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Abstract
There has been continued indication of the shortages of physicians and nurses in hospitals across Oman and this is often seen in the media on regular basis. As a consequence, there has also been increased debate on the policy circles among scholars, stakeholders and researchers. Most of these debates often seek to establish whether the shortages are caused by lack of supply of the healthcare workforces or there is increased demand for the caregivers.
Besides, there could also be a problem of misdistribution. The analysts and other experts also debate as to whether the solution to this problem would be to build more training institutions for graduate physicians and increased the number of slots for the healthcare providers as well as create more incentives to attract people into the profession. The study will aim at identifying the factors that influence the availability of the healthcare workers as well as those affecting the demand. The second objective will be to investigate the impact the unbalanced demand and supply of these workforces has had on the service provision in the healthcare sector.
To attain these results, the research will use a literature search to identify these factors and categorize them and finally assess them for better understanding. There are a number of categories that these factors fall under and this study will offer an analysis which will be very important for the stakeholders to comprehend and then finally address the problem of deficient healthcare workforce. Essentially when the stakeholders comprehensively understand the factors affecting need and supply of the healthcare workforce, they will be able to find ways to adapt or use the means recommended by this study. The study is valid as it applied analyses, databases and the Countrys supply and demand model to study the existing profile and the future supply of service providers.
Introduction
Background
The global shortage of healthcare employees at the moment has become a problem for both the developed and the developed nations as the world continue to witness dynamic migration of these workers as indicated by the Joint Learning Initiative (JLI) 2004; International Council of Nurses 2006 and the World Health Organisation 2006 reports). In the countries that have sufficiently high income, there are international programs for recruitment used for addressing the problems of scarcity, enticing the physicians and nurses from the developing nations (Burchan et al, 2003, p. 67).
Over the recent past, there has been a lot of literature and research about this crisis from the perspective of the internationally qualified nurses who were recruited to the United Kingdom NHS and also in the United States of America (Smith, et al. 2006; Bach 2007; Brush and Sochalski, 2007, p. 38).
Oman has a unique healthcare workforce system. The country occupies a small area in Middle East and expatriates form at least over one quarter of its two million population. The statistics could be higher considering that this was based on a report from the census in the late 1990s (Ministry of Information 2006a).
In this study, the investigator exploits the trends that have been observed in Oman. The country has experienced unique trends of recruitment of the local healthcare workers as well as the international strategies. The researcher has suggested that probably the social, historical, economical and political factors are the main challenges to the process (Brush and Sochalski, 2007, p. 38). This is because these factors could be the ones creating impediments to the participation of the healthcare workers in employments hence affected the healthcare workforce supply and demand (El-Haddad, 2006, p. 284).
The world health organisation report of 2006 was able to establish the causes of the problems scarce human resources in the healthcare. The report also identified this as the main challenge to the attainment of the millennium development goals (MDGs). The shortages of healthcare professionals are on top of the list of agenda under discussion in Oman and just like other countries suffering a similar fate; the country has been seeking to set up a workforce initiative to address the shortage (Brush and Sochalski, 2007, p. 38). The reason why this is yet to be effected is because the solutions developed have always been short-term and at times inadequate.
One main challenge facing the country has been to create a workforce plan that would effectively address the demands of the healthcare sector and supply workers continuously (El-Jardali, et al., 2007, p. 78). Nonetheless, although this is a goal for many countries, very few of them have been able to set up proper strategic plans that can meet the healthcare resource needs. Rather, many developed countries have considered implementing other short-term policies like increased dependence on immigrant, at times this happens to the detriment of the developing nations (Brush and Sochalski, 2007, p. 38). This phenomenon has prompted the need for these developed nations to establish their own model referred to as self-sustainable program for dealing with the healthcare needs (Seboni, 2009, p. 129).
The major strategy of reaching the goals in this research was to investigate the definition and models of and other human health options. Self sufficiency model was a potentially effective strategy and discussing the implication on policy creation was a great platform for studying the healthcare in Oman (El-Jardali, et al., 2007, p. 78).
There is a wide range of agreements in the healthcare profession concerning the needs for the developed nations to make sure that they still have their local supply of healthcare service providers hence reducing the degree of their dependence on the developing nations for supply (Seboni, 2009, p. 129). When there is good and effective healthcare human resource plan, which address the issue strategically by encouraging investment in the creating and training of professionals in the sector. Such a sustainable strategy would probably meet the demands of each nation well.
In the year 2004, a study on the policy implication of the migration of caregivers, the nurses Aiken et al, 2004, p. 72 shows that the most promising strategy for attaining the global stability in the healthcare workforce so that every nation would have its own sufficient supply and sustainable plan for creating employees. That would include the developed nations being diligent in training workforce (Aiken et al. 2004, p. 76). In essence the dependence of the developed countries on the foreign-trained professionals was a clear indication of their own failed workforce policy and poor investment in the healthcare systems.
The Joint Learning Initiative (JLI, 2004) reports present an argument that it would be a very wise idea for the developed nations to struggle to attain their self-sufficiency because their dependence on the immigrants was a very unstable, unbalanced and risky venture. The opposite which is self sufficiency was a much better option both sound and fair (Vujicic et al., 2009).
Problem Statement
In Oman there healthcare sector has been experiencing a reduction of labour supply and very high job turnover and this is a sign of a very dire weakness in the industry. The human resource management exercises in the healthcare organization seem to be dangerously out-of-date and not doing something about it would lead the system into irreversible damage (Sellgren et al, 2007, p. 172). For every problem there is a solution even though for this case, there is no quick fix, but the problem can be managed even though that would take some time, effort and determination (Seboni, 2009, p. 129).
The employee turnover has grown to extreme levels in the Omani healthcare sector; the rate is so high that it is almost reaching the double mark of the countries average in other sectors. This position is alarming and it is fast deteriorating. The statistics reveal that as a result, the healthcare sector loses millions of dollars each year and the problem is a direct danger to the sustainability of the healthcare systems at large (George et al., 2007, p. 106).
Hypothesis
The supply and demand of workforce in healthcare system in Oman is extensively influenced by social, economical and historical factors (El-Haddad, 2006, p. 284). The study will seek to specifically identify these factors and then to categorise them into themes that can be used for policy creation implementation to improve the current situation. Its from such research that the scholars can develop recommendation based on the acquired knowledge hence allowing the decision maker to make informed decisions (George et al., 2007, p. 106). The reason in part as to why the previous strategies of dealing with the problems of turnover and supply have not worked well is because of lack of clear understanding of the problem and the factors behind the problem.
The Rationale
In Oman, the location of study or the case study that the researcher will be working on, the turnover rates among healthcare employees particularly the nurses, paramedical staff and the physicians is very high. Even though, there are hundreds of fresh healthcare professionals graduating from the universities and colleges each year, they are not able to meet the ever increasing demand hence causing an imbalance between the supply and demand of these healthcare service providers (Brush and Sochalski, 2007, p. 39).
The impact of the high turnover rates have great impact on the way these healthcare services are provided at the abovementioned levels. The quality of healthcare is very important and when it is affected, then the quality of care is compromised and this risks the lives of patients (George et al., 2007, p. 109).
Research Questions
The questions that will guide the study will focus on the description of the factors in recruitment strategies and the development of the new workforce as well as those issues affecting retaining of the workers. There are a number of factors that can cause this. Therefore the questions to guide the study will include;
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What are the factors that influence the demand and supply of healthcare providers at the global scene?
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What similar factors that affect the international market of healthcare practitioners also affect Omani systems? This will help to make comparison of the international situation and the Omani condition. Similarities and differences in Omani and the rest of the world especially the major players in health market.
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Review the current impact of unbalanced demand and supply of the healthcare service provision at the various levels of provision and the quality of the services provided. This question addresses the current position of graduating numbers of practitioners and the number of those leaving the profession to other markets as well as those resigning from the profession or retiring. This will help to focus on the deficiencies and categorization of the causes of these shortages (Badrick, 2011, para. 3).
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What are the possible solutions to the problem of imbalance of demand and supply of healthcare providers and how to manage oversupply of healthcare workforce as well?
For all intents and purposes, the above questions are for guidance purposes and the research will still be very extensive to cover a wide range of information necessary to address the issue and generate recommendation that can help to manage the problem by developing a sustainable and highly efficient system of preparing and retaining professionals in the industry (Dovlo 2005, p. 78).
Significance of Study
A strategy developed in 2003 by the World Medical Association says that a country should not entirely depend on immigrating personnel from other countries to supply its medical care service demands (Turoyanagi 2008, p. 23). In the current position of healthcare recruitment and retention practices can be figuratively related to the act of pouring water into a bucket with holes, then the analogy is very simple to understand. This concept however gets intricate when analysis of the concept is done critically (Brush and Sochalski, 2007, p. 40).
At a glance, the idea of pouring water in a bucket with holes seems to be an understandable exercise. Now as the water is poured, the holes work and the reality in the healthcare system becomes clear when the water supply diminishes and the holes become bigger. The concept is very obvious in Oman because the healthcare systems keep on recruiting in a manner similar to the bucket analogy and their decision of hiring are based on the deficiently informed sources, pitiable organizational intelligence and improperly defined considerations (Dovlo 2005, p. 78).
All the healthcare organization is the country are at a point where supply is very low yet the exit is very high just like the many holes in the bucket. At this level, it is cheaper and easy to mend the bucket which is like the healthcare market rather than affect the supply (El-Jardali, et al., 2007, p. 78). This study offer a good platform for the reinvention of the human resources management practices (Sellgren et al, 2007, p. 172), leverage of the organizational models, culture in the healthcare systems, development of competencies, and development of rewards systems to take care of the problem of egress.
If this has been the problems that why is it that the healthcare practitioners have not been doing so? One of the reasons is that there is time constraint as that would require greater sacrifice of time, resources and general awareness of the bad management of the human resources, turnover issues and the wasted returns (Paul et al, 2006, p. 53). This study is very important because it will expose the holes in the bucket or the factors that affect the supply especially the turnover factors and those that cause reduced supply. However the astronomical expenses the wasted (water) human resources have been taking away from resource base was also a factor to take into consideration (El-Jardali, et al., 2007, p. 78).
This study will offer simpler analyses for the managers of the healthcare industry to comprehend and acknowledge the dynamic. This is because without such, then it would be very impossible to effectively execute the management of the human resources. Research has shown that this is true since the incremental and refinements have not been able to provide concrete solutions to the problem and the revolutionary changes still need to have very high level of organization to manage successfully (Sellgren et al, 2007, p. 176).
Literature Review
Introduction
Healthcare service delivery is very important to any nation because a healthy nation is a thriving nation. However, there has been a problem of balancing between the supply and demand of healthcare workers in Oman. This study will therefore seek to identify the factors that affect demand and supply of health workers in the country. In order to achieve the objective of the research, a number of sources not more than ten years ago will be searched for previous literature on the topic and other related material.
This means the sources will not go beyond 2000. The databases and materials to be searched will include Association of American Medical College, Alliance for health reforms, medpac, paraprofessional institute, BMC Health Services Research, biomedcentral.com, UNICEF Oman, World Health Organization, and Regional Office for Eastern Mediterranean, Omanisation Policy and World Health Reports among other sources. The words supply and demand of health workers, why health workers migrate, emigration of doctors and nurses, challenges of healthcare workers, recruitment of doctors and nurses, need for healthcare workers, and working conditions affecting healthcare workers home and abroad will be searched.
The objective of conducting this research will be attained by developing a process that investigates how innovating and sustaining the core training capability in medical practice can be efficient in managing the dependence on the US, UK and other nations especially from the developed world (Alonso-Garbayo & Maben 2009). By mentioning the words like core and moderation of the reliance of others implies that the problems of immigration among physicians and nurses was still hard to totally eliminate as there are a number of human rights also in play (Ahmad OB., 2005).
The ICNs report (2006) indicated that it was important the countries build their own national self sufficiency for managing their local needs on terms of supply and demand of healthcare services providers. This was a need for the developed and the developing countries alike.
Against this backdrop, there is an increased use of the terminology self-sufficiency when addressing the issue of healthcare workforce in the world. This review will also seek to understand what exactly could be the meaning of this terminology. The term is used interchangeably with self-sustainability and there are many other aspects that relate to it (Al Dhawi et al., 2007). These phrases are also used in different contexts as well. Sometimes it is not clear what the phrase means and how it applies to the context of medical care workforce in Oman (ICN 2006).
There is no generally agreed concept that guides the process of planning on how self-sustainability could be reached or even how the concept could be generally be assessed, or whether it could in fact be achievable. Part of the literature review defines the term in the context of Omani healthcare workforce. In this context, the paper identified the factors affecting sustainability describing them in terms of those that enable it against those that impede its feasibility (ICN 2006).
There has also been extensive research from the developing nations from African and others like India and Philippines (Lorenzo, et al. 2007; Seboni 2009). Nonetheless, there has been very little done on the problems that have been encountered in the Middle East nations like Iraq, Iran, Saudi Arabia, Oman and Bahrain (Brush and Sochalski, 2007, p. 38: Maben, et al., 2010, p. 293). There are a number of high income areas in this region that have come to be very influential in terms of determining the dynamics of the workforces.
This is because these countries are rich and greatly depend on the international recruitment so as to staff their increasing healthcare demands. These also pose a great competition to the other countries in the world (Maben, et al., 2010, p. 391). Whereas demand for physicians and nurses is increasingly growing, the matching international supply on the other hand has been decreasing.
Why Healthcare Professionals Migrate
There are a number of possible causes of migration among professionals of healthcare service provision (Group Meeting on International Migration and Development in the Arab Region, 2006). These determinants include social unrest in their home countries, poverty, and war.
These are the main causes in the low and middle income countries (Stilwel, 2004). Middle income countries still suffer the problem of unemployment and this also pushes healthcare professionals away especially those from Middle East and Africa. The workers then tend to move to areas where there is still some hope of employment. As a consequence, countries like Britain, Canada, and the United States are the main destination of these migrating workers (Stilwel et al, 2004). The major attraction in this context is the lucrative pay and better working terms.
Systems that Encourage Migration
It has been also found that some nations like Philippines encourage its citizens to emigrate (Stilwel et al., 2004). In Oman and other Arab nations, migration of healthcare workers is mainly because of the obstacles of the institutional systems hindering their personal prospects for social mobility. Besides, many emigrating healthcare workers complain that they are not well rewarded for their skills and the type of work they do plus there were many obstacles in their efforts to advance their professions (Fargues, 2006).
By and large, the factors that have been found to cause migration of professional healthcare providers fall into two broad categories, namely the push and pull factors:
The Push Factors
The push factors include; dangerous working conditions and crime many people in Arab countries in general have experienced crime first hand or they know someone who has suffered such fate (Lorenzo, et al. 2007). This is often a reason why healthcare professionals can choose to leave their country for fear of these violent experiences. They therefore opt to move and practice their profession in a place that is safer (Ahmad OB., 2005).
Another cause is often the low salaries given to professional health workers on their home countries. The developed countries have better pay for the foreign workers and at times it could be as much as over 20 times the country of origin (Buchan & North, 2009). This is the reason why counties like Nigeria and India have become grounds where doctors are trained and then exported to the international market.
The low wages and unguaranteed employment cause insecurity among the employees. This coupled with the fact that the cost of living is constantly increasing therefore very high expenditure; the workers are often unable to gain financial dependency (Buchan & Perfilieva, 2006). This often causes them to move to places where they are able to gain financial independence and even start a family as they are guaranteed of the job.
There are also a number of other job related dissatisfaction issues. The home countries offer very high workload for less pay, the health systems are dysfunctional, there are a lot of problems of deprived professional standards when interacting with workmates or handling patients and to make matters worse the rules that govern educational and professional advancement are unfair (Buchan & North, 2009). As a result there are many cases of nepotism in the recruitment programs and the employees lack motivation.
The home countries have very limited career options because of underdeveloped healthcare systems and specialization, as a result the qualifying doctors and nurses lack their desired type of specialty hence the zeal to work is affected (Dovlo 2005). As there are many qualifying professionals, there is very high competition for the limited positions in training and at work.
The Pull Factors
Most of the pull factors are just the opposite of the push factors. For instance, doctors, nurses, and paramedical personnel would migrate because of better pay and in search for better social and economic structures in foreign countries, something that they lack in their home countries (Buchan & North, 2009). Health professionals are also attracted to top foreign countries because there are able to access a wider range of career options and professional development to advance their careers.
This gives them the satisfaction and hope to better their lives. Foreign countries offer enough exposure to skills and the training focuses more on the procedural skills where the trainee are able to access more responsibilities and get trained on stick adherence to the set standards of care (Cutcliffe & Yarbrough, 2007).
The developed countries have well defined job responsibilities in the healthcare systems therefore present better working conditions. They also have regulated healthcare workload and the employees do not have to work under pressure. Workplace relationships are well managed and employees enjoy collegial relationships with each other. There are also better reward systems that are set in place for the healthcare workers for their dedicated and professional work (Cutcliffe & Yarbrough, 2007).
Regarding working conditions, the foreign countries offer lighter workload where employees work in functional health systems where there is better professional standard. The career advancements programs are based on the educational and research as well as teaching levels in the institutions of higher learning. Foreign nations especially the developed nations present a chance for continuous medical education and a guaranteed job security (Cutcliffe & Yarbrough, 2007).
Other pull factors in general include good living standards, easy access and availability of information, better communication technology, security and promise of better education for the children.
Recruitment of Professionals
The public sector depends on the private recruiting agents to this process and past research found out that the private practice did not depend too much on these agencies. These studies showed that for the recruitment agencies to maintain the ethical standards, they did not actively carry out the processes of recruitment in African countries since they were at the lower end of development (still developing countries) (Edward et al., 2008, p. 23). This is because the African nations still suffer the highest shortage of health service providers (International Labour Organization, 2005, p. 48). Work permit or licenses are only issued when the workers meet some eligibility criteria after which they would then be allowed to start working.
The study will seek to confirm or disapprove that the reasons for migration to and out of Oman were similar to those encountered in other GCC sates like the United Arab Emirates. The reasons behind emigration previously highlighted included the search for good salaries and work benefits, the search for better work conditions and wider career prospects (Buchan & North, 2009, p. 131), the search for a system that has international work standardization at the place of work and search for safer and stable job and also in pursuit of modern lifestyle where there are better infrastructure or social amenities and multi-cultural environment (World Health Assembly, 2006, p. 45).
Since 1970s many Omani graduates have been moving to the United States and European countries. Currently there are over 40% Omani medical graduates over the past 30 years working as nurses and doctors in the west (Martin, 2007, p. 49). This percentage is very high even though it basically seems to be very small but based on the countrys population size, Omani ranks among the highest countries exporting physicians and nurses to the US and the EU. These findings focused on the issues concerning the Omani medical graduated in the US and in the European nations (Bach, S. 2007, p. 387; International Labour Organization, 2005, p. 48).
Studies show that these graduates were aggressive in seeking board certificate in order to work in the medical research profession just like the American and other international graduates from the developed nations. The study will be keen on investigating the supply of health care professionals in terms of the graduating students as well as retaining those already in the workforce. Addressing the issues that lead them to immigrate to the developed nations to work there (Alonso-Garbayo, & Maben, 2009, p. 45).
The push and pull factor across the world have include those that deal with pay, better life, career development and modern technology or advancement as already indicated in the literature review (World Health Assembly, 2006, p. 45). These factors will be assessed and then described and categorized into groups including financial concerns, social factors, professional career advancement and residency training.
Nurse migration in Oman has very little information but it is quite significant. There are very few studies conducted to investigate it and even fewer have been done to assess its enormity as well as the predictors of the possible migration out of Oman (International Labour Organization, 2005, p. 48). Studies in the Arab countries indicate that at least one out of five nurses obtained a Bachelors of Science in Nursing Degree (BSN) in one to two years following graduation (El-Jardali et al. 2008b). In order for the nurses to qualify for assignment abroad, they are required to have at least one year of professional experience before they could be granted employment opportunity by an international employment agency.
The reasons for migration among nurses were mainly from the push factors and they basically included deficient career development opportunities, meagre salaries, and inequality with other workers and not being appreciated as health professionals (International Labour Organization, 2005, p. 54). Causes for leaving the countries were very varied across different careers. For instance, the financial reasons were the major factors causing the nurses to leave the Middle East.
While in the European Union region the factors influencing migration were mainly continuing education and career prospects. Even though most nurses intending to leave the country did not have intents of returning home, others indicated that both financial and non-financial enticements could encourage them to come back and practice at home (Bach, S. 2007, p. 387).
Most nurses reported that the main pull factors to encourage their stay in Oman or cause them to return would be better salaries, improvement of the work benefits, appreciation of their effect and support from the management, improved workplace polices and environment as well as better social infrastructure and technology to improve performance of the nurses (Pond & Barbara, 2006, p. 1453).
Self Sustainability in Oman
Defining Self Sustainability
Self sustainability means that the system should be able to produce the solutions or meet its needs independently (Merriam-Webster Online dictionary 2010). Applying this definition at workplace is somehow intricate particularly in the planning of the healthcare workforce.
Transferring the concept of having enough supply to meet the demand in healthcare results in a reasonable definition of the self-sustainable concept (Al Dhawi et al., 2007); This means that the healthcare system in Oman should have enough domestic stock of physicians and nurses who can meet the requirements or needs of the industry (Akl, et al., 2008). The concept has not however incorporate wider elements in Oman like the quality of care, the productivity of the practitioners, the employee mix and retention strategies. This breeds a broad range of policy alternatives for attaining self sufficiency that range far beyond mere increment of enrolment of the student nurses and doctors (Seboni, 2009).
Policy implication would translate into issues of reduction of student attrition and increasing the productivity of the employees. Increasing the participation is a tricky venture and can be achieved by bettering the available technology, elimination of the non-nursing duties, increment of the full-time working rates and increment of the participation rates in the profession.
Omanisation Program
In the year 1998, the Omani government developed a program termed Omanisation program (Al Dhawi et al., 2007). The Omanisation campaign was not only intended to ensure that the citizens found jobs but it would also decrease the countrys reliance on the foreigners for service provision and in the process it would be able to achieve self-reliance in human resource, (Ministry of Information, 2006a).
This meant that the country would be able to produce its own doctors and nurses to supply the growing demand of healthcare professionals. The program was a governments top priority venture and it had set the goals of ensuring that the government services would have at least 72% of the employees as Omani citizens in six years (Ministry of Information, 2006a). The government also set a stipulation that the private sector would do the same in so as to be allowed to operate in the country.
The program was however without obstacles though ministers came o
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