Improving Nursing Training and Conditions to Advance Universal Health Care Goals

The brief highlights severe shortages, uneven training quality, and poor working conditions for nurses across Asia and the Pacific, undermining progress toward universal health coverage. It calls for stronger education systems, fair compensation, robust accreditation, and better workforce policies to build resilient and equitable health care systems.

Prepared by researchers from the College of Nursing at Inje University in the Republic of Korea and the Asian Development Bank, the brief Enhancing Nursing Education and Training in Asia and the Pacific lays bare the widening gaps between health ambitions and realities across the region. Progress toward universal health coverage has stalled, with life expectancy in Bangladesh, the Lao People's Democratic Republic, the Philippines, Sri Lanka, and Vietnam still trailing OECD levels. Infant mortality remains high, especially in the Lao PDR, which records more than 35 deaths per 1,000 live births. Financial indicators are equally stark: Bangladesh and the Lao PDR spend less than $200 per capita on health annually, while out-of-pocket payments remain crushingly high. These disparities expose deep structural weaknesses that undermine equitable access to care.

The Workforce Crisis Behind the Numbers

At the heart of the region's health challenges is a nursing workforce stretched thin. Nurse-to-population ratios in several countries fall far below global norms. Bangladesh counts just 6.6 nurses per 10,000 people and has more doctors than nurses, an inversion rarely seen anywhere else. Sri Lanka and Vietnam face similar shortages, while the Philippines, despite producing thousands of graduates, continues to lose its talent to more lucrative overseas markets. COVID-19 magnified burnout and pushed many out of the profession. Salaries remain another sore point: nurses often earn less than half of what physicians do, even as workloads rise. The brief makes clear that until compensation, recognition, and career pathways improve, education reforms alone cannot stabilize the workforce.

Divergent Paths in Nursing Education

The report provides a comparative picture of how the five countries structure their nursing education systems. Bangladesh offers more than 400 programs at diploma, bachelor's, and master's levels, but still struggles to meet domestic demand. The Lao PDR relies heavily on the University of Health Sciences, the only institution offering a full four-year BSN program, leaving provincial schools hindered by limited faculty and outdated curricula. The Philippines has taken the opposite path, expanding rapidly after lifting a decade-long moratorium on new nursing programs, offering more than 400 BSN programs by 2024. Sri Lanka modernized its BSN curriculum with Korean support, replacing unstructured clinical hours with competency-based training. Vietnam maintains strong BSN standards and offers advanced degrees but continues to face shortages of qualified instructors. Across the board, the need for modern, skills-based, and globally aligned curricula is clear.

Licensing, Accreditation, and the Quality Gap

Quality assurance emerges as a major fault line. The Philippines stands out with its long-standing and rigorous national licensure examination, which tests both theory and practical skills. Bangladesh introduced its exam in 2015, while the Lao PDR is refining a newer system that still requires stronger assessment tools. Sri Lanka lacks a national nursing licensure exam altogether, and Vietnam plans to launch one by 2028. Accreditation systems are similarly inconsistent. While wealthy countries such as the United States, Australia, and the Republic of Korea have decades-old accreditation bodies, several of the focus countries lack dedicated mechanisms. Even where accreditation exists, as in Bangladesh and the Philippines, rural institutions remain under-resourced and struggle to meet standards. Without robust licensing and accreditation, the pathway to a competent nursing workforce remains shaky.

Voices From the Frontline and a Path Forward

The brief's most compelling insights come from focus group interviews with nurses, tutors, and students. Nurses describe overwhelming workloads, negative social attitudes, and chronic understaffing that push many to migrate. Tutors highlight sharp resource disparities: capital-city schools improve with international aid, while regional institutions operate with outdated equipment and insufficient simulation labs. Students express frustration over limited clinical practice, inconsistent evaluations, and the prospect of low salaries that dim their motivation. Many hope to study or work abroad, underscoring the ongoing risk of brain drain. The brief concludes that meaningful reform must expand access to education in underserved regions, modernize curricula, strengthen faculty development, improve working conditions, and establish strong systems of accreditation and licensure. Only by investing in nursing leadership and recognition can countries build resilient health systems capable of meeting future challenges.