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Sun 1 Apr 2007 03:11 PM

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Train to retain

Education, research posts and more accountability could prove key factors in overcoming low pay scales when it comes to medical recruitment in the Middle East. Sarah Campbell reports.

An increasing lack of qualified healthcare staff in the Middle East is leading to recruiters asking what more can be done to attract experienced doctors and nurses to the region. At present, skilled practitioners and healthcare workers are using the Middle East as a stepping stone to move on to better positions in Europe or the US, and it seems the two main reasons for this are low salaries and a lack of career progression.

As the cost of living in the Middle East rises, salaries for medical staff are remaining stagnant. Add to this a transient expatriate population, combined with a lack of professional opportunities for specialist care as patients travel abroad for treatment, and the region is becoming less attractive as a workplace.

"The main problem of recruitment is poor pay," confirms Ziad Fares, senior associate at Booz Allen Hamilton, a regional consultancy firm. "Doctors and nurses receive relatively low salaries compared to other professions and other benchmark countries, especially with nurses. This theme of low salaries is the most urgent problem that needs to be looked at," he adds.

"I recruit for public hospitals and the low salaries are not attractive for western staff, we need to pay more," agrees Diane Nicholson from Medacs Healthcare, a UK-based healthcare staffing company with operations in the UAE, Australia and New Zealand.

There is evidence that ongoing lobbying is going on, especially by the private sector, requesting governments to look again at the pay schemes of medical professionals. According to Fares a salary hike of more than 50% is needed to bring Middle East packages in line with international norms. "This is not a trivial difference," Fares stresses. "Just to be able to reach the minimum benchmark level there needs to be an increase of 50%."

In February, doctors in Dubai met to address the issue of state paid salaries, as the government put the block on once again to raise salaries to levels on a par with international benchmarks. The Emirates Medical Association (EMA) met with the Ministry of Health to discuss the fact that the delay in a pay rise was leading to staff shortages, overworked doctors and a decline in the quality of care.

Health minister, Humaid Al Qutami had promised to revise the pay structure for doctors and nurses when he took office a year ago. So far, no increase has been implemented, and it is now almost ten years since wages for this sector were reviewed.

For public sector workers, and their human resources departments, this salary freeze makes the job of enticing new recruits an especially difficult one.

According to Fares, one solution is to allow doctors to practice at both public and private sector clinics. "The laws here prevent public sector physicians from practicing outside of public sector hospitals," he says. "Healthcare workers are being encouraged to work in the public sector, but doctors are restricted from working after hours in a private clinic."

"Doctors need to become investors in their own rights," he adds, mentioning that some hospitals offer research posts that doctors can also take on to develop their career.

"Yes, we need to establish career opportunities as educators, researchers or clinicians and provide facilities and investment to world-class standards. Many countries in the region have identified education and healthcare as the major area for development of a knowledge based economy, notably Qatar," says Michael Vertigans, director, Weil Cornel Medical College in Qatar (WCMC-Q).

Invest in training

It seems that ‘train to retain' is one way in which medical institutes in the region can attract new recruits and retain current staff.

The costs of recruiting, interviewing, advertising and training new staff may be better used in offering training opportunities, compensation or recognition schemes for existing staff. "The main challenges for recruiting the next generation of doctors as students are raising awareness of the profession and the career opportunities locally, demystifying the stereotypes about the region, and investing in healthcare for the long term," says Vertigans.

Continuing medical education (CME) has recently become compulsory. This means doctors and nurses have to accrue a certain amount of CME hours a year to retain their medical licenses and to practice. CME conferences are pricey, and staff need paid leave and funding to afford to attend. However, it seems that once again, the Middle East is lagging behind its international counterparts. Rather than invest in formal training opportunities, hospitals instead recruit western-trained nurses, with the hope that they will provide sufficient knowledge transfer throughout the nursing staff. "The hospitals I recruit for prefer to take candidates from the US or Europe," admits Nicholson from Medacs Healthcare.

Booz Allen Hamilton's Fares is currently working on a business plan for a nursing school in the region, and has been struck by the difficulties of first attracting students and secondly, ensuring that they, and their skills, remain in the region.

"You have to spark an innovative environment, offer fellowships and research, and continued education," he says. "Looking at the nurses' side, I have been asking ‘How do I attract nurses to come here?' So I have put together a work-live-study package, whereby the nurses come here and are offered the chance to continue their education, along with subsidised housing and a guaranteed job. This type of package becomes interesting for nursing students or nurses looking to advance their careers."

Other institutes are developing their own education programmes. The Saudi German Hospital Group, for example, has developed its own nursing school in Jeddah and the synergies between the educational unit and hospital are proving huge. Student nurses can secure on-the-job experience, and can fill staff shortages in a host of roles, including administration, providing a rounded education.

Such examples provoke the question of why this has not been done before. "There are not many [hospitals] doing this," admits Fares.

"Health education is a low profit field. But if you have a hospital, which has pretty decent margins, you have to open a nursing education unit to guarantee sustainability. It becomes a must do," he adds.

However, creating such educational opportunities can prove a double-edged sword. Qualified doctors and nurses are using the Middle East as a springboard for careers abroad, gaining their qualifications and early experience here and then utilising it in the high paying countries of Europe and the US.

"The trend of outward migration is an inevitable trend," Fares admits. "You are always going to have well educated nurses and physicians migrating from Lebanon and Jordan to the US and Europe and the main reason is low pay. They are being offered incentives of higher pay and residencies."

He is quick to point out, however, that this could also work to the Middle East's advantage, if health care recruiters approach the migration trend in the right way.

"This provides one more reason why students should step out of school and step into a nursing career. It could restart this wheel. Nursing schools are average in capacity rather than filled to capacity, and this needs to be addressed," he says.

Fares proposes that educational institutes and hospitals look at ways to ‘lock in' local talent before releasing it to the international market. He suggests that students are required to work for a number of years in the region before being allowed to apply for posts abroad. This way, the student doctors and nurses obtain experience closer to home, and the region's hospitals gain from their hard work and enthusiasm. For Fares, this has the added benefit of, hopefully, reeling these professionals back in towards the end of their careers.

"Ultimately, they come back a few years down the line and add some spark to the profession here in region," he predicts. "Lebanon and Jordan have 100-year-old hospitals and schools offering four-year programmes, their graduates are very well educated both in the classroom and in the hospital, so it would be very easy to place these nurses in US and European hospitals."

Home grown talent

Seeing a need for more medical professionals, a number of international colleges have opened up in the region in recent years. The Weil Cornel Medical College in Qatar opened its first medical programme in 2004, and will graduate its first set of students in 2008.

Established through a partnership between Cornell and the Qatar Foundation for Education, Science and Community Development, WCMC-Q shares the triple mission of Weill Cornell Medical College: education, research and patient care. WCMC-Q students are introduced to patient care from the earliest stage of their medical education. Through an affiliation agreement with the Hamad Medical Corporation (HMC), this takes place in primary healthcare centres in the community, and at HMC hospitals in Doha. Students start observing the doctor-patient relationship in the first year, and go on to take their clinical clerkships at the hospitals in the third and fourth years. In addition, there are plans for collaboration with the HMC in the fields of research and clinical care.

"The first class of WCMC-Q graduates in May 2008 and it is too early to determine what percentage will find positions in the region, " Vertigans explains. "However, with the investment in healthcare in the region over recent years and in the future there are and will be many opportunities for healthcare professionals here. Many of our students also originate from the region.

"In Qatar, Hamad Medical Corporation has embarked on major healthcare investment and has recently opened a new education centre and training centre, launched an international neonatal screening programme, and has achieved JCI accreditation. It is also building a new Medical City in Doha and new hospitals around the country."

Alongside this, the new Sidra Medical and Research Centre is due to open in late 2010 and will see the first academic medical campus in the region on one site - WCMC-Q as a teaching college and the Sidra Medical and Research centre.

"All these developments will also witness a major biomedical research programme, another first for the Middle East with a number of our partners involved," says Vertigans.

The Qatar Foundation announced in 2004 the construction of a 350-bed Specialty Teaching Hospital (STH) close to the Medical College in Education City. Supported by an $8 billion endowment, the hospital is due for completion in 2009.

Meanwhile, in Dubai the Harvard Medical School Dubai Centre (HMSDC) Institute for Postgraduate Education and Research has been established to foster the professional development of physicians, nurses, research scientists, and allied health professionals in the Gulf Region.

Medical dichotomy

In the Middle East, the difference between doctors and nurses is close to that of black and white and this is also creating problems in recruitment. Nurses are still quite limited in their autonomy in the Middle East, compared to the demands of their role in other parts of the world. Therefore, more needs to be done to give nurses more responsibility, which in turn could help lower the turnover rate of nurses in the region.

"The shortage in doctors in Europe and the US is helping nurses to get more empowered and develop the role of nurse in the hospital," Fares explains. "Here, we could start promoting further specialisations and this specialisation will empower and give the nurse more autonomy. However, the decision has to be taken at the hospital and it is also up to the schools to add on extra courses, such as one year Masters programmes.

"This would be almost ground breaking for the nurse. It would encourage (them) to stay and would also add more value for the nurse," he adds.

There is also a call for more accountability, again to elevate the nurse's role. In the Middle East, the nurse is typically seen as a low paid and low respected role.

"Anytime there is a mistake it is typically thrown on the nursing staff," says Fares. "Increasing or promoting the accountability process in the hospital is something we are definitely lacking here. We need to maximise autonomy for the nurse and make sure roles and responsibilities are clearly defined, so they are not trampled on by the physicians or administration."

Nursing associations are also missing in the region. Middle East associations would lend weight and support to the nursing profession and would help promote the job as a viable career option for school leavers, Fares says.

"You never see a seminar dedicated to nurses. The nursing profession remains poor culturally and is not very well regarded. Therefore, you hardly ever see students wanting to go to nursing school. We need make (the profession) attractive to students."

Competitive edge

Both Saudi Arabia and the UAE are in the process of introducing compulsory private health insurance for expatriates, which could lead to more investors setting up hospitals and providing healthcare facilities. With greater investment comes greater competition and the industry now waits to see how this will impact the jobs pool.

"More investors are walking in or looking keenly at the [medical] market," says Fares. "This brings more competition, which means more reasons for hospitals to differentiate. This causes recruitment of qualified professionals to increase. Investors are going to look for the top professionals to differentiate their product. They cannot compromise their name. Even if they end up paying more they would be very happy to do so.

"This will raise the bar for everyone, so to keep this bar up high the others are going to have to look for these professionals too. How can you attract these professions if the pay scale is low? The pay scale has to go up in order to compete."

Pushing the recruitment boundaries even further, Fares claims that emiratisation is now needed in the healthcare profession to fill the manpower gap, and calls for locals to look at entering this vital field of study.

"There is a cultural stigma behind the nursing profession. It is seen as not very attractive and we need to work on that in the UAE," Fares explains. "It is an important profession and we do need emiratisation in these fields."

The Middle East needs to work hard to make medical professions an attractive career option for would-be doctors and nurses, as well as raising the bar on pay scales and recognition schemes, if it is to overcome its current staff shortage.

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