Potential of Exporting Nursing from Bangladesh: How much to be Spent
Before jumping into the potential of exporting nurses, we must acknowledge the fact that Bangladesh has serious lack of healthcare workforce; the situation is even dire when it comes to number of nurses. According to latest health care survey, there are only 0.2996 nurses per 1,000 population, lowest in the South East Asia. Sri Lanka has the highest density of nurses in the region: 2.8 per 1,000 population. The number of nurses for India, Nepal, Bhutan per 1000 population stand at 2.1, 2.0, and 1.5 respectively. Only Pakistan has a comparable number of Nurses (0.5 per 1000 population). To catch the standard of Sri Lanka, we need 2.5 lac additional nurses at this moment. Despite several efforts by the government, due to miserable social image of nurses, Nursing has not been a popular choice as profession. Lately, number of nurses is increasing but to catch up the requirement, it might take as long as 2040 at even a fourth gear. At a survey conducted by BMMRU, university students opined that they would prefer nursing as a career if they could get a job at Developed countries. The same study found that nursing students believe that migration in a developed country can increase the social standard of nurses.
Bangladesh faces a net trade deficit, the imports are mostly related to RMG raw materials, minerals and capital machineries. The importance of foreign reserve is very important in financing the gap; and stability of the currency also depends on the steadiness of foreign reserve. Historically, foreign remittance has played the second most important role apart from RMG to build a healthy foreign reserve. In recent times, Bangladesh is facing a hard time to get a healthy growth and steady flow in the inward remittances. The foreign remittance went down from 14.9 bn USD in 2015-16 to 12.8bn USD in 2016-17. In 2017-18 the number is getting back to the 2015-16 number, but a real growth is missing. The major hurdle behind the struggle is attributable to the mix of migration from Bangladesh: Bangladesh produces a very small percentage of professional work force to maintain a stability and growth of remittance earned. According to the latest BMET data, only 2% of total migration in 2017-18 are professionals. Doctors, engineers, teachers, nurses are included in the professional category.
There is a scarcity of nurses globally in the developed economy: a major contributing factor is rise of ageing population. The UN estimates that the number of people above the age of 80 will more than triple until the middle of the century, from 125 million in 2015 to 434 million in 2050 (UN, 2015). Population aging is presently mainly a problem of high-income countries, with Japan, Germany, and Italy being the most aged countries (2015) (OECD, 2014). Collected from OECD and other sources, by 2030, 40mn healthcare jobs will be created globally. There will be a shortfall of 7.6mn Nurses by the same timeframe. Alone China will need 1mn Nurses; US and Japan will require 0.44mn and 0.38mn Nurses by 2030. Healthcare shortfall will also be severe factor in the European countries as well. Among many factors contributing to the global shortfall of nurses are: lack of interest in Nursing; substandard working conditions; gender bias. With increasing need for healthcare forces, developed countries will move towards importing nurses and doctors. The percentage of foreign trained healthcare forces look like: Canada: 24%, UK: 28%, Australia: 18%, Switzerland: 27%, and New Zealand: 42.4%. The need for nurses is even more in middle east: Bangladesh already produces significant workforce for middle east, but most of them are less-skilled. The popular destination for Nurses could be categorized as: North America, Europe and UK, Gulf Countries, Easter Asia (Japan and China), and South Asia (Singapore, Malaysia, Thailand).
Many mobile nurses, migrate from middle-income countries like the Philippines India, Nigeria or Ukraine to richer countries in North America, Europe, and the Persian Gulf region. This trend is reflected by the countries of origin of foreign nurses in the U.S.: 76 percent of foreign-born RNs in the U.S. in 2015 were from Asia, Africa, Latin America and the Caribbean, compared to only 24 percent from Canada and Europe
.Immigrants from the Philippines accounted for nearly 30 percent of the 486,000 immigrants working as registered nurses, followed by those from India (6 percent) and Nigeria (5 percent)
. An Organization for Economic Co-operation and Development study reported that one of every six foreign-born nurses in the OECD countries is from the Philippines. Of all employed Filipino RNs, roughly 85% are working overseas (source:wiki
). The United States has an especially prominent representation of Filipino nurses. Of the 100,000 foreign nurses working in the U.S. as of 2000, 32.6% were from the Philippines (source: wiki).India, in particular, the southern state of Kerala, is another top supplier of migrant nurses worldwide.
There is no specific data available on how much nurse went from Bangladesh. But as per a BMET 2004 report, 1195 nurses as of 2004 were working outside Bangladesh mostly to Middle East countries.Suadi Arab has been the major destination for Nurses: more than 80% went to the Muslim Country.There is a sharp decline in the number of nurses going abroad since then. Many of the countries gave BSc as minimum requirement for Nurse migration, and nursing education in Bangladesh has been diploma based mostly. Only recently special attention is given to higher education potential in nursing in Bangladesh. However, apart from education level, education and professional standard have been a major concern to the destination countries.A Focused group study in (Aminuzamman, 2007) came up with the following categorical reasons behind the decline in the number of nurses going abroad:Lack of professional skills and training; Lack of behavioral skills and cultural orientation; Poor communication skills; Absence of Inter-personal skills and professional attitude; ‘Too conservative’ towards their male counterparts and professional colleagues; Lack of a comprehensive strategic plan for the exportation of skilled manpower (including nurses)
Government has to take multidimensional policy approaches to create an export heavy nursing profession in Bangladesh. It needs to start from education: Historically nursing has been diploma based in Bangladesh; only recently BSc qualification available. In 2012, there were 500 seats for BSc in nursing against 3070 seats for Diploma in nursing education. As of 2017, number of seats in BSc in nursing is 5195 and number of seats in diploma stand at 2630. Many thanks to the government for addressing the issue: many countries give a bar of BSc requirement for nursing migration. To lift up the standard of nursing education, foreign collaboration is required. Few institutions in Bangladesh are working on models to promote nursing education of high standard. IUBAT’s nursing college, The Grameen Caledonian College of Nursing (GCCN), and Sonar Bangla Foundation Nursing Institute (SBFBI) are great examples of promising quality nursing education in Bangladesh. IUBAT has nursing college in collaboration with Canada; a Dr. Karen Lund is a chair in that school. GCCN has an extra ordinary self-sustainable social business model, in collaboration with Scotland’s Glasgow Caledonian University and financed by Nike foundation. SBFNI is strategically positioned at Lamonirhat to attract students from Nepal, Bhutan and India. More innovative private sector contribution is required, partnership with the government can help improve the quality of education.
In Philippines, nursing education is led by the private institutions, but migration process is handled by the government. It is a very important learning for Bangladesh from such a successful case. The government needs to streamline migration procedure, otherwise all efforts can go astray. Another important aspect we can learn from Philippines and our past experience, communication, behavioral and cross-cultural skills are very important for nurses and Bangladeshi nurses lack in these skills. being an extremely service oriented practice, nursing education must entail these learning objectives. Language learning is also very important: Bangladesh could set country-wise targets and avail language opportunities proportionately. A G2G agreement is very effective in these cases, as recently India has done with UK.
Promoting private nursing education is challenging in Bangladesh, due to the rules published in 2009. A 2013 policy survey showed, this 2009 rules is a major hurdle behind a private sector investment in nursing education in Bangladesh. To offer nursing courses and to establish nursing institutes, a huge infrastructure is required. As per the previous policy, 100-bed general hospitals were required for nursing education. Thankfully in the latest version it has been waived by an agreement with any hospital with such facility. More realistic policies need to be developed with the best intention in mind and ensuring the quality of education.
A simplistic analysis is done with the available and surveyed information. At present around 504k university grads are either unemployed or underemployed (Authors’ Calculation). Increasing the number of nurses will help the address the issue of unemployment. Latest data shows a 6.5% growth in number of doctors, and growth in number of nurses is 12.3%. An accelerated growth in number of nurses can help us achieve a standard doctor-nurse ratio and reach a level of unemployment and underemployment with tertiary level education to theoretical zero. At present 50% seats are in the government institutions. It is assumed to reach 30% by 2030, to get a peer level average. The cost of nursing education in the government institutions is kept zero; however, there is a huge prospect for private organizations. We did not find the exact profitability from nursing education, but the export potential of nurses gives a huge growth insurance for the private organizations. Government has at least two major incentives to promote nursing education:
An organic domestic need and demand of nurses: this can address the unemployment as already discussed and a balance in the healthcare workforce.
Immense export potential of exporting nurses: migration of nurses can provide stability in remittance and foreign reserve. This will also meet the target set by the government to increase professionals and skilled labor export. It will also attract private investment into education space of Bangladesh, increase the attractiveness of nursing as a profession. Find at the below chart, we have come up with the outcome of investment from the government and remittance earned. Only till 2030, new establishment investment is considered. After that only operating expenses are the costs from the government. To come up with the outcome, many assumptions are taken from the evidences of India, Philippines.
Lastly, the migration procedures have to be as clean and efficient as possible. Migration of nurses is a lengthy and costly process. Philippines has an NCLEX testing center in Manilla: the exam is a requirement for work permit in the US. Many other north American countries allow the exam passed nurses to work. Bangladesh should work to establish a center in Bangladesh. Government can establish a fund to finance the students who are migrating to developed countries. They are assured a steady income, and can pay off easily. IN this respect, the social business model of GCCN is very encouraging.
Nursing as a profession brings huge potential for Bangladesh, both as a tool for reducing unemployment and bringing balance in the healthcare system. The global demand of nurses and potential supply of nurses in Bangladesh is a great opportunity to grab. This can bring a steady flow of foreign remittance, and make the profession attractive. A conducive policy is required- evidence from Philippines and India can help us build a more rigid policy. Philippines is a country that has used the gap potential for more than decade. India is the latest one to leverage the potential. However, it comes at an expense of brain-drain, which is a big concern in India. However, in Bangladesh it will upend the social image of nursing. And the positive effect is likely to surpass the negative ones. The three important preparations are needed: a) educational excellency; b) professional standard increase; and c) migration process easiness. Financing is an important issue, because people might not want to invest so heavily in human resource. The social business model of Grameen Caledonian College of Nursing can give us a good case study of socially and economically viable financing system. Moreover, collaboration with international institutions can also upgrade the level of education. A long-term view is needed from the government; a brand could be created to increase awareness among the mass. We hope that Bangladesh will ensure a healthier future by investing in Nursing education.
Source: Research paper (MM Haque).