Lebanon revealed many challenges pertaining to the health workforce.

a) Challenges facing Lebanon

i. Professional and geographic mal-distribution

Key informants frequently cited issues around professional and geographic mal-

distribution as one of the primary challenges facing the health workforce in

Lebanon. Geographical mal-distribution exists across different regions (urban,

rural). Mal-distribution also extends to different health institutions (hospitals,

PHC) and sectors (public, private). Key informants stated that the majority of the

health workforce is concentrated in the urban areas of the country which leaves

rural areas with a poor supply of health workers. Moreover, health workers prefer

working in private healthcare centers and urban areas, this is attributed to better

financial incentives. Furthermore, key informants cited major imbalance in HRH

in terms of an undersupply in some specialties/health professions and an

oversupply in others. Even though Lebanon lacks a precise database on its health

workforce, there exists a clear oversupply of physicians and a severe undersupply

of nurses.

ii. Migration - brain drain

Key informants believe that political and economical instability, lack of financial

and non- financial incentives, lack of recognition, and difficult work environment

are reasons behind the excessive migration of qualified health professionals. This

problem is a significant factor that leads to shortages in some specialties;

particularly in nursing.

iii. Limited financial and non-financial incentives

Key informants highlighted one of the main challenges of dissatisfaction of HRH,

that is, the lack of both financial and non-financial incentives. This issue is leading


to migration or shifting of staff from the profession and is one of the reasons why

health care professionals have a short life span in Lebanon

iv. Outdated curricula

Participants also questioned the current status of HRH educational curricula. They

expressed serious concerns regarding the content and the quality of the educational

programs that train and educate Lebanese health professionals. Many believed that

the curricula were outdated, not context-specific and do not meet the health needs

of the population. The participants went on to discuss the wide variation in

curricula, particularly between universities and technical schools. Participants also

highlighted the poor quality of technical trained nurses. This is an outcome of the

lack of a monitoring or auditing system to check the content and quality of

available curricula. There is no record of any legislation that enforces revision of

medical curricula and no record or knowledge of recent revisions to such curricula.

v. Lack of re-licensing of health professionals and accreditation of educational

curricula

Closely linked to the above theme is the lack of a national policy for re-licensing

of health professionals. The Lebanese government is not interested in licensing

higher education institutions, developing accreditation standards for educational

and training programs and developing a structured licensure system for health

professionals. Both licensing and accreditation are indispensable, yet they are not

part of the health education system. While many health professionals are required

to obtain a license to practice before they are allowed to practice, this process does

not involve a periodical renewal; once the license has been issued it is valid

indefinitely.

vi. Limited CME programs and career development

The Lebanese healthcare system lacks an effective continuing education program

for health care personnel. In addition, there are no mechanisms for compulsory

continuing education or career development of the health workforce.


b) Successes and Opportunities in Lebanon

Findings from Lebanon showed no evidence of recent activities to remedy

perceived shortages or to better manager existing stock of health workers. Moreover, no

documentation of a national HRH strategy was found. Still, HRH issues, specifically

nursing issues, have started to gain more attention. In fact, in June 2008, a national

conference entitled Developing the Nursing Workforce in Lebanon: Challenges and

Opportunities was held by the School of Nursing at the American University of Beirut.

This conference was conducted in collaboration with the MOPH in Lebanon, the Lebanese

Order of Nurses, the World health Organization and the Italian Corporation. The

conference hosted a number of local and international key speakers and experts on nursing

research. A number of strategies resulted from this conference, they are summarized

below:

National level

– Recognize nursing as an area of national need in Lebanon

– Create a nursing unit at the MOPH

– Develop a collaborative strategy with input from educators, clinicians,

administrators and policy makers to meet the nursing workforce challenges

– Organize national campaigns that inform the public of the value of the

profession

– Revise the nursing law that regulates the profession

– Improve working conditions of nurses (flexible scheduling, self scheduling…)

– Increase remuneration (salaries/benefits)

– Promote mandatory CE for nurses

– Develop a national strategy for nursing

– Involve nurses in development of health care policy

Nursing education

– Enhance faculty development and retention strategies

– Maximize opportunities to promote evidence-based nursing practice

– Promote core proficiencies for nurses

– Create clinical partnerships

– Create bridging programs to holders of technical degrees


– Provide scholarships for nursing education

– Promote specialization in nursing

– Promote research on the nursing workforce

Nursing practice

– Create an empowering and safe work environment for nurses

– Develop leadership skills at the nurse executive level

– Plan staffing (number and skill mix) that ensure quality and cost effective care

– Create innovative retention and recruitment strategies

– Ensure collaborative practice between nursing education and nursing services to

promote evidence-based practice

– Develop career advancement programs

– Promote the role of nurses in the community (school health, primary care

centers, home health)

– Empower nurses in HC agencies ex. Board of directors to include a nurse

– Enhance collaborative relationships between physicians and nurses ex. Regular

interdisciplinary staff meetings and multidisciplinary collaboration on projects

such as quality improvement

In light of the above successful conference, much more can be done to improve not

only the nursing profession, but the status of the health workforce as a whole.

c) Recommendations for Lebanon

Several key recommendations for improving the health workforce in Lebanon

were documented, these are detailed below:

i. Develop system for managing migration

Key informants reported an urgent need to develop a system to manage the

excessive migration of the health workforce. They highlighted the importance of

establishing HRH retention strategies at a national level that can help retain the

current workforce.


ii. Creating an HRH plan

The key informants recommended developing a national plan for HRH. This

includes conducting needs assessment to establish a system that targets the

population needs and anticipates future needs of HRH. This involves needs-based

HRH planning to address shortages in numbers, specialties, geographic and

sectoral mal-distribution. Key informants suggested creating a national database

for HRH which can be regularly updated. Such a database can provide accurate

estimates of the current workforce and future needs.

iii. Rectifying HRH imbalances: undersupply or oversupply

To alleviate shortages, the key informants suggested allowing non-Lebanese

nurses to work in Lebanese hospitals; revising laws that govern nursing practice,

and recognizing different degrees, particularly nursing degrees. Participants also

recommended finding alternative employment opportunities for unemployed

health workforce, and encouraging physicians to work in PHC.

iv. Revising educational curricula

Key informants stressed the needs to evaluate and revise current educational

curricula. Curricula should follow international standards and reflect the health

needs of the population. Key informants also highlighted the need create

educational program for some unavailable specialties.

v. Implement continuing education and career advancement programs

Key informants stressed the importance of developing continuing education

programs for all types of health professionals. They also suggested developing

career advancement programs to allow health professionals the opportunity to

advance their education, improve their practice and advance in their career ladder.

vi. Creating Financial and Non-Financial Incentives

To retain quality health professionals, retention and incentive system needs to be

developed at a national level. Key informants suggested development of both

financial and non-financial incentives for this purpose. Financial incentives can


include increasing wages whereas non-financial incentives can include

improvement in practice environment, and instituting rewards and recognition

system.

VII. Limitations

Some limitations encountered while conducting activities pertaining to this two-

country case study should be acknowledged.

The most important limitation related to the time during which this study was

conducted, i.e. June to August 2008. During the summer period, many of the key

informants we had planned to include were on vacation. All identified key informants in

UAE were contacted but many did not reply due to summer vacation. The delayed

response from key informants in UAE delayed also the data collection trip. As a result,

additional time was requested to analyze and report the data collected during this trip.

The effect of the summer season also extended to educational institutions.

Directors of most educational institutions were on vacation and a number of them short

working hours which affected data collection. As a result, many institutions, particularly

in Lebanon, did not respond to the survey. Furthermore, only 3 of the 6 branches of the

Lebanese University replied to our survey. This university alone produces most of the

nurses in Lebanon. As a result, the total supply of health workers in Lebanon, particularly

nurses, is underestimated.

Some data limitations should also be acknowledged. Specifically, there was some

difference in the reported number of health workers by each of the health authorities in

UAE. Similar limitations exist in Lebanon whereby no accurate estimates of physicians

and nurses exist. This creates a common need for both countries to develop a national

health workforce database that regularly collects and reports such information.

In terms of selection of key informants in Lebanon, the Ministry of Public Health

was the sole governmental source that was interviewed for this case study. This is because

the ministry is the most involved in HRH issues in Lebanon as compared to Ministries of

Education and Labor or other government affiliated associations.

In addition to the above, one major limitation in the UAE was the lack of

information on the private sector and also on the health authorities affiliated with the


Ministry of Internal Affairs and the Armed forces. This hindered our ability to make

accurate estimates on the available health workforce in the UAE since the three referenced

health authorities are also major players in the UAE health sector. It should also be noted

that very limited information was found on midwives, and some key informants reported

that this profession is not in high demand in UAE.

VIII. Conclusion

As documented in this two-country case study, both UAE and Lebanon are facing

challenges in recruiting and retaining their health workforce. This is due to the lack of

evidence-based HRH planning and a national strategy for health workforce in both

countries. There is much that can be done to better manage and retain health workers in

both countries. Building on the 2006 World Health Report which focused on the need for

country specific HRH strategies, both countries can use the above outlined

recommendations to respond to their specific challenges. The development of timely and

appropriate health workforce strategies is urgently needed since the quality of health

services delivered by each system highly depends on the availability of qualified health

workers in sufficient numbers. The findings generated from the two country case study

require immediate attention. The common challenge between the two countries, and

perhaps the most significant, is their limited ability to retain their existing health

workforce. Retention challenges common to both countries include unsatisfactory salaries,

limited career development opportunities, stressful working conditions and low job

satisfaction.

The unique context of the UAE creates exceptional challenges that may not be

faced by many countries. The UAE population is primarily composed of expatriates

(around 77%) who mostly come from poor Asian countries such as India and Pakistan and

to a lower extent from some Middle Eastern and Western countries. The country also has

limited entry by nationals into medical and nursing fields. To meet the growing health

needs of its expanding population, the country had to resort to recruiting non-national

health workers to meet population health needs. These collective challenges make it hard

for UAE to be self sufficient in terms of health workers. This is compounded by the poor

social image associated with the nursing profession and also the long time needed to


become a physician in a country which is primarily dependant on its business sector which

involves quick and high financial returns. This has created a heavy reliance on foreign

health workers, especially nurses. Financial incentives for national and foreign nurses

were previously a major attraction to the nursing profession in UAE. However, these

incentives have changed over the years and exacerbated by the high cost of living. In

addition, benefits packages are becoming less and less attractive. Financial incentives are

no longer attractive neither for nationals nor for foreign workers whether in nursing or in

the medical profession. However, foreign nurses are still attracted to the UAE since it is

viewed as a transit country where they can get exposed to the latest medical technology

which provides them with the experience needed to apply to job opportunities in Western

countries. Moreover, nurses working in countries like Canada, UK and USA can apply for

citizenship; an option which is not available in UAE and even other Gulf countries. Some

problems lie in the recruitment of foreign-trained health workers, specifically when it

comes to the qualifications of the health workforce. Continuing medical education is also

an issue in the UAE. Although it is important for staff development, it has also played a

role in increasing turnover rates since many of the non-national health workers cannot

afford such sessions which are essential for re-licensure. All these problems were

acknowledged by the key informants but little has been done since UAE and Lebanon lack

a health workforce strategy.

The lack of a health workforce strategy is also a challenge in the context of

Lebanon. However, policies exist in the areas of education, training and licensure, but

these policies are not periodically updated. An oversupply of physicians and an

undersupply of nurses constitute one of the major health workforce challenges for

Lebanon. Despite the oversupply of physicians in the country, the problem of geographic

maldistribution still exists. Moreover, the profession also suffers from specialty

maldistribution. A promising strategy is the newly emerging geographic information

system in Lebanon which can help determine the distribution of hospitals, beds, health

workforce, medical technology and other issues relating to health resources. However, the

effectiveness of this new system will depend on policies dealing with the stock and

qualifications of health workers. Nurse out-migration is a major issue that should be

focused on. Nurses are not only emigrating to work abroad, they are moving to different

careers altogether. In fact, 1 in 5 Lebanese nurses receiving a Bachelors degree is


migrating within 1 or 2 years of graduation. The most important reasons for migration

included financial incentives and career development. The assessment of nursing directors

also highlighted many retention challenges in Lebanese hospitals, namely unsatisfactory

salary and benefits; unsuitable shifts and working hours; presence of better opportunities

abroad; better opportunities in other hospitals within the country; workload; and instability

of the country. Working conditions in Lebanese health institutions are not proper and they

act as push factors for nurses either to find careers abroad or to leave the profession

altogether. Limited opportunities for continuing education is a serious problem in

Lebanon, whether for nurses or physicians. No formal continuing education program is

present or even required (a policy on re-licensure does not exist). These are the main

challenges that should be addressed in addition to the development of a strategy to manage

health workers in Lebanon.

The findings of this case study indicate that the UAE, in its position as a dynamic

and fast growing country, will continue to depend on foreign trained health workers to

meet current and future needs. On the other hand, Lebanon as a source country will

continue to lose its health workforce if nothing is done to address HRH challenges

particularly push factors. Prioritizing issues related to health workforce in both countries

will require solid leadership and a more efficient health sector. Health sector initiatives to

improving the health workforce required strong management and leadership capacities. If

the HRH leadership gap continues to exist, both countries will face severe challenges that

will impact its health care systems. This two-country case study clearly shows the need

for immediate action to address HRH in both countries.


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X. Appendices

Appendix I: Methods

A. General Data Sources Several data sources were used in compiling data for this case study. These

included:

– Literature search and review: For this case study, we reviewed evidence in the

literature and grey reports pertaining to health workers (specifically physicians,

nurses and midwives) in UAE and Lebanon. Compared to international literature,

information about HRH in the EMR and other Arab countries is scarce and

sometimes outdated. A search strategy was developed for the purpose of this search.

Using the strategy, we were able to identify numerous articles related to physicians,

nurses and midwives in the UAE and Lebanon and other developing Arab countries

in the region. The search was conducted using a database (Medline, CINAHL,

EMBASE) search, as well as websites of international organizations and

governmental agencies. We also searched the website of Ministries of Health and

Education, health authorities in UAE, websites of universities that have medical or

nursing schools, and websites of recruiting agencies. We also looked for

documentation available on websites of international organizations and health

professional associations (including United Nations, World Bank, International

Labor Organization, World Health Organization, the Eastern Mediterranean

Regional Office of the World Health Organization and the EMRO HRH observatory

among others). Information from these identified sources has been compiled and

was augmented by the findings from key informant interviews in the UAE and

Lebanon. The full search strategy used in this case study is enclosed in Appendix II.

– Survey of schools and universities in UAE and Lebanon: To assess the national

annual production of UAE and Lebanon in terms of health workers, we contacted all

university level medical, nursing and midwifery schools in both countries. All

participants were asked to report the number of graduates from their medical and/or

nursing schools since the year 2000. We initially planned to request data since the


year 1998 but many institutions in UAE and Lebanon did not have access to data

before 2000, moreover, many educational institutions in both countries started

admitting students into medical and nursing programs after the year 2000. The

survey used for schools in UAE differed slightly from those in Lebanon due to the

fact that Lebanon is a source country and UAE is a destination country. This is

further detailed in subsequent sections of this report.

– Recruiting agencies: Recruiting agencies in UAE and Lebanon were contacted and

requested to fill in a one-page survey. Recruiting agencies in UAE had a different

survey than agencies in Lebanon since each have their own operational context and

clientele. These differences are further detailed in subsequent sections of this report.

– Interviews with Key Informants: Key informants in UAE and Lebanon were

identified and recommended by WHO Geneva and WHO EMRO, in addition to

personal contacts in Lebanon and research network members in the region. Key

informants included representatives of:

Public Sector: Ministry of Health and Health Authorities in UAE

Health Professionals groups: Order of Physicians, Order of Nurses,

Syndicate of Hospitals, Associations of public health

Educational Institutions: Major universities and academic programs for

physicians, nurses and midwives

Hospital Administrators: Top executives at major hospitals in both UAE

and Lebanon

Recruiters: Recruiting agencies that specialise in the recruitment of health

professionals to countries of the Gulf, and particularly UAE

An interview schedule, supplemented by a list of questions, was created for key

informants in UAE and Lebanon. Similarly to other data sources, key informants in UAE

had a different interview tool than those in Lebanon. Data was collected through face to

face interviews, phone interviews and focus group discussions. Most interviews were tape

recorded (after consent of participants) and transcribed. Details pertaining to the questions

used in UAE and Lebanon are detailed in subsequent sections of this report.

Below is a detailed description of data collection and activities for the case study

for each of UAE and Lebanon.


B. Methods and Data Sources in UAE

1. Academic institutions in UAE With the assistance of several key informants and through an extensive search of

available information on WHO EMRO website, we identified the universities that train

and graduate physicians, nurses and midwives in the UAE. A letter detailing the

objectives of the study was prepared and sent to the deans and directors of the identified

schools and universities requesting their participation (See Appendix III). A data

collection template was also developed for schools and universities in UAE (See

Appendix IV). This template initially requested information dating back to 1998, but after

piloting the template, we realized that many schools have recently opened and the older

and more established schools may not have access to data dating before 2000. The

template was modified accordingly to request information on first year students, annual

number of graduates and number of national graduates from all participating schools and

universities from the year 2000 to 2008. It is worth noting, however, that some schools

were able to provide us with data dating back to 1998; this is reported accordingly in the

finding section in the report.

2. Recruiting agencies in UAE Recruitment agencies in the UAE were identified through contacting key

stakeholders in UAE. Two such agencies were contacted through a letter developed for

this purpose (See Appendix V for sample letter). A data collection template was

developed for recruitment agencies in UAE (See Appendix VI). This template included

questions on recruitment of physicians, nurses and midwives to the UAE, number of

recruited health workers since the year 2000, most attractive source countries, and

examples of benefits provided to recruited health workers.

3. Key informants/Stakeholders in UAE With the cooperation of WHO Geneva and WHO EMRO, we were able to identify

and contact key stakeholders in the UAE. These stakeholders hold positions in the

Ministry of Health, the Dubai Regional Health Authority and the Abu Dhabi Regional


Health Authority. Upon contacting those stakeholders, we asked them to identify

additional key informants using a template (See Appendix VII). The list of identified key

informants is enclosed in Appendix VIII. In addition to putting us in touch with key

informants in the UAE, they also provided us with data on supply of physicians, nurses

and midwives in the UAE in addition to reports and grey literature specific to the UAE.

During the months of June, July, and August we conducted field visits, and key

informant interviews in the UAE (See Appendix IX). A data collection trip to the UAE

was conducted between July 11th and 16th 2008. During this trip, we met with several key

informants (See Appendix IX) from the Ministry of Health, Regional Health Authorities

and hospital administrators who provided us with additional information that was missing

in our initial assessment for UAE. To gain a better understanding of recruitment and

turnover of foreign trained health workers in hospitals in UAE, we met with the director of

a major hospital in Abu Dhabi, Tawam hospital. This hospital served as a case study for

hospitals in the UAE, data collected from this hospital is detailed within the section on

findings from UAE.

C. Methods and Data Sources in Lebanon

1. Academic institutions in Lebanon We were able to identify all universities that train and graduate physicians, nurses

and midwives in Lebanon. Letters were sent to the identified schools and universities

informing them of the study objectives and requesting their participation (See Appendix

X). A data collection template was developed to collect information on number of first

year students and number of graduates between 2000 and 2008. We had originally

intended to request information dating back to 1998, but upon piloting the template, we

were informed that many universities, even the most well-established, did not start

regularly collecting such data until recently. We therefore changed the template

accordingly. The sample data collection template used for medical, nursing and midwifery

schools is enclosed in Appendix XI.


2. Recruiting agencies in Lebanon Recruitment agencies that recruit physicians, nurses and midwives to work in all

countries around the world, including UAE, were identified and contacted (See Appendix

XII for sample letter). A data collection template was developed for recruitment agencies

and was sent directly to the managers (See Appendix XIII). Some of the agencies have

replied and provided us with the needed information. Other agencies reported that they do

not recruit physicians, nurses or midwives to work in any country outside Lebanon.

3. Key Informants/Stakeholders in Lebanon Focus group discussions were conducted comprising stakeholders from

professional associations, educational institutions, hospital administrators, public sector

and recruitment agencies. Face-to-face interviews and focus group discussions were also

conducted with additional stakeholders to assess the challenges and priorities in regard to

HRH and specifically physicians, nurses and midwives in Lebanon. The list of informants

interviewed is enclosed in Appendix XIV.

We were also able to identify and interview some Lebanese nurses currently

working in UAE. A list of questions that were asked during phone interviews conducted is

enclosed in Appendix XV.

D. Data Analysis Data from different sources were compiled into databases to assist with data

analysis. Data was collected in both a qualitative and quantitative form. Thematic analysis

was used to analyze qualitative data. The data collected through one-to-one interviews,

phone interviews and focus groups was coded to better manage the rich data. Open coding

was first conducted; findings were read and broken into chunks that relate to different

concepts or ideas. Axial coding was then conducted; this involved organizing the

emerging concepts into topics. The data were then analyzed by recurring themes and

emerging patterns. Data from face to face interviews, phone interview and focus groups

were analyzed separately for each country. We also synthesized information from grey

report and literature was also conducted. Quantitative data was entered and analyzed on


MS Excel and SPSS as applicable. Data from UAE was analyzed separately from data

from Lebanon.


Appendix II: Search Strategy

List of Keywords used in Literature and Web Search

Regions: – Middle East and North Africa (MENA) – Eastern Mediterranean Region (EMRO) – Middle East, Arab countries

Countries:

– Lebanon – United Arab Emirates

If we are to search other countries in the region, we can use the following keywords: EMRO MENA 1 Afghanistan Algeria 2 Bahrain Bahrain 3 Cyprus Djibouti 4 Djibouti Egypt 5 Egypt Iran 6 Iran Iraq 7 Iraq Israel 8 Jordan Jordan 9 Kuwait Kuwait 10 Lebanon Lebanon 11 Libya Libya 12 Morocco Malta 13 Oman Morocco 14 Pakistan Oman 15 Qatar Qatar 16 Saudi Arabia Saudi Arabia 17 Somalia Syria 18 Sudan Tunisia 19 Syria United Arab Emirates 20 Tunisia West Bank and Gaza 21 United Arab Emirates Yemen 22 West Bank and Gaza Strip 23 Western Sahara 24 Yemen

EMRO does not include: Algeria, Israel and Malta MENA does not include: Afghanistan, Cyprus, Djibouti, Pakistan, and Sudan Human Resources for Health

– Health human resources – Human resources for health


– Health workers – Health Professionals – Nurses – Physicians – Scope of practice – Production – Attrition – Migration – Brain drain – Retention – Shortages – Supply and demand – Turnover – Physician to nurse ratios

Search strategy used for Medline, CINAHL and EMBASE Boolean operators such as “AND/OR/NOT” were used to combine some of the search terms below. Medline/CINAHL EMBASE Health Personnel/ “Health Personnel/” exp AND

[embase]/lim Health Manpower/ “Health Manpower” AND [embase]/lim Human Resources for Health.mp “human resources for health” AND

“human”/exp OR resources OR “health/”exp AND [embase]/lim

Health Human Resources.mp “health human resources” AND “health”/exp OR “human”/exp OR “resources” AND [embase]/lim

Health Workers.mp “health workers” AND [embase]/lim Nurses/ “Nurses”/exp AND [embase]/lim Nurs$.mp Nurse's Role/ “Nurses Role” AND [embase]/lim Physician's Role/ “Physicians Role” AND [embase]/lim Nurses, Male/ “Male Nurses” AND [embase]/lim Physicians/ “Physicians”/exp AND [embase]/lim Midwifery/ “Midwifery”/exp AND [embase]/lim Midwif$.mp Health Personnel/ “Health Personnel”/exp AND

[embase]/lim Nursing Staff, Hospital/ “nursing staff” OR “nursing”/exp AND

“staff”/exp AND [embase]/lim Job description/ “Job description”/exp AND

[embase]/lim Career Mobility/ “Career Mobility”/exp AND


Medline/CINAHL EMBASE [embase]/lim

Personnel Turnover/ “Personnel Turnover”/exp AND [embase]/lim

Staff Development/ “Staff Development”/exp AND [embase]/lim

Emigration and Immigration/ Emigration OR “Immigration”/exp AND [embase]/lim

Migration.mp “Migration”/exp AND [embase]/lim Brain drain.mp “brain drain” OR “brain”/exp AND

“drain”/exp AND [embase]/lim Job Satisfaction/ “job satisfaction” OR “job”/exp AND

“satisfaction”/exp AND [embase]/lim Employee Retention.mp “employee retention” OR

“employee”/exp AND retention AND [embase]/lim

Personnel Staffing and Scheduling/ “staffing” OR “scheduling” AND [embase]/lim

Health worker shortage.mp “health worker shortage” AND [embase]/lim

Nurse Shortage.mp “Nurse Shortage” AND [embase]/lim Physician Shortage.mp “Physician Shortage” AND

[embase]/lim Nurse turnover.mp “Nurse turnover” AND [embase]/lim Nursing Staff/ “Nursing Staff”/exp AND [embase]/lim Personnel Turnover/ “Personnel Turnover”/exp AND

[embase]/lim Physician turnover.mp “Physician turnover” AND

[embase]/lim Nurse to patient ratios.mp “Nurse to patient ratios” AND

[embase]/lim Country/Region Medline/CINAHL EMBASE (Middle East and North Africa).sh,cp,tw,ti.

Middle East and North Africa/ “Middle East and North Africa” AND [embase]/lim

(Eastern Mediterranean Region).sh,cp,tw,ti.

Eastern Mediterranean Region/ “Eastern Mediterranean Region” AND [embase]/lim

(Middle East).sh,cp,tw,ti. Middle East/ “Middle East”/exp AND [embase]/lim (Arab Countries).sh,cp,tw,ti.


Medline/CINAHL EMBASE Arab Countries/ “Arab Countries” AND [embase]/lim (Low Income Countries).sh,cp,tw,ti. Low Income Countries/ “Low Income Countries” AND

[embase]/lim (Low-Middle Income Countries).sh,cp,tw,ti.

Low-Middle Income Countries/ “Low-Middle Income Countries” AND [embase]/lim

(Middle Income Countries).sh,cp,tw,ti. Middle Income Countries/ “Middle Income Countries” AND

[embase]/lim (Developing Countries).sh,cp,tw,ti. Developing Countries/ “Developing Countries”/exp AND

[embase]/lim (Afghanistan).sh,cp,tw,ti. Afghanistan/ “Afghanistan”/exp AND [embase]/lim (Algeria).sh,cp,tw,ti. Algeria/ “Algeria”/exp AND [embase]/lim (Bahrain).sh,cp,tw,ti. Bahrain/ “Bahrain”/exp AND [embase]/lim (Cyprus).sh,cp,tw,ti. Cyprus/ “Cyprus”/exp AND [embase]/lim (Djibouti).sh,cp,tw,ti. Djibouti / “Djibouti”/exp AND [embase]/lim (Egypt).sh,cp,tw,ti. Egypt/ “Egypt”/exp AND [embase]/lim (Islamic Republic of Iran).sh,cp,tw,ti. Islamic Republic of Iran / “Islamic Republic of Iran”/exp AND

[embase]/lim (Iraq).sh,cp,tw,ti. Iraq/ “Iraq”/exp AND [embase]/lim (Jordan).sh,cp,tw,ti. Jordan/ “Jordan”/exp AND [embase]/lim (Kuwait).sh,cp,tw,ti. Kuwait/ “Kuwait”/exp AND [embase]/lim (Lebanon).sh,cp,tw,ti. Lebanon/ “Lebanon”/exp AND [embase]/lim (Libya).sh,cp,tw,ti. Libya/ “Libya”/exp AND [embase]/lim (Malta).sh,cp,tw,ti. Malta/ “Malta”/exp AND [embase]/lim (Morocco).sh,cp,tw,ti. Morocco/ “Morocco”/exp AND [embase]/lim (Oman).sh,cp,tw,ti. Oman/ “Oman”/exp AND [embase]/lim


Medline/CINAHL EMBASE (Qatar).sh,cp,tw,ti. Qatar/ “Qatar”/exp AND [embase]/lim (Kingdom of Saudi Arabia).sh,cp,tw,ti. Kingdom of Saudi Arabia/ “Kingdom of Saudi Arabia”/exp AND

[embase]/lim (Palestine).sh,cp,tw,ti. Palestine/ “Palestine”/exp AND [embase]/lim (West Bank and Gaza).sh,cp,tw,ti. West Bank and Gaza/ “West Bank and Gaza” AND

[embase]/lim (Occupied Palestinian Territories).sh,cp,tw,ti.

Occupied Palestinian Territories/ “Occupied Palestinian Territories” AND [embase]/lim

(Pakistan).sh,cp,tw,ti. Pakistan/ “Pakistan”/exp AND [embase]/lim (Somalia).sh,cp,tw,ti. Somalia/ “Somalia”/exp AND [embase]/lim (Sudan).sh,cp,tw,ti. Sudan/ “Sudan”/exp AND [embase]/lim (Syria).sh,cp,tw,ti. Syria/ “Syria”/exp AND [embase]/lim (Tunisia).sh,cp,tw,ti. Tunisia/ “Tunisia”/exp AND [embase]/lim (United Arab Emirates).sh,cp,tw,ti. United Arab Emirates/ “United Arab Emirates”/exp AND

[embase]/lim (Yemen) .sh,cp,tw,ti. Yemen/ “Yemen”/exp AND [embase]/lim


Appendix III: Letter sent to schools and universities in UAE

Dear (Name),

As you know, health worker retention and migration are two major challenges faced by many countries, especially lower income countries. To address this, the Department of Human Resources for Health, in WHO Geneva, has been working with Member States in offering guidance on effective human resource management policies and practices regarding migration and retention. One important element of the Department's work will be the formulation of recommendation regarding health worker migration and retention. The two Eastern Mediterranean countries selected for this case study are the United Arab Emirates and Lebanon.

This work will target physicians, nurses and midwives in the two selected

countries. The objective of this work is to analyze and discuss the context and the patterns of health professionals’ production, migration, recruitment and retention in the United Arab Emirates and Lebanon. Please note that this is the first of a series of case studies that will include other countries in the region with the aim of generating evidence that will inform health policy makers in formulating evidence based policies for the health workforce.

Kindly note that we have a very limited timeline, this UAE case study should be complete by July 15th 2008, including synthesis of all available literature and interviews with stakeholders. Thus all documentation and analysis should be completed during the month of June. Please find attached the one-page template for data collection. Due to the limited time we have available, we appreciate if you can provide us with the requested information by June 25th 2008. Kindly return the information template to Dr. Fadi El-Jardali by email on [email protected] or by fax on the number +961-01-744470.

We thank you in advance for your collaboration and we commit to sharing with

you the final report for this case study once it is complete. On behalf of WHO Geneva, and WHO EMRO, we would like to thank you in advance for your valuable contribution for this project. Please note that this contribution will be acknowledged. Should you have any questions, please feel free to contact me on the numbers provided below.


Appendix IV: Data collection template for medical, nursing and

midwifery schools in UAE

Data Collection Template School Name

Program Name

Number of years required to complete degree requirements: In the table below, kindly fill out the number of first year students and number of graduates from your (medical/nursing/midwifery) school for the indicated years.

Number of First Year Students

Number of Graduates

Number of National Graduates*

2000

2001

2002

2003

2004

2005

2006

2007

2008

*National graduates refers to UAE citizens

Do you know how many of your graduates are emigrating abroad within three years of

practice?

– Can you estimate how many graduates are emigrating?

– To your knowledge, what are the top three reasons for emigrating?

1.

2.

3.


Appendix V: Letter sent to Recruitment agencies in UAE

To: (Name of Recruitment Agency Manager)

You have been identified as a key stakeholder by the UAE Ministry of Health. As you know, health worker retention and migration are two major challenges

faced by many countries, especially lower income countries. To address this, the Department of Human Resources for Health, in WHO Geneva, has been working with Member States in offering guidance on effective human resource management policies and practices regarding migration and retention. One important element of the Department's work will be the formulation of recommendation regarding health worker migration and retention. The two Eastern Mediterranean countries selected for this case study are the United Arab Emirates and Lebanon.


countries. The objective of this work is to analyze and discuss the context and the patterns of health professionals production, migration, recruitment and retention in the United Arab Emirates and Lebanon. Please note that this is the first of a series of case studies that will include other countries in the region with the aim of generating evidence that will inform health policy makers in formulating evidence based policies for the health workforce.

Kindly note that we have a very limited timeline, this UAE case study should be complete by July 15th 2008, including synthesis of all available literature and interviews with stakeholders. Thus all documentation and analysis should be completed during the month of June. Please find attached the one-page template for data collection. Due to the limited time we have available, we appreciate if you can provide us with the requested information by June 25th 2008. Kindly return the information template to Dr. Fadi El-Jardali by email on [email protected] or by fax on the number +961-1-744470.




Appendix VI: Data collection template sent to Recruitment agencies in

UAE

Analysis of Health Professionals Migration, Recruitment and Retention Two Country Case Study

Recruitment Agency Name

1. Do you actively recruit physicians, nurses or midwives to practice in the UAE?

2. Can you please estimate how many physicians, nurses or midwives have been

recruited through your agency to work in the UAE since the year 2000?

Estimated number Nationals ExpatriatesPhysicians Nurses Midwives

3. Do you recruit physicians, nurses or midwives to practice in other countries? If

yes, what are the three most attractive countries for recruitment of health professionals?

4. Why do you think physicians, nurses or midwives choose to emigrate to UAE?

5. Can you provide some examples of what is included in a benefits package offered

by health organizations in the UAE offer to physicians, nurses or midwives?

6. What are the top three source countries from which you recruit health

professionals to work in the UAE?


Appendix VII: Template for Key Informant Identification (UAE)

This template will be used to identify key informants for interviews (both face to face

and phone interviews) in the UAE. Please suggest to us up to 3 key informants

representing each of:

– Officials at the Ministry of Health, and if possible Ministry of Education

– Representatives from Professional associations (health professional orders and/or

syndicates),

– Directors of medical, nursing and midwifery schools

– Directors of key health organizations and hospitals in the UAE.

– Recruitment agencies that specialize in recruitment of health professionals in the

UAE.

Below is a table you can fill in for this purpose.

Name of Key Informant Position/professional title Contact Information Given the limited timeline, we really appreciated if you can provide it to us by June 7th, 2008.


Appendix VIII: UAE Key informants identified

Affiliation Name Position/professional title Best Practice Jacqui Parle Director-Benchmarking Services Department of Health & Medical Services-Dubai Essa Kazim Assistant Director General (Medical

Affairs) Department of Health & Medical Services-Dubai

Essa Kazim Assistant Director General (Medical Affairs)

Dubai Medical College Prof. Mohammed Galal El Din Dean

Dubai Regional Health Authority

Laila Al Jassami Director of Planning & Statistics, Director of Health Funding Project for DHA

Emirates Medical Association

Dr.Abdulla Ibrahim Al-Khaiat President

Emirates Medical Association Abdullrahim Mostafawi Vice President

General Authority for Health Service for the Emirate of Abu Dhabi

Mariam Elmobasher CME/CPD

Government of Dubai Hassan Mohammad Murad Almazmi

Office of the Asst. Director General (Medical Affairs), Department of Health and Medical Services - DOHMS

Government of Dubai Judith Brown Director of Nursing and Midwifery Services

Gulf Medical College Dr. Gita Ashok Raj Dean and Professor of Pathology Health Authority-Abu Dhabi

Nawal Khalid CME/CPD officer

Health Authority-Abu Dhabi

Maysoon Alkaram Head PGE

Health Authority-AbuDhabi Eng. Zaid Dawood General Director

Horizon Younis Amiri Chairman

Ministry of Health Dr. Ali ahmed bin Shakar General Director

Ministry of Health Dr. Mahmoud Fikri Executive Director Of Health Policies

Ministry of Health Ameen Al-Ameeri Executive Director For Medical Practices And Licensing

Ministry of Health AbdulGhaffar Abdulghaffur Minister Consultant MOH-Dubai Ali Bin Shaker Director General MOH-Dubai Munther Al Kayyali Advisor


Affiliation Name Position/professional title MOH-Dubai Maryam Al Marri HR Manager MOH-Dubai Fatima Al Rifai Director of Department of Nursing,

Federal Department of Nursing MOH-Dubai Ghada Sherry Head, Practice Development Section,

Federal Department of Nursing RITCH Malik Mlhim General Director Sharjah Univerdity Dr. Hossam Hamdy Dean of College of Health Sciences Tawam Hospital (Al Ain, Abu Dhabi)

Maha Chaltaf Executive Medical Assistant

Tawam Hospital (Al Ain, Abu Dhabi)

Michael E. Heindel CEO


Steven A. Matarelli Chief Clinical Officer


Jack C. Borders Chief Medical Officer

UAE University Dr. George Carruthers Deans of Medicine and Health Sciences

UAE University Ms. Nawal Al Dhafri Office of Research and Graduate Studies

Zayed University Chris Nuttman Professor and Department Chair, Natural Science and Public Health


Appendix IX: UAE Key informants interviewed

Name Affiliation Position Ali Bin Shaker MOH-Dubai Director General Munther Al Kayyali MOH-Dubai Advisor Maryam Al Marri MOH-Dubai HR Manager Fatima Al Rifai MOH-Dubai Director of Department of Nursing,

Federal Department of Nursing Hassan Mohammad Murad Almazmi

Government of Dubai Office of the Asst. Director General (Medical Affairs), Department of Health and Medical Services - DOHMS

Judith Brown Government of Dubai Director of Nursing and Midwifery Services

Essa Kazim Department of Health & Medical Services-Dubai

Assistant Director General (Medical Affairs)

Laila Al Jassami Dubai Regional Health Authority

Director of Planning & Statistics, Director of Health Funding Project for DHA

Ghada Sherry MOH-Dubai Head, Practice Development Section, Federal Department of Nursing

Mariam Elmobasher General Authority for Health Service for the Emirate of Abu Dhabi

CME/CPD

Nawal Khalid Health Authority-Abu Dhabi CME/CPD officer Maysoon Alkaram Health Authority-Abu Dhabi Head PGE Jacqui Parle Best Practice Director-Benchmarking Services Maha Chaltaf Tawam Hospital (Al Ain, Abu

Dhabi) Executive Medical Assistant

Michael E. Heindel Tawam Hospital (Al Ain, Abu Dhabi)

CEO

Steven A. Matarelli Tawam Hospital (Al Ain, Abu Dhabi)

Chief Clinical Officer

Jack C. Borders Tawam Hospital (Al Ain, Abu Dhabi)

Chief Medical Officer


Appendix X: Letter sent to schools and universities in Lebanon

Dear (Name),

As you know, health worker retention and migration are two major challenges faced by many countries, especially lower income countries. To address this, the Department of Human Resources for Health, in WHO Geneva, has been working with Member States in offering guidance on effective human resource management policies and practices regarding migration and retention. One important element of the Department's work will be the formulation of recommendation regarding health worker migration and retention. The two Eastern Mediterranean countries selected for this case study are Lebanon and the United Arab Emirates. As you know, and due to the culture of migration, Lebanon as the highest emigration factor in the Middle East and North Africa and thus it is an illustrative case of health professional migration.


countries. The objective of this work is to analyze and discuss the context and the patterns of health professionals’ production, migration, recruitment and retention in Lebanon and the United Arab Emirates. Please note that this is the first of a series of case studies that will include other countries in the region with the aim of generating evidence that will inform health policy makers in formulating evidence based policies for the health workforce.

Kindly note that we have a very limited timeline, this Lebanon case study should be complete by July 15th 2008, including synthesis of all available literature and interviews with stakeholders. Thus all documentation and analysis should be completed during the month of June. Please find attached the one-page template for data collection. Due to the limited time we have available, we appreciate if you can provide us with the requested information by June 25th 2008. Kindly return the information template to Dr. Fadi El-Jardali by email on [email protected] or by fax on the number +961-01-744470.




Appendix XI: Data collection template for medical, nursing and

midwifery schools in Lebanon

Analysis of Health Professionals Migration, Recruitment and Retention Data Collection Template

University Name

Number of years required to complete degree requirements:

In the table below, kindly fill out the number of first year students and number of graduates from your medical school for the indicated years.

Number of First Year Students* Number of Graduates 2000

2001

2002

2003

2004

2005

2006

2007

2008

*in case you do not know the exact number, please provide the nearest estimate

Do you know how many of your graduates are emigrating abroad within three years of

practice?

– Can you estimate how many students are emigrating?

What are the three most preferable destination countries?

Gulf Countries Europe North America (USA and Canada)

Other: Please specify:


Appendix XII: Letter sent to Recruitment agencies in Lebanon

To: (Name of Manager of Recruitment Agency)

As you know, health worker retention and migration are two major challenges faced by many countries, especially lower income countries. To address this, the Department of Human Resources for Health, in WHO Geneva, has been working with Member States in offering guidance on effective human resource management policies and practices regarding migration and retention. One important element of the Department's work will be the formulation of recommendation regarding health worker migration and retention. The two Eastern Mediterranean countries selected for this case study are Lebanon and the United Arab Emirates. As you know, and due to the culture of migration, Lebanon as the highest emigration factor in the Middle East and North Africa and thus it is an illustrative case of health professional migration.


countries. The objective of this work is to analyze and discuss the context and the patterns of health professionals production, migration, recruitment and retention in Lebanon and the United Arab Emirates. Please note that this is the first of a series of case studies that will include other countries in the region with the aim of generating evidence that will inform health policy makers in formulating evidence based policies for the health workforce.

Kindly note that we have a very limited timeline, this Lebanon case study should be complete by July 15th 2008, including synthesis of all available literature and interviews with stakeholders. Thus all documentation and analysis should be completed during the month of June. Please find attached the one-page template for data collection. Due to the limited time we have available, we appreciate if you can provide us with the requested information by June 25th 2008. Kindly return the information template to Dr. Fadi El-Jardali by email on [email protected] or by fax on the number +961-01-744470.




Appendix XIII: Data collection template sent to Recruitment agencies in

Lebanon

Analysis of Health Professionals Migration, Recruitment and Retention

Recruitment Agency Name

1. Do you recruit physicians, nurses or midwives to practice in the UAE? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

2. Can you please estimate how many physicians, nurses or midwives were recruited

through your agency to work in the UAE since the year 2000?

Estimated numberPhysicians Nurses Midwives

3. Do you recruit physicians, nurses or midwives to practice in other countries? If

yes, what are the three most attractive countries for recruitment of health professionals?

___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________

4. Why do you think physicians, nurses or midwives choose to emigrate? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 5. Can you provide some examples of what is included in a benefits package offered

by health organizations in the UAE offer to physicians, nurses or midwives? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 6. To your knowledge, are the health professionals recruited from Lebanon offered

better positions (higher rank not only salary) than the ones they had in Lebanon? ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________


Appendix XIV: Key informants interviewed in Lebanon

Affiliation Position

Syndicate of Private Hospitals President

Order of Nurses in Lebanon President

Rafic Hariri Hospital Chief Executive Officer

Lebanese Order of Physicians - Beirut President

Order of Medecin _North President

Universite Antonine Directrice du Departement des Sciences Infermiere

Makassed University Director College of Nursing

American University of Beirut -Faculty of Medicine Professor

University of Balamand- Faculty of Medicine Dean

Internal Security Forces Medical Doctor

S t. George Hospital Director

International Health Resources Cooperation Managing Director

American University of Beirut Associate Dean of Clinical Affaires

Ministry of Health Director General


Appendix XV: Questions asked during phone interviews with Lebanese

nurses working in UAE

1. When did you leave to UAE? 2. Why did you choose to emigrate to UAE? 3. Why do you think Lebanese nurses choose to go to UAE? 4. Did you find many other Lebanese nurses working in UAE? 5. What are the nationalities of other nurses in UAE? 6. What is the intensity of migration of Lebanese nurses to UAE? 7. Do you think that hospitals in the UAE engage in active recruitment of Lebanese

nurses? How about nurses of other specialties? 8. Do you know whether the UAE has bilateral agreements with any countries in the

region? 9. Do you think Lebanese nurses have any problems integrating with the UAE

culture? How about other nurses? How about patients? 10. Do you have any idea about the availability of institutional nurse retention

strategies? 11. Do you think that there are many vacancies for nurses in UAE? Do you think there

is a preference for Lebanese nurses or Pakistani and Indian nurses? Why? 12. How were you recruited to the UAE (recruitment agency…)? 13. Do you work in a private or public healthcare center? 14. In general is emigration to the UAE temporary or permanent? 15. Do you know if working conditions, salaries and contracts differ between the

private and public sector? 16. Did you receive any training upon your arrival to the organization? 17. Do foreign nurses receive any training? 18. How are the working conditions (workload/safety/communication) in you

organization and in the UAE in general? 19. Can you estimate the percentage of foreign/national nurses working in your

organization? 20. What countries do the majority of foreign nurses come from? 21. Is there a difference in salaries between workers with similar job titles? Do you, as

a Lebanese, get paid more than foreign nurses who come from other countries? 22. Do nationals get paid more than foreigners? Better benefits? 23. Do you think that, as a Lebanese, you are more qualified than other foreign nurses?

National nurses? 24. How is your relationship with other foreign nurses (differences in education, skills,

communication, language, culture)? National nurses? 25. Are there a lot of Lebanese nurses/doctors in the organization you work in or in

UAE in general? Is there a specific region in the UAE that attracts Lebanese nurses/doctors more than others?

26. Are national nurses treated better than foreign nurses? 27. Do national/foreign nurses receive continuing education? 28. Do you have any idea about how doctors, particularly national doctors?


Appendix XVI: Detailed distribution of physicians registered in DOHMS

by nationality

Country N %UAE 225 32.6%Iraq 84 12.2%India 70 10.1%Pakistan 69 10.0%Egypt 64 9.3%Jordan 29 4.2%Sudan 21 3.0%Palestine 19 2.8%Syria 15 2.2%Iran 13 1.9%UK 8 1.2%German 7 1.0%Yemen 7 1.0%Lebanon 5 0.7%Bahrain 4 0.6%Australia 3 0.4%Bosnia 3 0.4%Canada 3 0.4%Oman 3 0.4%Somalia 3 0.4%Bulgaria 2 0.3%France 2 0.3%Sweden 2 0.3%USA 2 0.3%Yugoslavia 2 0.3%Argentina 1 0.1%Austria 1 0.1%Bangladesh 1 0.1%Cuba 1 0.1%Ireland 1 0.1%Libya 1 0.1%Macedonia 1 0.1%Mauritania 1 0.1%Nigeria 1 0.1%Norway 1 0.1%Romania 1 0.1%Tanzania 1 0.1%Tunisia 1 0.1%Ukraine 1 0.1%Others 11 1.6%Total 690 100.0%


Appendix XVII: Detailed distribution of nurses employed in MOH

facilities across districts

District Number of Nurses

Dubai Medical District NumberMOH 1Al Barah Hospital 186Al Amal Hospital 69PHC 46School Health 79Prev. Med. 16Dental 9Total 406

Sharjah Medical District NumberMOH 2Al Qassimi Hospital. 370Khorfakan Hospital. 145PHC 75Dhaid Hospital. 110Kalba Hospital. 153School Health 77MCH 20Prev. Med. 18Kuwait Hospital. 180Dental Services 18Total 1168


Ajman Medical District NumberMOH 2Sheikh Khalifa Hospital. 238School Health 33PHC 29Prev.Med. 2MCH 7Dental Clininc 3Nurses' Hostel 1Total 315

UAQ Medical District NumberMOH 3UAQ Hospital. 148PHC 20School Health 24Prev.Med. 8Dental services 8Total 211

RAK Medical District NumberMOH 3Seif B. Ghabash 164Saquar Hospital 280PHC 87Shaam Hospital. 33Prev. Med. 6School Health 41Dental Centre 9Total 623


Fujeirah Medical District NumberMOH 1Fujeirah Hospital. 232Dibba Hospital. 111Prev. Med.. 9PHC 33School Health 26Dental Centre 8Total 420


Appendix XVIII: Detailed distribution of nurses registered in DOHMS

by nationality

Country N %India 1,010 53.6%Philippines 642 34.0%UAE 63 3.3%Jordan 29 1.5%Palestine 26 1.4%Iran 24 1.3%Sudan 23 1.2%Egypt 22 1.2%Pakistan 13 0.7%UK 6 0.3%Nigeria 5 0.3%Somalia 4 0.2%Syria 3 0.2%Australia 2 0.1%Kenya 2 0.1%Algeria 1 0.1%Bahrain 1 0.1%Canada 1 0.1%Indonesia 1 0.1%Iraq 1 0.1%Lebanon 1 0.1%Morocco 1 0.1%Tanzania 1 0.1%USA 1 0.1%Yemen 1 0.1%Others 2 0.1%Total 1,886 100.0%


Appendix XIX: Detailed response from MOH ION and Institute of

Applied Technology

Table 1: Number of Graduates in the Ministry of Health Institutes of Nursing in the Three Branches

Sharjah Fujairah Ras Al Khaima

1st year Graduates 1st year Graduates 1st year Graduates 1998 41 12 31 10 0 0 1999 35 12 39 7 0 0 2000 48 24 32 12 0 0 2001 42 42 39 27 54 0 2002 47 33 56 26 43 0 2003 59 45 46 36 56 0 2004 57 40 72 35 55 44 2005 70 36 67 41 66 32 2006 76 41 78 25 79 38 2007 69 31 70 26 78 31 2008 51 23 34 Total 544 367 530 268 431 179

Table 1: Number of Graduates in the Institute Applied Technology in the two Branches* Abu Dhabi Al-Ain Total1998 32 10 421999 0 0 02000 29 24 532001 50 43 932002 46 42 882003 47 40 872004 68 52 1202005 57 44 1012006 50 32 822007 45 48 93Total 424 335 759* Institute Applied Technology only provided number of graduates


Appendix XX: Detailed list of nationalities of physicians and nurses

employed in Tawam hospital

Physicians Nurses N % N %Algeria 5 1.1% 0 0.0%Australia 0 0.0% 27 2.1%Austria 1 0.2% 0 0.0%Bangladesh 0 0.0% 5 0.4%Belgium 3 0.6% 0 0.0%Brazil 1 0.2% 0 0.0%Britain 21 4.5% 42 3.3%Canada 10 2.2% 0 0.0%Denmark 3 0.6% 1 0.1%Egypt 32 6.9% 4 0.3%Ethiopia 0 0.0% 34 2.7%Fiji 0 0.0% 3 0.2%Finland 1 0.2% 1 0.1%France 3 0.6% 0 0.0%Germany 16 3.5% 1 0.1%Hungary 13 2.8% 0 0.0%India 28 6.1% 196 15.3%Iran 1 0.2% 0 0.0%Iraq 52 11.3% 1 0.1%Ireland 4 0.9% 0 0.0%Jordan 23 5.0% 160 12.5%Kuwait 0 0.0% 1 0.1%Lebanon 37 8.0% 59 4.6%Libya 9 1.9% 0 0.0%Malaysia 0 0.0% 13 1.0%Marshal Island 0 0.0% 1 0.1%Morocco 0 0.0% 1 0.1%New Zealand 3 0.6% 12 0.9%Nigeria 1 0.2% 1 0.1%Oman 0 0.0% 6 0.5%Pakistan 54 11.7% 12 0.9%Palestine 5 1.1% 17 1.3%Philippines 0 0.0% 477 37.2%Poland 1 0.2% 0 0.0%Romania 1 0.2% 1 0.1%Scotland 0 0.0% 1 0.1%Singapore 0 0.0% 2 0.2%Somalia 0 0.0% 2 0.2%South Africa 11 2.4% 122 9.5%Spain 1 0.2% 0 0.0%


Physicians Nurses N % N %Sri Lanka 0 0.0% 6 0.5%Sudan 19 4.1% 20 1.6%Sweden 8 1.7% 2 0.2%Switzerland 0 0.0% 1 0.1%Syria 32 6.9% 0 0.0%Tunisia 0 0.0% 2 0.2%UAE 25 5.4% 36 2.8%Ukraine 1 0.2% 0 0.0%USA 33 7.1% 8 0.6%Yemen 3 0.6% 4 0.3%Yugoslavia 1 0.2% 0 0.0%Total 462 100.0% 1282 100.0%


Appendix XXI: Detailed distribution of 1st year students and graduates from three branches of the Lebanese

University School of Nursing

Saida English* Saida French* Ain Wzein Zahle Total 1st year Graduates 1st year Graduates 1st year Graduates 1st year Graduates 1st year Graduates2000 25 15 27 15 15 6 30 15 97 512001 24 21 24 24 12 15 46 26 106 862002 26 24 26 22 11 15 53 26 116 872003 27 23 29 22 16 12 44 28 116 852004 25 17 27 22 14 12 52 34 118 852005 26 20 25 21 12 10 54 44 117 952006 26 22 26 22 8 9 56 38 116 912007 26 23 28 25 10 11 42 40 106 992008 35 20 35 21 15 8 51 45 136 94

Total 240 185 247 194 113 98 428 296 1028 773*It should be noted that the Saida branch offers one program in French and another in English


Appendix XXII: Data received from Nursing Schools in Lebanon on program duration, number of students

migrating and most preferable destination

Program duration

Number of nurses migrating out within 3 years

Most preferable destination

Saint Joseph University School of Nursing 3 Gulf, Europe, North America

Beirut Arab University 4

AUB School of Nursing school 3 110 over the last 3 years, average 37 per year North America

Lebanese University (Saida -English) 4 7-10 per year Gulf, North America Lebanese University (Saida -French) 4 5-8 per year Europe Lebanese University (Ain Wazein) 4 3-4 per year Gulf, Europe

Lebanese University (Zahle) 4 23 Gulf (5), Europe (8), North America (10)

analysis of health professionals migration: a two-country ... · analysis of health professionals...

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