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
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
El-Jardali, et al. 2008
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b) Successes and Opportunities in Lebanon ____________________________ 108
c) Recommendations for Lebanon ___________________________________ 109
VII.
Limitations_____________________________________________________ 111
VIII.
IX.
X.
Conclusion___________________________________________________ 112
References _____________________________________________________ 115
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
El-Jardali, et al. 2008
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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 (19962004) ________________________________________________________________ 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
El-Jardali, et al. 2008
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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
El-Jardali, et al. 2008
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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
El-Jardali, et al. 2008
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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
El-Jardali, et al. 2008
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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.
El-Jardali, et al. 2008
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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
El-Jardali, et al. 2008
8
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.
El-Jardali, et al. 2008
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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.
El-Jardali, et al. 2008
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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
El-Jardali, et al. 2008
11
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).
El-Jardali, et al. 2008
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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).
El-Jardali, et al. 2008
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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).
El-Jardali, et al. 2008
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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
El-Jardali, et al. 2008
15
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.
El-Jardali, et al. 2008
16
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%)
El-Jardali, et al. 2008
17
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
Iran
2%
Other
5%
Jordan/Palestine
5%
Philippines
5%
Sri Lanka
7%
India
44%
Bangladesh
4%
Yemen
2%
Egypt
6%
Pakistan
20%
Table 1 below also summarizes some demographic characteristics of the
population of UAE.
El-Jardali, et al. 2008
18
Table 1: Population and Health Indicators for UAE
Lebanon
Total Population (2006)
4,248,000
Urban population as % of total (2006)
Annual Growth Rate (1996-2006)
In urban areas
77%
5%
-
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)
Maternal Mortality Rate (per 100,000 live births) (2005)
Dependency Ratio
8
37
-
Percentage of population aged under 15 (2006)
20%
Percentage of Population aged over 60 (2006)
Source: World Health Statistics 2008
2%
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
El-Jardali, et al. 2008
19
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.
El-Jardali, et al. 2008
20
Table 2: National graduates of selected higher educational institutions
Males
N
%
395 15.0%
111
7.2%
0
0.0%
0
0.0%
24 13.4%
14 40.0%
4 20.0%
25 43.9%
573 12.8%
UAE University
Higher Colleges of Technology
Nursing Institutes
Dubai College for Medicine
Ajman University
Dubai University College
American University, Dubai
Institute for banking Studies
Total
Females
N
%
2236
85.0%
1422
92.8%
21 100.0%
12 100.0%
155
86.6%
21
60.0%
16
80.0%
32
56.1%
3915
87.2%
Total
2631
1533
21
12
179
35
20
57
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.
El-Jardali, et al. 2008
21
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
Restrictions in the number of approved
work visas for employers*
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 issuing a work visa and visa
renewal
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
A benefit pension scheme for nationals in
the private sector was introduced in 1999.
foreigners are subject to higher water and
electricity tariff bills
In 1997, transfer of sponsorships between
employers became possible after one year
of service subject to the approval of all
parties
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
Quotas on expatriates
Quotas on nationals
Fees for use of expatriate labor
Education and training
Enhance private sector benefits
Mobility, placement, support and
information dissemination policies
Enforcements on legislations on visa
requirements and work restrictions
* 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 GovernmentHealth). Therefore, health care is shared between the private and the public sector
El-Jardali, et al. 2008
22
(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 wellequipped 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
Abu Dhabi
Dubai
Sharjah
Ajman
Umm al-Qaiwain
Ras Al Khaima
Al-Fujeira
Total
Private
Hospital
11
13
3
1
0
1
0
29
Private
Clinics
432
485
383
75
13
71
21
1480
Public
Hospitals
12
2
5
1
1
4
2
27
Governmental
hospitals*
7
6
0
0
0
0
0
13
Total
462
506
391
77
14
76
23
1549
*government hospitals besides MOH
Source: Younies et al., 2007
El-Jardali, et al. 2008
23
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
El-Jardali, et al. 2008
24
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).
El-Jardali, et al. 2008
25
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
El-Jardali, et al. 2008
26
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).
El-Jardali, et al. 2008
27
Table 5: Breakdown of Health Workers in UAE Facilities*
Emirate
Abu Dhabi
Dubai
Sharjah
Ajman
Umm al-Qaiwain
Ras Al Khaima
Al-Fujeira
Total
Private
Hospitals
1543
2254
402
65
0
17
0
4281
(15.6%)
Private
Clinics
1812
1702
996
162
18
133
76
4899
(17.8%)
Public
Hospitals
7821
1563
2557
791
571
1671
942
15916
(57.9%)
Government
hospitals**
612
1767
0
0
0
0
0
2379
(8.7%)
Total
11788
7286
3955
1018
589
1821
1018
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
18000
Public Sector
Private Sector
16000
14000
12000
10000
8000
6000
4000
2000
0
Nationals
Expatriates
All health workers
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
El-Jardali, et al. 2008
28
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).
El-Jardali, et al. 2008
29
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.
El-Jardali, et al. 2008
30
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
UAE
Egypt
Iraq
India
Sudan
Pakistan
Palestine
Jordan
Syria
Yemen
UK
Iran
Canada
Total
# of physicians
349
300
230
198
129
93
51
41
33
27
9
8
7
1,475
%
23.7%
20.3%
15.6%
13.4%
8.7%
6.3%
3.5%
2.8%
2.2%
1.8%
0.6%
0.5%
0.5%
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.
El-Jardali, et al. 2008
31
Figure 4: Distribution of physicians across different facilities – HAAD (2007)
Clinic
8.9%
Primary Health Care
Center
21.2%
Hospital
69.9%
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.
El-Jardali, et al. 2008
32
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%)
486
806
Total
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
El-Jardali, et al. 2008
33
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
2007
MOH
3,115
3,157
Abu Dhabi Health Authority
3,624
5,211
Dubai Health Authority
2,786
3,500
Health Services-Abu Dhabi Police
184
337
Health Services-Defense
1,051
1,126
Private-MOH
2,000
4,652
Total
12,760
17,983
Source: 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.
El-Jardali, et al. 2008
34
Figure 5: Distribution of nurses working in UAE by nationality
Others, 2%
Nationals, 7%
Arabs, 28%
East Asia, 63%
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
Number
Dubai
21
Sharjah
76
Ajman
7
UAQ
6
Fujeirah
65
RAK
65
Federal Department of Nursing
4
Total
244
Source: 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
El-Jardali, et al. 2008
35
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
Sharjah Medical District
RAK Medical District
Fujeirah Medical District
Dubai Medical District
Ajman Medical District
UAQ Medical District
Total
N
1168
623
420
406
315
211
3159
%
37.1%
19.8%
13.3%
12.9%
10.0%
6.7%
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 (%)
Dubai Medical District
319 (83.7%)
62 (16.3%)
Sharjah Medical District
738 (89.9%)
83 (10.1%)
Ajman Medical District
236 (83.7%)
46 (16.3%)
UAQ Medical District
217 (92.7%)
17 (7.3%)
RAK Medical District
494 (88.4%)
65 (11.6%)
Fujeirah Medical District
162 (88.0%)
22 (12.0%)
Total
2,166 (88.0%)
295 (12.0%)
Total
381
821
282
234
559
184
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
El-Jardali, et al. 2008
36
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.
El-Jardali, et al. 2008
37
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)
Primary Health Care
Center
8.8%
Clinic
1.9%
Hospital
89.2%
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.
El-Jardali, et al. 2008
38
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)
486
806
Total
Nationals
Non-Nationals
N (%)
N (%)
Males
3 (2.9%)
434(12.5%)
Females
99 (97.1%)
3,035 (87.5%)
102
3,469
Total
Source: DOHMS, 2008
For further information on detailed distribution of nurses registered with DOHMS
by nationality, please refer to Appendix XVIII.
El-Jardali, et al. 2008
39
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
Total
Physicians
287
971
1,258
Nurses
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.
El-Jardali, et al. 2008
40
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).
El-Jardali, et al. 2008
41
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
Hospital
2307
Out Patient Clinics
208
New Wards in Hospital, School Health and
Preventive Medicine
Health Centers
303
School Health
281
Preventive Medicine
58
Total
3157
Required*
2639
263
% Shortage
12.6%
20.9%
120
100.0%
450
347
81
3900
32.7%
19.0%
28.4%
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.
El-Jardali, et al. 2008
42
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
El-Jardali, et al. 2008
43
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
El-Jardali, et al. 2008
44
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.
El-Jardali, et al. 2008
45
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
El-Jardali, et al. 2008
46
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
2000
2001
2002
2003
2004
2005
2006
2007
2008
Total
Number of 1st
year students
96
73
80
59
73
63
65
60
569
Number of
Graduates
75
54
129
National
Graduates
8
8
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.
El-Jardali, et al. 2008
47
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.
El-Jardali, et al. 2008
48
Table 22: Number of 1st year students and graduates from nursing schools from 1998 to 2008
DOHMS in Dubai
Ministry of Health
Institute of Applied University of Sharjah
Government Institute
Institute of Nursing
Technology
School of Nursing
of Nursing*
1st year Graduates
1st year Graduates
1st year Graduates
1st year Graduates
1998
72
22
15
42
1999
74
19
39
0
2000
80
36
19
53
2001
135
69
24
93
17
15
2002
146
59
24
88
18
13
2003
161
81
27
87
15
6
2004
184
119
44
120
21
13
2005
203
109
101
29
12
2006
233
104
82
19
6
2007
217
88
93
17
7
2008
108
Total
1,501
814
192
759
136
72
Total
1st year Graduates
72
79
74
58
80
108
152
201
164
184
176
201
205
296
232
222
252
192
234
188
0
108
1,637
1,837
*Institute was shut down in 2004 due to poor admission from nationals in the institute
El-Jardali, et al. 2008
49
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
Affiliation Contribution
N (%)
Ministry of Health Institute of Nursing
814 (44.3%) Public
DOHMS in Dubai Government Institute
96.1%
of Nursing
192 (10.5%) Public
Institute of Applied Technology
759 (41.3%) Public
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
Institute
ION Sharjah
ION RAK
ION Fujeirah
Total from three branches
Nationals Non-Nationals
N (%)
N (%)
1 (3.2%)
30 (96.8%)
25 (73.5%)
9 (26.5%)
16 (61.5%)
10 (38.5%)
42 (46.2%)
49 (53.8%)
Total
31
34
26
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.
El-Jardali, et al. 2008
50
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
El-Jardali, et al. 2008
51
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
MOH ION (formerly known as the
– Assistant Nurse Program
school of nursing)
– Technical Nursing Program
– Basic Nursing Program
– Diploma nursing program
– Assistant Nurse Program
Directorate of Defense Medical
Services (GHQ)
– Practical Nurse Program
– Bridging Practical Nursing program
for Assistant Nurses
– Registered Nurse Program
– Higher Diploma in Nursing
Dubai Department of Health, ION
– Diploma in General Nursing Program
– Assistant Nurse Program
– Nursing Aid Program
– 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
El-Jardali, et al. 2008
52
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
El-Jardali, et al. 2008
53
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
El-Jardali, et al. 2008
54
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.
El-Jardali, et al. 2008
55
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.
El-Jardali, et al. 2008
56
Table 26: Nurse Recruitment and Resignation in MOH facilities by district (2006)
Dubai
Sharjah
Ajman
UAQ
RAK
Fujeiira
FDON
Total
Current Nurses
2006
2007
409
406
1,160
1,168
307
315
209
211
601
623
415
420
14
16
3,115
3,159
Recruitment
2006
2007
36
37
147
73
23
23
13
14
63
48
71
22
4
1
357
218
Resignations
2006
2007
10
40
57
55
6
9
7
11
18
31
8
18
1
0
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
Hospitals
PHC
School Health
Preventive Medicine
Total
Existing staff Recruitment Resignation
2514
197
131
290
14
22
280
5
9
59
1
2
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
El-Jardali, et al. 2008
57
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
National
Non-National
Total
Physicians
N
%
25
5.4%
437
94.6%
462
100.0%
Nurses
N
%
36
2.8%
1246
97.2%
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.
El-Jardali, et al. 2008
58
Table 29: Physician trainees and physicians in rotation at Tawam hospital
Physician Trainees
UAE Interns
UAE Residents
Total trainees
Physicians in rotation
N
12
56
68
131
%
17.6%
82.4%
100.0%
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
Recruited Terminated Turnover Recruited
2004*
127
142
111.8
223
2005
143
48
33.6
262
2006
123
44
35.8
146
2007
128
38
29.7
205
* GAHS Policy changes shows high turnover in year 2004
Nursing
Terminated Turnover
101
45.3
79
30.2
85
58.2
55
26.8
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.
El-Jardali, et al. 2008
59
Table 31: Medical Termination summary for 2007 and 2008
January
February
March
April
May
June
July
August
September
October
November
December
Total
Sr.
Special
Consultant Specialist
MO/ GP
Grade
Consultant
2007 2008 2007 2008 2007 2008 2007 2008 2007 2008
1
1
1
0
1
1
1
0
2
1
1
1
1
1
1
1
1
2
2
1
6
0
1
0
2
1
1
0
1
0
2
1
2
1
4
1
1
2
1
1
1
1
2
0
8
3
4
3
15
3
8
5
Total
2007
2
3
1
2
9
4
1
8
1
3
0
3
37
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
Resignation (eligible for rehire at different organization)
Termination
End of contract
Resignation-not eligible for rehire
Deceased
Absconded
Transferred
Total
El-Jardali, et al. 2008
2006
46
19
8
7
3
0
0
83
2007
24
14
1
12
0
10
4
65
2008
19
1
7
6
1
6
0
40
60
2008
3
1
2
4
1
3
0
0
0
0
0
0
14
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
Physicians Vacancies
Consultants
Specialists
MO
Total physician vacancies
Nurse Vacancies
Technical
Administrative
Total nurse vacancies
All vacancies
Number
45
16
15
76
178
19
197
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
Reasons why they believe that Tawam
Hospital is a 'truly great place to work'
Barriers that are stopping Tawam
Hospital from becoming a 'truly great
place to work'
Identify the 3 most important things
they expect from Tawam Hospital
Survey outcome
Pay 13%
Improvement 10%
Service to Clients 9%
The People 8%
Benefits + Incentives 7%
Lack of Fairness 18%
Job Security 12%
Upper Management 11%
Benefits + incentives 10%
Lack of Pay 10%
Salary 51% (40% satisfied)
Allowances and Benefits 45% (40% satisfied)
Fairness 26% (40% satisfied)
Education 23% (52% satisfied)
Support 14% (46% satisfied)
El-Jardali, et al. 2008
61
Question
Identify the reason they were initially
attracted to work in Tawam Hospital
Identify the types of issues that might
affect any decision to stay working in
Tawam Hospital in the future
Identify the types of issues that might
affect any decision to leave Tawam
Hospital in the future
Identify the things (if any) that have
IMPROVED over the last year in
Tawam Hospital
Identify the things (if any) that have
DETERIORATED over the last year in
Tawam Hospital.
Survey outcome
Money – The Pay 31%
Entitlements 17%
Money – Good Pay 16%
Location 15%
Experience – Development 14%
Money – The Pay 31%
Experience + Development 23%
Influence of Family and Friends 19%
Entitlements 14%
Colleagues 14%
Better Pay Elsewhere 33%
Lack of Fairness 22%
Lack of Entitlements 17%
Inadequate Accommodation 13%
Family Influences 13%
Facilities 24%
Training + Education 18%
Pay 17%
Quality of Service 14%
Systems + Procedures 11%
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.
El-Jardali, et al. 2008
62
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
El-Jardali, et al. 2008
63
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
El-Jardali, et al. 2008
64
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.
El-Jardali, et al. 2008
65
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 foreigntrained 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 nonnationals. 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 wellrespected 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
El-Jardali, et al. 2008
66
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
El-Jardali, et al. 2008
67
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
El-Jardali, et al. 2008
68
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.
El-Jardali, et al. 2008
69
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
El-Jardali, et al. 2008
70
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).
El-Jardali, et al. 2008
71
– 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 selfsufficient 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
El-Jardali, et al. 2008
72
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.
El-Jardali, et al. 2008
73
Table 35: DOHMS Continuing Education Department, Scholarship and Higher
Education Department
Year
2004
2005
2006
2007
2008
Total
Number of sponsored graduates
16
17
8
7
4
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.
El-Jardali, et al. 2008
74
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).
El-Jardali, et al. 2008
75
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 selfsufficient. 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 nonnationals 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).
El-Jardali, et al. 2008
76
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
El-Jardali, et al. 2008
77
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,
El-Jardali, et al. 2008
78
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.
El-Jardali, et al. 2008
79
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).
El-Jardali, et al. 2008
80
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
1
Total Population (2005)
Urban population as % of total (2002) 2
Annual Growth Rate (1995-2005) 1
In urban areas (2005) 1
Life Expectancy (2004) 1
Males (2004) 1
Females (2004) 1
Under-5 mortality per 1000 (2004) 1
Males (2004) 1
Females (2004) 1
Infant Mortality (per 1000 live births) (2005) 3
Maternal Mortality Rate (per 100,000 live births) (2000) 4
Dependency Ratio (2004) 5
Percentage of population aged under 15 (2002) 2
Percentage of Population aged over 60 (2004) 5
Lebanon
3,577,000
87.2%
1.2%
87%
70
68
72
31
35
26
24.5
150
57%
6.2%
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
El-Jardali, et al. 2008
81
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.
El-Jardali, et al. 2008
82
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
El-Jardali, et al. 2008
83
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
El-Jardali, et al. 2008
84
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.
El-Jardali, et al. 2008
85
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).
El-Jardali, et al. 2008
86
Figure 7: Distribution of physicians and nurses in the EMR
5.00
Physician Density
Nurse Density
4.50
4.00
Density in 1000s
3.50
3.00
2.50
2.00
1.50
1.00
0.50
Low Income
Low Middle Income
Low and Middle Income
Global Average
EMR Average
Cyprus
UAE
Qatar
Kuwait
Bahrain
Upper Middle
Income
Saudi Arabia
Lebanon
Oman
Libya
Jordan
Syria
Tunisia
Iraq
Egypt
Morocco
Iran
Djibouti
Pakistan
Yemen
Sudan
Afghanistan
Somalia
0.00
High Income
Middle to High Income
Averages
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
El-Jardali, et al. 2008
Total
87
Year
1999
2000
2001
2002
2003
2004
Total
Order of physicians
of Beirut
504
415
400
279
276
268
2,142
Order of physicians
of North Lebanon
75
28
70
43
29
56
301
Total
579
443
470
322
305
324
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
Beirut
Beirut inscribed at North Lebanon
Mount Lebanon
Mount Lebanon (Jbail) inscribed at North Lebanon
North Lebanon
North Lebanon inscribed at Beirut
South Lebanon
Bekaa
Bekaa inscribed at North Lebanon
Total
N
4159
33
2800
3
1157
185
1316
796
5
10,454
%
39%
0.3%
27%
0.03%
11%
2%
13%
8%
0.05%
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
El-Jardali, et al. 2008
88
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
Order of Physicians of Beirut
Order of Physicians of North
Total
Female
N (%)
1766 (19.1%)
191 (16.3%)
1857 (17.8%)
Male
N (%)
7490 (80.9%)
983 (83.7%)
8473 (81.2%)
Total
9256
1174
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.
El-Jardali, et al. 2008
89
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 maldistribution 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:
El-Jardali, et al. 2008
90
– 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
El-Jardali, et al. 2008
91
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 contextspecific. 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).
El-Jardali, et al. 2008
92
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 Medical
Sciences*
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%
El-Jardali, et al. 2008
93
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
2000
2001
2002
2003
2004
2005
2006
2007
2008
Total
AUB
1st year Graduates
75
74
75
71
76
76
77
72
81
79
79
74
82
80
84
84
87
716
610
Balamand University
1st year Graduates
26
31
35
36
40
41
55
25
30
36
35
264
126
Total
1st year Graduates
75
74
101
71
107
76
112
72
117
104
119
104
123
116
139
119
87
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
El-Jardali, et al. 2008
94
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.
El-Jardali, et al. 2008
95
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 Graduates
2000
58
66
35
19
97
51
190
136
2001
62
59
46
17
106
86
214
162
2002
79
50
39
36
116
87
234
173
2003
89
63
55
32
116
85
260
180
2004
77
68
41
34
118
85
236
187
2005
60
71
42
32
117
95
219
198
2006
78
68
26
45
43
116
91
265
202
2007
58
61
36
47
32
106
99
247
192
2008
47
36
45
25
136
94
264
119
Total
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.
El-Jardali, et al. 2008
96
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
st
st
st
1 year Graduates 1 year Graduates 1 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
El-Jardali, et al. 2008
97
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
Training
Availability of desired specialty,
specialty, intense competition
opportunities
availability of a large number of
for few training positions, unfair
training positions, fair
competition for training
competition for training positions
positions
based on competences
Insufficient exposure or the lack Clinical training Better exposure, focusing more
of a variety of cases,
on procedural skills, giving
insufficient training in
trainees more responsibilities,
procedural skills, insufficient
conformity to standards of care
El-Jardali, et al. 2008
98
Push factors in source country Specific area
Pull factor in recipient
countries
autonomy, inability to practice
and thus the ability to practice
theoretical concepts
theoretical concepts
Lack of financial resources, lack Research training More resources, more
of human resources,
opportunities, better mentorship,
dissatisfactory mentorship,
better chances to publish in a
weak research culture
culture where research is highly
appreciated
Weak institutional commitment Teaching
Higher commitment to teaching
to teaching, attending
in well defined curricula, respect
physicians not committed
and appreciation for trainees as
enough to teaching, absence of
opposed to considering them as
explicit curriculum, no
cheap labor
governmental accreditation or
supervisions
No explicit delineation of duty, Residency
Well defined duties, regulated
high and unregulated workload, working
workload, collegial relationship
distressing relationship with
conditions
with trainers, better reward
trainers and nurses, deficient or
systems and the support for
unfair rewarding and evaluation
extra-curricular activities
systems
Training systems which are
Impact on career Ability to enter foreign job
imported and not totally
markets, ability to compete in the
adequate for local practice,
local job market, having a chance
inability to enter in foreign job
at entering an academic career
markets, competitive
disadvantage in the local job
market, poor chances of
academic careers
Fierce unfair competition, very
Job opportunities Competence based competition
limited career opportunities in
and more job opportunities,
academia and major health
ability to work in the trained-in
centers, no attractive job
specialty
opportunities in remote areas,
risk of not working in trained in
specialty
High workload, dysfunctional
Working
Lighter workload in a functional
health care system, poor
conditions
health system better professional
professional standards in
standards, basing academic
dealing with colleagues and
advancement on research and
patients, inequitable rules of
teaching, continuous medical
academic and professional
education and stable jobs
advancement, incompetent
supporting staff, no organized
or required continuous medical
education
El-Jardali, et al. 2008
99
Push factors in source country Specific area
Low un-guaranteed income,
high expenses, inability to start
a family, financial dependency,
poor prospects of national
economy
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
Discontent with social norms
(interdependency of individual
with family), sectarian social
system affecting social rights
and finally social inequalities
Financial
Pull factor in recipient
countries
Higher income thus leading to
financial independency, ability to
start a family and financially
assist parent in home country
Political
Political stability, opportunity to
acquire foreign citizenship thus
ensuring further security and
social justice
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
El-Jardali, et al. 2008
100
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
Graduates of 2000
Graduates of 2001
Graduates of 2002
Graduates of 2003
Graduates of 2004
Graduates of 2005
Graduates of 2006
Total
In Lebanon
N (%)
76 (67.3)
81 (71.1)
92 (75.4)
115 (79.3)
113 (81.3)
137 (90.1)
147 (96.1)
761 (81.1)
Abroad
N (%)
37 (37.2)
33 (28.9)
30 (24.6)
30 (20.7)
26 (18.7)
15 (9.9)
6 (3.9)
177 (18.9)
Total
N
113
114
122
145
139
152
153
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).
El-Jardali, et al. 2008
101
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.
El-Jardali, et al. 2008
102
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).
El-Jardali, et al. 2008
103
Figure 8: Top Retention Challenges as perceived by Lebanese Nursing Directors
Salaries and benefits, 80.8%
Shifts and working hours,
38.4%
Better opportunities abroad,
30.1%
Better opportunities in other
hospitals, 30.1%
Work load, 27.4%
Instability of the country,
16.4%
Marriage, 16.4%
Location of the hospital,
12.3%
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.
El-Jardali, et al. 2008
104
Figure 9: Retention strategies adopted by hospitals
Financial rewards and
benefits, 62.7%
Salary scale, 47.8%
Flexibility of schedule, 31.3%
Staff development, 29.9%
Praise, incentives and
motivation, 19.4%
Good management and
nurses relationship, 19.4%
Healthy work environment,
14.9%
Promotion, 11.9%
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).
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105
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 maldistribution 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
El-Jardali, et al. 2008
106
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.
El-Jardali, et al. 2008
107
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
El-Jardali, et al. 2008
108
– 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.
El-Jardali, et al. 2008
109
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
El-Jardali, et al. 2008
110
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 twocountry 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
El-Jardali, et al. 2008
111
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
El-Jardali, et al. 2008
112
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
El-Jardali, et al. 2008
113
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.
El-Jardali, et al. 2008
114
IX. References
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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
El-Jardali, et al. 2008
122
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:
ƒ Public Sector: Ministry of Health and Health Authorities in UAE
ƒ Health Professionals groups: Order of Physicians, Order of Nurses,
Syndicate of Hospitals, Associations of public health
ƒ Educational Institutions: Major universities and academic programs for
physicians, nurses and midwives
ƒ Hospital Administrators: Top executives at major hospitals in both UAE
and Lebanon
ƒ 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.
El-Jardali, et al. 2008
123
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
El-Jardali, et al. 2008
124
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.
El-Jardali, et al. 2008
125
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
El-Jardali, et al. 2008
126
MS Excel and SPSS as applicable. Data from UAE was analyzed separately from data
from Lebanon.
El-Jardali, et al. 2008
127
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
El-Jardali, et al. 2008
128
–
–
–
–
–
–
–
–
–
–
–
–
–
–
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
Health Personnel/
Health Manpower/
Human Resources for Health.mp
Health Human Resources.mp
Health Workers.mp
Nurses/
Nurs$.mp
Nurse's Role/
Physician's Role/
Nurses, Male/
Physicians/
Midwifery/
Midwif$.mp
Health Personnel/
Nursing Staff, Hospital/
Job description/
Career Mobility/
EMBASE
“Health Personnel/” exp AND
[embase]/lim
“Health Manpower” AND [embase]/lim
“human resources for health” AND
“human”/exp OR resources OR
“health/”exp AND [embase]/lim
“health human resources” AND
“health”/exp OR “human”/exp OR
“resources” AND [embase]/lim
“health workers” AND [embase]/lim
“Nurses”/exp AND [embase]/lim
“Nurses Role” AND [embase]/lim
“Physicians Role” AND [embase]/lim
“Male Nurses” AND [embase]/lim
“Physicians”/exp AND [embase]/lim
“Midwifery”/exp AND [embase]/lim
“Health Personnel”/exp AND
[embase]/lim
“nursing staff” OR “nursing”/exp AND
“staff”/exp AND [embase]/lim
“Job description”/exp AND
[embase]/lim
“Career Mobility”/exp AND
El-Jardali, et al. 2008
129
Medline/CINAHL
Personnel Turnover/
Staff Development/
Emigration and Immigration/
Migration.mp
Brain drain.mp
Job Satisfaction/
Employee Retention.mp
Personnel Staffing and Scheduling/
Health worker shortage.mp
Nurse Shortage.mp
Physician Shortage.mp
Nurse turnover.mp
Nursing Staff/
Personnel Turnover/
Physician turnover.mp
Nurse to patient ratios.mp
EMBASE
[embase]/lim
“Personnel Turnover”/exp AND
[embase]/lim
“Staff Development”/exp AND
[embase]/lim
Emigration OR “Immigration”/exp
AND [embase]/lim
“Migration”/exp AND [embase]/lim
“brain drain” OR “brain”/exp AND
“drain”/exp AND [embase]/lim
“job satisfaction” OR “job”/exp AND
“satisfaction”/exp AND [embase]/lim
“employee retention” OR
“employee”/exp AND retention AND
[embase]/lim
“staffing” OR “scheduling” AND
[embase]/lim
“health worker shortage” AND
[embase]/lim
“Nurse Shortage” AND [embase]/lim
“Physician Shortage” AND
[embase]/lim
“Nurse turnover” AND [embase]/lim
“Nursing Staff”/exp AND [embase]/lim
“Personnel Turnover”/exp AND
[embase]/lim
“Physician turnover” AND
[embase]/lim
“Nurse to patient ratios” AND
[embase]/lim
Country/Region
Medline/CINAHL
(Middle East and North
Africa).sh,cp,tw,ti.
Middle East and North Africa/
(Eastern Mediterranean
Region).sh,cp,tw,ti.
Eastern Mediterranean Region/
(Middle East).sh,cp,tw,ti.
Middle East/
(Arab Countries).sh,cp,tw,ti.
EMBASE
“Middle East and North Africa” AND
[embase]/lim
“Eastern Mediterranean Region” AND
[embase]/lim
“Middle East”/exp AND [embase]/lim
El-Jardali, et al. 2008
130
Medline/CINAHL
Arab Countries/
(Low Income Countries).sh,cp,tw,ti.
Low Income Countries/
(Low-Middle Income
Countries).sh,cp,tw,ti.
Low-Middle Income Countries/
“Low Income Countries” AND
[embase]/lim
“Low-Middle Income Countries” AND
[embase]/lim
(Middle Income Countries).sh,cp,tw,ti.
Middle Income Countries/
(Developing Countries).sh,cp,tw,ti.
Developing Countries/
(Afghanistan).sh,cp,tw,ti.
Afghanistan/
(Algeria).sh,cp,tw,ti.
Algeria/
(Bahrain).sh,cp,tw,ti.
Bahrain/
(Cyprus).sh,cp,tw,ti.
Cyprus/
(Djibouti).sh,cp,tw,ti.
Djibouti /
(Egypt).sh,cp,tw,ti.
Egypt/
(Islamic Republic of Iran).sh,cp,tw,ti.
Islamic Republic of Iran /
(Iraq).sh,cp,tw,ti.
Iraq/
(Jordan).sh,cp,tw,ti.
Jordan/
(Kuwait).sh,cp,tw,ti.
Kuwait/
(Lebanon).sh,cp,tw,ti.
Lebanon/
(Libya).sh,cp,tw,ti.
Libya/
(Malta).sh,cp,tw,ti.
Malta/
(Morocco).sh,cp,tw,ti.
Morocco/
(Oman).sh,cp,tw,ti.
Oman/
EMBASE
“Arab Countries” AND [embase]/lim
“Middle Income Countries” AND
[embase]/lim
“Developing Countries”/exp AND
[embase]/lim
“Afghanistan”/exp AND [embase]/lim
“Algeria”/exp AND [embase]/lim
“Bahrain”/exp AND [embase]/lim
“Cyprus”/exp AND [embase]/lim
“Djibouti”/exp AND [embase]/lim
“Egypt”/exp AND [embase]/lim
“Islamic Republic of Iran”/exp AND
[embase]/lim
“Iraq”/exp AND [embase]/lim
“Jordan”/exp AND [embase]/lim
“Kuwait”/exp AND [embase]/lim
“Lebanon”/exp AND [embase]/lim
“Libya”/exp AND [embase]/lim
“Malta”/exp AND [embase]/lim
“Morocco”/exp AND [embase]/lim
“Oman”/exp AND [embase]/lim
El-Jardali, et al. 2008
131
Medline/CINAHL
(Qatar).sh,cp,tw,ti.
Qatar/
(Kingdom of Saudi Arabia).sh,cp,tw,ti.
Kingdom of Saudi Arabia/
(Palestine).sh,cp,tw,ti.
Palestine/
(West Bank and Gaza).sh,cp,tw,ti.
West Bank and Gaza/
(Occupied Palestinian
Territories).sh,cp,tw,ti.
Occupied Palestinian Territories/
(Pakistan).sh,cp,tw,ti.
Pakistan/
(Somalia).sh,cp,tw,ti.
Somalia/
(Sudan).sh,cp,tw,ti.
Sudan/
(Syria).sh,cp,tw,ti.
Syria/
(Tunisia).sh,cp,tw,ti.
Tunisia/
(United Arab Emirates).sh,cp,tw,ti.
United Arab Emirates/
(Yemen) .sh,cp,tw,ti.
Yemen/
EMBASE
“Qatar”/exp AND [embase]/lim
“Kingdom of Saudi Arabia”/exp AND
[embase]/lim
“Palestine”/exp AND [embase]/lim
“West Bank and Gaza” AND
[embase]/lim
“Occupied Palestinian Territories” AND
[embase]/lim
“Pakistan”/exp AND [embase]/lim
“Somalia”/exp AND [embase]/lim
“Sudan”/exp AND [embase]/lim
“Syria”/exp AND [embase]/lim
“Tunisia”/exp AND [embase]/lim
“United Arab Emirates”/exp AND
[embase]/lim
“Yemen”/exp AND [embase]/lim
El-Jardali, et al. 2008
132
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 ElJardali 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.
El-Jardali, et al. 2008
133
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.
El-Jardali, et al. 2008
134
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.
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 ElJardali by email on [email protected] or by fax on the number +961-1-744470.
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.
El-Jardali, et al. 2008
135
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
Expatriates
Physicians
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?
El-Jardali, et al. 2008
136
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.
El-Jardali, et al. 2008
137
Appendix VIII: UAE Key informants identified
Affiliation
Best Practice
Department of Health &
Medical Services-Dubai
Department of Health &
Medical Services-Dubai
Dubai Medical College
Dubai Regional Health
Authority
Name
Jacqui Parle
Essa Kazim
Essa Kazim
Prof. Mohammed Galal El
Din
Laila Al Jassami
Position/professional title
Director-Benchmarking Services
Assistant Director General (Medical
Affairs)
Assistant Director General (Medical
Affairs)
Dean
Director of Planning & Statistics,
Director of Health Funding Project
for DHA
Emirates Medical
Association
Dr.Abdulla Ibrahim AlKhaiat
President
Emirates Medical
Association
Abdullrahim Mostafawi
Vice President
General Authority for
Health Service for the
Emirate of Abu Dhabi
Government of Dubai
Mariam Elmobasher
CME/CPD
Hassan Mohammad Murad
Almazmi
Government of Dubai
Judith Brown
Gulf Medical College
Health Authority-Abu
Dhabi
Health Authority-Abu
Dhabi
Health AuthorityAbuDhabi
Horizon
Dr. Gita Ashok Raj
Nawal Khalid
Office of the Asst. Director General
(Medical Affairs), Department of
Health and Medical Services DOHMS
Director of Nursing and Midwifery
Services
Dean and Professor of Pathology
CME/CPD officer
Maysoon Alkaram
Head PGE
Eng. Zaid Dawood
General Director
Younis Amiri
Chairman
Ministry of Health
Dr. Ali ahmed bin Shakar
General Director
Ministry of Health
Dr. Mahmoud Fikri
Ministry of Health
Ameen Al-Ameeri
Ministry of Health
MOH-Dubai
MOH-Dubai
AbdulGhaffar Abdulghaffur
Ali Bin Shaker
Munther Al Kayyali
El-Jardali, et al. 2008
Executive Director Of Health
Policies
Executive Director For Medical
Practices And Licensing
Minister Consultant
Director General
Advisor
138
Affiliation
MOH-Dubai
MOH-Dubai
Name
Maryam Al Marri
Fatima Al Rifai
MOH-Dubai
Ghada Sherry
RITCH
Sharjah Univerdity
Tawam Hospital (Al Ain,
Abu Dhabi)
Tawam Hospital (Al Ain,
Abu Dhabi)
Tawam Hospital (Al Ain,
Abu Dhabi)
Tawam Hospital (Al Ain,
Abu Dhabi)
Malik Mlhim
Dr. Hossam Hamdy
Maha Chaltaf
Position/professional title
HR Manager
Director of Department of Nursing,
Federal Department of Nursing
Head, Practice Development Section,
Federal Department of Nursing
General Director
Dean of College of Health Sciences
Executive Medical Assistant
Michael E. Heindel
CEO
Steven A. Matarelli
Chief Clinical Officer
Jack C. Borders
Chief Medical Officer
UAE University
Dr. George Carruthers
UAE University
Ms. Nawal Al Dhafri
Zayed University
Chris Nuttman
El-Jardali, et al. 2008
Deans of Medicine and Health
Sciences
Office of Research and Graduate
Studies
Professor and Department Chair,
Natural Science and Public Health
139
Appendix IX: UAE Key informants interviewed
Name
Ali Bin Shaker
Munther Al Kayyali
Maryam Al Marri
Fatima Al Rifai
Affiliation
MOH-Dubai
MOH-Dubai
MOH-Dubai
MOH-Dubai
Hassan Mohammad
Murad Almazmi
Government of Dubai
Judith Brown
Government of Dubai
Essa Kazim
Department of Health &
Medical Services-Dubai
Dubai Regional Health
Authority
MOH-Dubai
Laila Al Jassami
Ghada Sherry
Mariam Elmobasher
Nawal Khalid
Maysoon Alkaram
Jacqui Parle
Maha Chaltaf
Michael E. Heindel
Steven A. Matarelli
Jack C. Borders
General Authority for Health
Service for the Emirate of Abu
Dhabi
Health Authority-Abu Dhabi
Health Authority-Abu Dhabi
Best Practice
Tawam Hospital (Al Ain, Abu
Dhabi)
Tawam Hospital (Al Ain, Abu
Dhabi)
Tawam Hospital (Al Ain, Abu
Dhabi)
Tawam Hospital (Al Ain, Abu
Dhabi)
El-Jardali, et al. 2008
Position
Director General
Advisor
HR Manager
Director of Department of Nursing,
Federal Department of Nursing
Office of the Asst. Director General
(Medical Affairs), Department of Health
and Medical Services - DOHMS
Director of Nursing and Midwifery
Services
Assistant Director General (Medical
Affairs)
Director of Planning & Statistics, Director
of Health Funding Project for DHA
Head, Practice Development Section,
Federal Department of Nursing
CME/CPD
CME/CPD officer
Head PGE
Director-Benchmarking Services
Executive Medical Assistant
CEO
Chief Clinical Officer
Chief Medical Officer
140
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.
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 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.
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.
El-Jardali, et al. 2008
141
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:
El-Jardali, et al. 2008
142
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.
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 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.
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.
El-Jardali, et al. 2008
143
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 number
Physicians
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?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
El-Jardali, et al. 2008
144
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
University of Balamand- Faculty of
Medicine
Professor
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
El-Jardali, et al. 2008
145
Appendix XV: Questions asked during phone interviews with Lebanese
nurses working in UAE
1.
2.
3.
4.
5.
6.
7.
When did you leave to UAE?
Why did you choose to emigrate to UAE?
Why do you think Lebanese nurses choose to go to UAE?
Did you find many other Lebanese nurses working in UAE?
What are the nationalities of other nurses in UAE?
What is the intensity of migration of Lebanese nurses to UAE?
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?
El-Jardali, et al. 2008
146
Appendix XVI: Detailed distribution of physicians registered in DOHMS
by nationality
Country
UAE
Iraq
India
Pakistan
Egypt
Jordan
Sudan
Palestine
Syria
Iran
UK
German
Yemen
Lebanon
Bahrain
Australia
Bosnia
Canada
Oman
Somalia
Bulgaria
France
Sweden
USA
Yugoslavia
Argentina
Austria
Bangladesh
Cuba
Ireland
Libya
Macedonia
Mauritania
Nigeria
Norway
Romania
Tanzania
Tunisia
Ukraine
Others
Total
N
225
84
70
69
64
29
21
19
15
13
8
7
7
5
4
3
3
3
3
3
2
2
2
2
2
1
1
1
1
1
1
1
1
1
1
1
1
1
1
11
690
%
32.6%
12.2%
10.1%
10.0%
9.3%
4.2%
3.0%
2.8%
2.2%
1.9%
1.2%
1.0%
1.0%
0.7%
0.6%
0.4%
0.4%
0.4%
0.4%
0.4%
0.3%
0.3%
0.3%
0.3%
0.3%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
1.6%
100.0%
El-Jardali, et al. 2008
147
Appendix XVII: Detailed distribution of nurses employed in MOH
facilities across districts
District
Number of Nurses
Dubai Medical District
MOH
Al Barah Hospital
Al Amal Hospital
PHC
School Health
Prev. Med.
Dental
Total
Number
1
186
69
46
79
16
9
406
Sharjah Medical District
MOH
Al Qassimi Hospital.
Khorfakan Hospital.
PHC
Dhaid Hospital.
Kalba Hospital.
School Health
MCH
Prev. Med.
Kuwait Hospital.
Dental Services
Total
Number
2
370
145
75
110
153
77
20
18
180
18
1168
El-Jardali, et al. 2008
148
Ajman Medical District
MOH
Sheikh Khalifa Hospital.
School Health
PHC
Prev.Med.
MCH
Dental Clininc
Nurses' Hostel
Total
Number
2
238
33
29
2
7
3
1
315
UAQ Medical District
MOH
UAQ Hospital.
PHC
School Health
Prev.Med.
Dental services
Total
Number
3
148
20
24
8
8
211
RAK Medical District
MOH
Seif B. Ghabash
Saquar Hospital
PHC
Shaam Hospital.
Prev. Med.
School Health
Dental Centre
Total
Number
3
164
280
87
33
6
41
9
623
El-Jardali, et al. 2008
149
Fujeirah Medical District
MOH
Fujeirah Hospital.
Dibba Hospital.
Prev. Med..
PHC
School Health
Dental Centre
Total
Number
1
232
111
9
33
26
8
420
El-Jardali, et al. 2008
150
Appendix XVIII: Detailed distribution of nurses registered in DOHMS
by nationality
Country
India
Philippines
UAE
Jordan
Palestine
Iran
Sudan
Egypt
Pakistan
UK
Nigeria
Somalia
Syria
Australia
Kenya
Algeria
Bahrain
Canada
Indonesia
Iraq
Lebanon
Morocco
Tanzania
USA
Yemen
Others
Total
N
1,010
642
63
29
26
24
23
22
13
6
5
4
3
2
2
1
1
1
1
1
1
1
1
1
1
2
1,886
%
53.6%
34.0%
3.3%
1.5%
1.4%
1.3%
1.2%
1.2%
0.7%
0.3%
0.3%
0.2%
0.2%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
0.1%
100.0%
El-Jardali, et al. 2008
151
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
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Total
1st year Graduates
41
12
35
12
48
24
42
42
47
33
59
45
57
40
70
36
76
41
69
31
51
544
367
1st year Graduates
31
10
39
7
32
12
39
27
56
26
46
36
72
35
67
41
78
25
70
26
23
530
268
1st year Graduates
0
0
0
0
0
0
54
0
43
0
56
0
55
44
66
32
79
38
78
31
34
431
179
Table 1: Number of Graduates in the Institute Applied Technology in the two
Branches*
Abu Dhabi
Al-Ain
Total
1998
32
10
42
1999
0
0
0
2000
29
24
53
2001
50
43
93
2002
46
42
88
2003
47
40
87
2004
68
52
120
2005
57
44
101
2006
50
32
82
2007
45
48
93
Total
424
335
759
* Institute Applied Technology only provided number of graduates
El-Jardali, et al. 2008
152
Appendix XX: Detailed list of nationalities of physicians and nurses
employed in Tawam hospital
Algeria
Australia
Austria
Bangladesh
Belgium
Brazil
Britain
Canada
Denmark
Egypt
Ethiopia
Fiji
Finland
France
Germany
Hungary
India
Iran
Iraq
Ireland
Jordan
Kuwait
Lebanon
Libya
Malaysia
Marshal Island
Morocco
New Zealand
Nigeria
Oman
Pakistan
Palestine
Philippines
Poland
Romania
Scotland
Singapore
Somalia
South Africa
Spain
Physicians
N
%
5
1.1%
0
0.0%
1
0.2%
0
0.0%
3
0.6%
1
0.2%
21
4.5%
10
2.2%
3
0.6%
32
6.9%
0
0.0%
0
0.0%
1
0.2%
3
0.6%
16
3.5%
13
2.8%
28
6.1%
1
0.2%
52
11.3%
4
0.9%
23
5.0%
0
0.0%
37
8.0%
9
1.9%
0
0.0%
0
0.0%
0
0.0%
3
0.6%
1
0.2%
0
0.0%
54
11.7%
5
1.1%
0
0.0%
1
0.2%
1
0.2%
0
0.0%
0
0.0%
0
0.0%
11
2.4%
1
0.2%
Nurses
N
%
0
0.0%
27
2.1%
0
0.0%
5
0.4%
0
0.0%
0
0.0%
42
3.3%
0
0.0%
1
0.1%
4
0.3%
34
2.7%
3
0.2%
1
0.1%
0
0.0%
1
0.1%
0
0.0%
196
15.3%
0
0.0%
1
0.1%
0
0.0%
160
12.5%
1
0.1%
59
4.6%
0
0.0%
13
1.0%
1
0.1%
1
0.1%
12
0.9%
1
0.1%
6
0.5%
12
0.9%
17
1.3%
477
37.2%
0
0.0%
1
0.1%
1
0.1%
2
0.2%
2
0.2%
122
9.5%
0
0.0%
El-Jardali, et al. 2008
153
Sri Lanka
Sudan
Sweden
Switzerland
Syria
Tunisia
UAE
Ukraine
USA
Yemen
Yugoslavia
Total
Physicians
N
%
0
0.0%
19
4.1%
8
1.7%
0
0.0%
32
6.9%
0
0.0%
25
5.4%
1
0.2%
33
7.1%
3
0.6%
1
0.2%
462 100.0%
Nurses
N
%
6
0.5%
20
1.6%
2
0.2%
1
0.1%
0
0.0%
2
0.2%
36
2.8%
0
0.0%
8
0.6%
4
0.3%
0
0.0%
1282 100.0%
El-Jardali, et al. 2008
154
Appendix XXI: Detailed distribution of 1st year students and graduates from three branches of the Lebanese
University School of Nursing
Saida English*
1 year Graduates
25
15
24
21
26
24
27
23
25
17
26
20
26
22
26
23
35
20
240
185
st
2000
2001
2002
2003
2004
2005
2006
2007
2008
Total
Saida French*
1 year Graduates
27
15
24
24
26
22
29
22
27
22
25
21
26
22
28
25
35
21
247
194
st
Ain Wzein
1 year Graduates
15
6
12
15
11
15
16
12
14
12
12
10
8
9
10
11
15
8
113
98
st
Zahle
1 year Graduates
30
15
46
26
53
26
44
28
52
34
54
44
56
38
42
40
51
45
428
296
st
Total
1st year Graduates
97
51
106
86
116
87
116
85
118
85
117
95
116
91
106
99
136
94
1028
773
*It should be noted that the Saida branch offers one program in French and another in English
El-Jardali, et al. 2008
155
Appendix XXII: Data received from Nursing Schools in Lebanon on program duration, number of students
migrating and most preferable destination
Program
duration
Saint Joseph University School of Nursing
Beirut Arab University
Number of nurses migrating
out within 3 years
3
4
AUB School of Nursing school
Lebanese University (Saida -English)
Lebanese University (Saida -French)
Lebanese University (Ain Wazein)
3
4
4
4
110 over the last 3 years,
average 37 per year
7-10 per year
5-8 per year
3-4 per year
Lebanese University (Zahle)
4
23
El-Jardali, et al. 2008
Most preferable
destination
Gulf, Europe, North
America
North America
Gulf, North America
Europe
Gulf, Europe
Gulf (5), Europe (8),
North America (10)
156