MARKET ASSESSMENT REPORT. Supply & Demand for Health Service Providers

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1 MARKET ASSESSMENT REPORT Supply & Demand for Health Service Providers

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3 MARKET ASSESSMENT REPORT Supply and Demand for Health Service Providers Edited by: Dr. Arslan Malik & Yasir Ilyas American Refugee Committee, Pakistan September, 2015

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5 CONTENTS Introduction 1 1. Study Design 2 Scope of Work 2 Objective of the Study 2 Methodology 2 Research Questions 2 Duration 3 Limitations of the Study 3 2. Focused Areas of Study 4 i) What constraints do Afghan refugees face in accessing health services? 4 ii) What constraints do Afghan refugees face in delivering health services to Afghan communities? 5 3. In-Demand Technical Skills 6 4. Discussion: Opportunities to Address Challenges, Constraints in the Healthcare Market 7 and Demand for Trained Afghan Health Personnel Links between language and medical care 7 Links between capacity building of Afghan youth and health service delivery for Afghan 7 communities Potential for obtaining jobs in private sector hospitals after having a particular medical skill 7 Links between technical skill and repatriation 7 5. Key Findings and Recommendations 8

6 INTRODUCTION The Afghans settled in the refugee villages and peri-urban areas are living with very poor access to health services. The main challenge is access to quality health services within their locality. As of December, 2015, according to UNHCR there are 1,478,030¹ Afghan refugees living in different parts of Pakistan. There are 14 districts in Khyber Pakhtunkhwa where Afghans are living in refugee camps. In total there are 48 health facilities for a registered refugee population of 829,221 in the refugee villages, making access to health services a challenge. To improve access to healthcare, as well as create opportunity for Afghan refugees, ARC developed a vocational training diploma program for Afghan refugee youths on healthcare services and delivery through various medical courses. In 2014, ARC conducted focus group discussions (FGDs) to assess market trends for healthcare skills and gather information on the most sought-after healthcare skills. In doing so, ARC also sought to understand what challenges Afghan refugees faced in accessing appropriate healthcare, and what constraints they faced in joining the medical industry. From these discussions, numerous issues were identified, related to livelihoods and healthcare. Public hospitals are unable to provide sufficient services to Pakistanis due to poor infrastructure and lack of human and financial resources. Furthermore, there is a lack of awareness among Afghans related to health-seeking practices. Most Afghans follow traditional health practices at home. Low demand for family planning leads to high rates of morbidity and mortality among reproductively active women. The language barrier is yet another reason that prevents Afghan refugees, especially women, from accessing public health facilities. These challenges suggest a strong unmet demand for affordable, culturally appropriate medical care for which Afghans would be most suited to provide. This analysis of the constraints to providing this care resulted in the identification of promising opportunities for technical and vocational training to fill this void. ARC signed an agreement with BPRM to arrange trainings for Afghan refugee youths in medical courses. The primary goal of the project is to build the capacity of Afghan refugee youths on healthcare service delivery through a vocational training diploma program in different medical courses. ¹ 1

7 1STUDY DESIGN Scope of Work Scope of the study is to gather information about most in demand skills in the market. More specifically, to research health technical trades in high demand that will enhance the skills of Afghan refugee youths. This assessment used both primary and secondary data sources for data collection. Objective of the Study To assess market trends for most employable skills among different paramedical trades. 4 Methodology In depth interviews were conducted using a semi structured questionnaire with different experts in private and public health sector. This included private health practitioners, officials of private hospitals, public health care specialists and academia linked with health. Respondents were selected from the population of health care workers currently working in Lahore, Rawalpindi and Islamabad. An ARC staff person led the discussions. After the discussion, we reviewed responses to identify the most common constraints and opportunities to address them through vocational training for in-demand medical skills. Research Questions We based our investigation of market trends and demand for healthcare skills on the following research questions to help identify trends, unmet demand and opportunities in the health care market. 1) What constraints do Afghan refugees face in accessing health services? What are the current health needs of refugees? What are the constraints/barriers to accessing health services for Afghan refugees in Pakistan? 2) What are different barriers for getting paramedical trainings for Afghan refugees What links exist between capacity building of Afghan youth and health service delivery for Afghan communities? What challenges confront Afghan refugees trying to enter in the health sector at individual and community level? Links between a technical skill and repatriation 3) What are the market trends for healthcare skills? What health care trades in high demand in the Pakistan's market, and what is the jobs market in private sector hospitals? What is the employability for youth with a particular medical skill in private sector hospitals? What are the average pay scales/remunerations for most demanded health skills? What challenges confront Afghan refugees trying to open a private midwifery/dispensary setup? 2

8 STUDY DESIGN Duration The duration of this study was ten days. It was conducted from September 1 to 10, Limitations of the Study There were two main limitations to this study. The first is the limited number of respondents (60 participated in focus group discussions, and ten participated in the survey). The second is that this survey was conducted with a small sample of only ten individuals. However, this study provides a strong first assessment of this issue, and can be combined with other more comprehensive instruments to enhance and confirm the results. Future studies can duplicate the research with a greater number of participants that are directly linked with service delivery to Afghan refugees. Future studies might get more conclusive results by expanding the sample to include respondents from various locations and provinces within Pakistan, as well as from Afghanistan. 3

9 2 FOCUSED AREAS OF STUDY 1) What constraints do Afghan refugees face in accessing health services? Below we summarize the study's findings the challenges faced by Afghan refugees in accessing healthcare services. These challenges can indicate demand for health services unfilled by the current market, and highlight opportunities that could be addressed through technical education. Constraints to accessing health services for Afghan communities in Pakistan In Pakistan, many organizations are involved in medical care especially for Afghan refugees, but these health facilities are established in refugee villages. There are no clinics or health centers specifically for Afghan refugees in urban settlements, so they visit public health centers established for Pakistanis. There is no discrimination for Afghans refugees or outsiders in getting health services from Pakistani health facility; however serving both populations (Afghan and Pakistani) puts a strain on the limited resources. Pharmaceuticals and supplies are provided to health facilities by the government, based on the Pakistani population, without taking into account the numerous Afghan refugees relying on the same health facilities to get the medicines and services they require. Current health service delivery needs of refugees Refugees are suffering from poverty and lack the resources to provide their loved one with basic health needs. Afghans with chronic diseases or life threatening conditions represent 3.5% of the total population of Afghan refugees in Pakistan. Hepatitis (31%) and asthma (28%) are the leading ailments followed by diabetes (20%) and heart diseases (19%). Females are more susceptible (57%) to the different diseases. Moreover, 11% of the Afghans suffer from some form of disability, mostly with difficulties in sight (45%). Hearing difficulties (17%), mental illnesses (11%) and problems with walking (12%) are other health concerns. As per the results of UNHCR's Population Profiling, Verification and Response Survey (PPVR), women who reported pregnancies in the last two years, 24% did not have any medical check-up and only 13% had help from a skilled attendant during deliveries. However, 83% of households live within a distance of 30 minutes or less from the nearest medical facility. Refugees need facilities for treatment of minor injuries as well as major operations. There is a need for facilities and trained medical staff to provide medical attention. Results of focus group discussion with Afghan refugees show that a number of challenges being faced by these communities in getting health services in Pakistan. Some of those challenges are listed below: Poverty: Most of the Afghan refugees are living below the poverty line. Afghan refugees settled in urban areas are financially sound in comparison to the refugees settled in camps/refugee villages. Therefore, it is hard for poor community to bear the expenses on health, i.e. fee of doctor, medical tests, transportation and medicines. Language Barriers: Language barriers complicate Afghan refugee's access to health care. Pashto is the mother tongue of Afghan refugees, however most Pakistani health professionals communicate in Urdu, a ² UNHCR, PPVR Report

10 FOCUSED AREAS OF STUDY language not understood by most Afghans. Similarly, the Information, Education and Communication (IEC) material developed for health facilities is in English/Urdu. While language barriers were common, in KPK and some parts of Balochistan, paramedical staff can speak Pashto, allowing for better communication for Afghan refugees during medical checkups. Many Afghan males can easily communicate in Urdu; however this is not the case for most females, making them even more vulnerable to language barriers. Afghan patients can leave the visit confused, possibly misdiagnosed, and with little confidence in the care provided and the medical system in general. Language-assistance services should be provided at no cost to the patient, at all points of contact, in a timely manner, and during all hours of operation. Verbal and written notices informing patients of their right to receive language assistance should be provided as well. Unless requested by the patient, family members or friends should not serve as interpreters as this can cause further confusion. Patient-related materials and signage must be provided in the commonly encountered patient language group(s). 2) What constraints do Afghan refugees face in delivering health services to Afghan communities? Below we summarize our findings on the constraints Afghan refugees face in meeting the health delivery needs of Afghan communities. These barriers may present opportunities that could be addressed through targeted interventions or training. Constraints faced by Afghans to establish a private clinic or get health job The following problems are faced by Afghans in establishing their own health facility/clinic: 1. Lack of funding or access to financing to start a facility. 2. Obtaining a 'No Object Certificate' from government for establishing such unit. This is a process which takes both time and money. 3. Initial lack of confidence among the Afghan community in facilities/clinics run by recently graduated Afghans with relatively low experience levels. 4. They might face confidence problems in running the facility on their own due to lack of experience or networking in the health sector. 5. As they are not Pakistani, therefore, they cannot get job in government health sector Challenges for Afghan refugees in the health sector at individual and community level Obtain No Object Certificate from Director General Health Acquire certification of establishing a training institute from ministry of health. Registration of trained students in government health department They need time for developing their reputation in the target community Applying for jobs / establishing health care units. There are limited facilities established in Afghanistan which provide health care services therefore getting such trainings will not only offer them with a good career but also the mental satisfaction of helping their community and country. 5

11 3 IN-DEMAND TECHNICAL SKILLS Below we summarize our assessment of the demand for different medical trades and technical skills, which we determined from consultations with health practitioners. Consultations with health practitioners revealed the following average pay scale/ remunerations for health technical trades are given below: 6

12 4 DISCUSSION: OPPORTUNITIES TO ADDRESS CHALLENGES, CONSTRAINTS IN THE HEALTHCARE MARKET AND DEMAND FOR TRAINED AFGHAN HEALTH PERSONNEL Links between language and medical care One key way that training Afghan refugees in medical trades can influence the access to appropriate medical care for Afghan communities is by providing medical care and information in Afghan languages. Links between capacity building of Afghan youth and health service delivery for Afghan communities Healthcare trainings will not only build the capacity of Afghan youths, but will also be a resource for their community with much needed medical care related support. Building the capacity of Afghan youth in health technical skills is a good idea as it will not only help the community in receiving health services but will also be a source of income generation. Families that don't let their members get medical treatment due to stereotypes and rigid behavior will be more comfortable in getting treated by those they trust i.e. those who belong to their own community and have received proper training. Potential for obtaining jobs in private sector hospitals after having a particular medical skill There is a very high potential for such jobs due to rapid increase in population as well as an increase in establishment of health related facilities. The lack of health and hygiene awareness results in increased disease outbreaks among Afghan refugees. They have limited knowledge of how to maintain good health through cleanliness and simple day to day remedies. It will be easier for them to communicate with a trained member of their community instead of an outsider as they share both language and tribe. Links between technical skill and repatriation The current situation in Afghanistan is getting calmer and the country is moving towards development. Some parts of the country are still under the war, while most cities are now are approaching peace and stability. Youth has to be motivated to receive these training as only properly motivated individuals will pursue this field. Regular tests and examinations have to be conducted specially from certified trainers apart from those who have trained these students in order to ensure the quality of training. Only individuals meeting the certification criteria should be trained and after training only those receiving benchmarked scores should be awarded degree/ training certificate. 7

13 5 KEY FINDINGS AND RECOMMENDATIONS Key Findings: Recommendations: Linguistic barriers exist for Afghan refugees, and especially for women, during their check-ups. Refugees living in refugee villages have greater access to health facilities as compared with those living in urban areas. Health practitioners support and encourage efforts to build capacity among Afghan youth as a strategy for increased efficiency in the refugee communities' health service delivery system as well as providing a mode of income generation. Medical trades that rank highest for market demand are; Dispenser/Medical Technician, Surgical/OT Technician, Dental Technician, Radiographer/ Imaging Assistant, Medical Laboratory Technician and Midwifery. Remuneration for above health trades differs greatly between facilities in the public and private sectors. Government employees report a higher wage than private sector employees in the same position. Multiple skills should be provided whenever there is a training program, which increases their chance of employment. Job-training programs should focus on skills that are in highest demand. Enhancing linguistic as well as computer skills of the trainees increases their value as employees, and improves their ability to provide needed medical care to Afghan communities. Certification from a reputable organization/institution will place value on the skill acquired. 8