A Comprehensive Approach to a Critical Issue: the Nurse Shortage

In every country’s health system, nurses are the backbone of health care delivery. They provide four-fifths of care delivery, and work around the clock to do it. Nurses provide essential hospital-based and primary care, and they also deliver care in emergency settings. They are often the first and sometimes the only health professional that people see. As part of their local community, they have a unique understanding of how best to shape and deliver effective interventions to meet the needs of patients and their families. Nurses are key to the sustainability of health systems.

Women account for approximately two-thirds of the global health and care sector workforce, many of them as nurses and midwives, and as such they contribute to the wider economy. The nursing sector can drive women’s economic empowerment, contributing to life changing poverty alleviation.

However, a shortage of nurses is hampering efforts to deliver quality health care in many countries. The Asian Development Bank (ADB) is helping to address this shortage, including in two Central Asia Regional Economic Cooperation (CAREC) countries, Pakistan and Turkmenistan.

Critical shortage of nurses in Pakistan

In Pakistan, the World Health Organization (WHO) estimates that there will be a shortage of 4.5 million nurses and 0.31 million midwives by the year 2030, with significant regional disparities. Pakistan was first listed as one of the 57 countries experiencing a human resources for health (HRH) crisis by WHO is their 2006 World Health Report, with the situation worsening since. The country still has one of the lowest densities of health workers both in the region and globally. One of the factors affecting the nurse shortage is that there is only a 25%, female labor force participation, one of the lowest in the world.

Moreover, instead of the WHO-recommended ratio of 2 to 4 nurses for every doctor, in Pakistan the ratio is reversed, with 0.61 nurses for every doctor, and there is an estimated nurse shortage of 1 million for the country, resulting in gaps in quality, while making care delivery expensive.

Provincial disparities are stark: Punjab hosts the largest nursing workforce, while faces the most acute shortages, and rural/underserved areas lag across provinces. Pakistan’s frontline cadres differ from India; references to “auxiliary nurse midwives (ANM)” are not applicable. Instead, Pakistan deploys Lady Health Visitors/Community Midwives and other community cadres, alongside registered nurses and midwives.

Out-migration

The nursing gap is widening too, due to out-migration of nurses, which has increased substantially during and since COVID-19. Emigration exerts pressure on staffing—driven by low remuneration, difficult working conditions, limited recognition, and constrained career pathways—further widening gaps in hard‑to‑serve locations. From 2022–2023, the Punjab government reported that half of all new graduate nurses left the country. Projections based on current nursing levels, and anticipated nurse coming into the workforce, there will be a shortage of over 400,000 nurses by 2030 in Punjab province, Islamabad Capital Territory and federally administered areas, a gap of over 80%. By contrast, the corresponding gap for physicians is estimated at just over 29,000, a gap of about 18%.

Systemic problems

One of the systemic problems underlying this shortage is the lack of high-quality nursing education, and a critical shortage of educators. While private sector nursing colleges had been offering a Bachelor of Science in Nursing (BScN) degree, the public sector in Punjab only started offering this in 2019. As a result, only 5% of nurses who have graduated from the public sector in Punjab have an education level of BScN. In addition, while Punjab’s public nursing schools have had their status upgraded to offer a degree program in nursing, there has been little upgrading of equipment and faculty requirements, resulting in low quality of student housing, substandard training facilities, and a shortage of educators.

This is further complicated by the perception, amongst the population, of nursing as a career option. Nursing is perceived to have a low status as a profession, resulting in few people option to enroll in nursing schools. This has recently improved somewhat with the introduction of a stipend the government pays to all nursing students enrolled in public sector schools.

Pakistan’s diploma‑to‑BScN transition outpaced readiness: only ~5% of nurses held BScN or higher by 2020, with many institutions lacking adequate faculty, infrastructure, equipment, and clinical teaching capacity. Specializations (e.g., oncology, mental health, geriatrics, community health) remain nascent for degree‑holders. Societal perceptions, career ceilings, and working conditions continue to suppress enrollment and retention—despite recent stipend measures in public schools.

Weak planning

Planning and management of HRH is weak, and the country lacks mechanisms to match existing human resources to need, or to effectively gauge future needs. Pakistan Nursing and Midwifery Council (PNMC) regulates nursing education/institutions while the Higher Education Commission (HEC) accredits degrees—creating overlap and uneven enforcement. Through its 18th constitutional amendment, the country has devolved health planning, service delivery and program implementation to the provincial level. However, due to a lack of HRH planning infrastructure, the country faced poor absorption capacity, retention issues especially in rural settings, both internal and external immigration pressures, and gaps in career structures, resulting in maldistribution of nurses and other health workers between urban and rural areas, and a mismatch of skills to needs.

Recent policy actions

To quickly expand capacity, PNMC authorized evening classes in public nursing colleges (Sept 2024) to utilize existing infrastructure and double intakes. A national policy framework for nursing & midwifery (2025–2034) sets direction for provincial strategies, workforce production, and quality assurance.

ADB assistance

Asian Development Bank (ADB) is working closely with both the federal and provincial governments in Pakistan to address this critical situation. The first step was taken in December 2023, when ADB approved a $1.5 million technical assistance project. This provides needs, capacity and systems assessments, knowledge and advisory services, and project preparation and implementation support for human and social development projects in Pakistan. Alongside other projects, these will include support to health care and education sectors in Punjab and Sindh.

Building on this, ADB is supporting the Government of Punjab through a $150 million Punjab Nursing and Health Workforce Reform program which focuses on establishing three Centers of Excellence, modernizing nursing education (faculty development, competency‑based curricula, quality assurance), and strengthening governance and accreditation systems, to accelerate progress toward universal health coverage and women’s economic participation.

A proposed $100 Million Sindh Nursing and Health Workforce Strengthening Project will also upgrade nursing colleges, improve faculty skills, and modernize teaching through digital and simulation‑based learning. Complementing this, a $2 million National Nursing Grant will strengthen accreditation, regulation, and curriculum standards nationwide. These investments aim to build a larger, more competent nursing workforce to improve health services across Pakistan.

Need for improved nursing quality and capacity In Turkmenistan

Turkmenistan’s health sector is performing well, with improvements in life expectancy at birth and infant and maternal mortality rates over the last decades, and generally good access to maternal and child health services. Like many upper middle-income countries, Turkmenistan’s rising living standards are leading to two common trends: an increasing burden of noncommunicable diseases (NCDs) and rising population demands for higher quality health services. Addressing both of these calls for more qualified health workers, and the government is working to plug gaps, and improve the education and qualifications of the health workforce.

Harnessing the potential of nurses

Currently, there are approximately 4.4 nurses per 1,000 population compared to an average of 8.3 nurses per 1,000 population in Europe and Central Asia. The ratio of nurses to doctors in Turkmenistan is 1.8:1 compared to the Organisation for Economic Co-operation and Development (OECD) average of 2.6:1. The shortage of nurses has been identified by the government as a key area to address, not least to help the country tackle its burden of NCDs. By increasing the number of nurses and strengthening the role of nurses, Turkmenistan will be able to harness their full potential for the prevention and management of chronic diseases in primary health care as recommended by WHO. Nurses are also key to helping people make lifestyle changes to minimize their risk of developing NCDs.

Upgrades needed

One pressing need is to upgrade facilities at the country’s existing six nursing schools. At the same time, the government has recognized the importance of improviong the medical education system. This includes strengthening teaching, the curriculum, nursing skills, and education quality assurance, and shifting from doctors to nurses as the lead educators, in line with international best practice. Nurses’ qualifications can be further strengthened by including soft skills such as problem solving, critical thinking and communication and interpersonal skills. At the service management level, moving to evidenced-based standards, rather than historic norms, for forecasting and long-term resource planning will improve supply planning and distribution of health workers, including nurses and midwives.

ADB’s support to reform

ADB is working with the Government of Turkmenistan to support the reform of the country’s nursing workforce and profession. This support comprises three elements. The first is the design and construction of a new nursing school in Ashgabat with modern teaching and medical equipment. The second focuses on improving the quality of nursing education through upskilling the teaching faculty and senior training nurses; quality-assured, competency-based general nursing and midwifery curricula; and increasing the participation of nurses and midwives nursing school governance. The third aims to support the Ministry of Health and Medical Industry to develop its planning and forecasting capabilities, implement an upgraded gender- and climate-sensitive continuing professional education curriculum; develop codes of professional ethics for nurses and midwives; and develop gender-sensitive job descriptions for all nurses and midwives in line with the updated curriculum. .

Written by Jane Parry and Ali Afzal Shaikh.