human resources for health - School of Public Health and Community ...

hrh issues and challenges

HUMAN RESOURCES FOR HEALTH

ISSUES AND CHALLENGES IN 13 PACIFIC ISLANDS COUNTRIES 2011

Jennifer Doyle, Augustine Asante and Graham Roberts

www.hrhhub.unsw.edu.au

The Human Resources for Health Knowledge Hub

Acknowledgements The authors would like to acknowledge Temarama Anguna (Cook Islands), Ben Jesse (Federated States of Micronesia), Oripa Niumataiwalu (Fiji), Veronica Taake Binoka (Kiribati), Marissa Cook (Nauru), Bob Tunifo

This technical report series has been produced by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales. Hub publications report on a number of significant issues in human resources for health (HRH), currently under the following themes: leadership and management issues, especially at district level

Talagi (Niue), Merlyn Basilius (Palau), Russell

maternal, neonatal and reproductive health workforce at the community level

Edwards (Republic of the Marshall Islands),

intranational and international mobility of health workers

Pelenatete Stowers (Samoa), Coldrine Kolae

HRH issues in public health emergencies.

(Solomon Islands), Kele Lui (Tokelau), Tu’Akoi Ahio (Tonga), Markson Tetaun (Vanuatu).

The HRH Hub welcomes your feedback and any questions you may have for its research staff. For further information on these topics as well as a list of the latest reports, summaries and contact details of our researchers, please visit www.hrhhub.unsw.edu.au or email [email protected]

An external review of this publication was conducted by Dr Zeke Nukuro, WHO Suva

© Human Resources for Health Knowledge Hub 2011

Published by the Human Resources for Health Knowledge Hub of the

Suggested citation:

School of Public Health and Community Medicine at the University of

Doyle, J et al. 2011, Human resources for health (HRH) issues and

New South Wales.

challenges in 13 Pacific Islands countries, 2011, Human Resources

Level 2, Samuels Building, School of Public Health and Community

for Health Knowledge Hub, Sydney, Australia.

Medicine, Faculty of Medicine, The University of New South Wales,

National Library of Australia Cataloguing-in-Publication entry

Sydney, NSW, 2052, Australia

Doyle, Jennifer

Telephone: +61 2 9385 8464

Human resources for health (HRH) issues and challenges in 13 Pacific Islands countries, 2011 / Jennifer Doyle, Augustine Asante and Graham Roberts. 9780733430749 (pbk.) Public health personnel—workforce issues—Pacific Island countries Public health personnel—education and training—Pacific Island countries

Facsimile: +61 2 9385 1104 [email protected] www.hrhhub.unsw.edu.au Please contact us for additional copies of this publication, or send us your email address and be the first to receive copies of our latest publications in Adobe Acrobat PDF.

Public health personnel—working conditions—Pacific Island countries Public health personnel—migration—Pacific Island countries Asante , Augustine. Roberts, Graham. University of New South Wales. Human Resources for Health Knowledge Hub. 362.1099

Design by Gigglemedia, Sydney, Australia.

Contents

2 Acronyms 3 Executive summary 3 Introduction 4 Section 1. Overview of participating Pacific Island countries 7 Section 2. Methodology 9 Section 3. Perceived HRH issues and challenges 11 Section 4. Needs and priorities 12 Section 5. Discussion 14 Section 6. Policy implications 16 Conclusion 17 References 19 Appendix Table 1. Selected infant mortality rates (IMR), under age 5 mortality rates and maternal mortality rates (MMR) 22 Appendix Table 2. HRH issues and challenges by country

LIST OF FIGURES 7 Figure 1. HRH roadmap

List of Tables 5 Table 1. Selected demographic and socio-economic characteristics 6 Table 2. Selected expenditure and health indicators 9 Table 3. Summary of HRH issues and challenges

HRH issues and challenges in 13 Pacific Islands countries: 2011

Doyle et al.

1

Acronyms

AusAID

Australian Agency for International Development

BNPL

Basic Needs Poverty Line

CHIPS

Country health information profiles

DFaT

Department of Foreign Affairs and Trade, Canberra

FSM

Federated States of Micronesia

GDP

gross domestic product

Govt.

Government

HIV

human immunodeficiency virus

HRH

human resources for health

IMR

infant mortality rate

IOM

International Organization for Migration

JICA

Japan International Cooperation Agency

MBBS

Bachelor of Medicine/Bachelor of Surgery

MDG

Millenium Development Goal

MMR

maternal mortality rate

MoH

Ministry of Health

NZAID

New Zealand Agency for International Development

OECD

Organisation for Economic Cooperation and Development

PC

per capita

PHRHA

Pacific Human Resources for Health Alliance

PICs

Pacific Island countries

PNG

Papua New Guinea

POLHN

Pacific Open Learning Health Network

PRISM

Pacific Regional Information System

RMI

Republic of the Marshall Islands

SPC

South Pacific Commission, Noumea

THE

total health expenditure

UN

United Nations

UNICEF

United Nations Children’s Fund

UNFPA

United Nations Population Fund

USD

United States dollars

WB

World Bank

WHO

World Health Organization

WPRO

Western Pacific Regional Office of the World Health Organization

A note about the use of acronyms in this publication Acronyms are used in both the singular and the plural, e.g. MDG (singular) and MDGs (plural). Acronyms are also used throughout the references and citations to shorten some organisations with long names.

2


Doyle et al.

EXECUTIVE SUMMARY

INTRODUCTION

Background

The roles of the PHRHA1 are to help identify and address HRH challenges experienced by PICs, to assist in the implementation of strategic policy and planning, and more generally, to facilitate the strengthening of national HRH capacities within the Pacific region. Its supportive activities include the organisation of forums to facilitate discussion of HRH issues and concerns amongst stakeholders. This paper presents the results of one such meeting.

In February of 2011 the Pacific Human Resources for Health Alliance (PHRHA) met in Nadi, Fiji, where representatives from 13 Pacific Island countries (PICs) discussed current issues and challenges in human resources for health (HRH), and identified needs and priorities to address them. Focussing on participants’ presentations, this paper documents their perspectives and understandings and presents policy recommendations arising from discussions. In addition we present selected country comparative demographic, socio-economic, health expenditure and health status indicators to characterise the variable health service contexts among the participating countries.

Methods

Representatives from 13 PICs (Cook Islands, Federated States of Micronesia (FSM), Fiji, Kiribati, Nauru, Niue, Palau, Republic of the Marshall Islands (RMI), Samoa, Solomon Islands, Tokelau, Tonga and Vanuatu) came together at a PHRHA meeting held in Fiji in February 20112 to present what they perceived to be the key HRH challenges currently being faced within their respective health sectors.

Contributions in the form of PowerPoint presentations from each of the participating countries were structured according to pre-arranged format and have been tabulated to identify common themes. Country comparative indicators have been compiled from source documents.

This paper considers current HRH issues within PICs from the perspectives of people who manage HRH within their country health ministry. The aim of this paper is to document and highlight their key areas of common concern expressed at the forum.

Results

Section 1 presents selected key demographic and socioeconomic indicators for each country, Section 2 focuses on the methods used for participants to prepare for the meeting and the methods we have used to identify and synthesise the themes emerging from the presentations, Section 3 describes issues currently being experienced within each country, Section 4 focuses on perceived needs and priorities, Section 5 presents discussions of the key themes emerging from participants’ contributions and Section 6 presents the policy implications arising.

Five challenges emerged from the presentations and discussions: 1. health workforce issues (skills shortages, retention, recruitment and workforce ageing) 2. the lack of effective HRH policy, management and information systems; 3. education and training for HRH production; 4. public sector working conditions, and 5. migration of Pacific health personnel, both internally and internationally.

Participants agreed that education and training, and policy and management issues, should be given priority. Essential elements for addressing these needs were seen as national workforce planning, financial support and technical assistance from donor countries and other stakeholders. The fulfilment of needs was also seen to require political commitment and strong leadership of Ministries of Health (MoHs) capable of advocating for support from other key stakeholders.

Conclusions Policy implications emerged for action at three levels: national governments, regional training institutions, and donor organisations.

Membership of PHRHA includes all PICs, key development partners, representatives of health training institutions, professional associations, Pacific regional organisations, and WHO. The PHRHA Secretariat is currently housed at the WHO sub-regional office in Suva, Fiji. 2 The meeting, Draft Framework for Action on HRH 2011-2015: Country Situation on Human Resources for Health (HRH), was held in Nadi, Fiji, February, 2011. 1


Doyle et al.

3

SECTION 1. OVERVIEW OF PARTICIPATING PACIFIC ISLAND COUNTRIES Table 1 presents key demographic and socioeconomic indicators for each of the 13 participating PICs. Given the lack of reliable data for many of the countries, comparisons such as these must rely on relatively basic and traditional indicators such as population, urban/rural proportions and gross domestic product per capita (columns 1, 2 and 3). The final column (column 4) presents the percentage of each population estimated to be living below the Basic Needs Poverty Line (BNPL). This measure provides a broad comparative indication of the proportion of the population who are unable to fulfil minimum dietary needs and do not have enough income for basic non-food needs such as health care, housing, education, transport, and community and kinship responsibilities and obligations (AusAID 2009). Given that the notion of basic needs is relative, with definitions varying from country to country, it should be treated with some caution. However, the BNPL is a useful descriptive measure that serves the purpose here of providing a contextual indication of the relative experience of poverty among peoples of the participating PICs. Although the populations of most PICs are relatively small, there is some variation across the region. Niue, Tokelau, Nauru, Palau and RMI qualify as ‘micro-states’ (defined as populations below 50,000 (Docquier & Schiff 2009)3 and represent just 3.7% of the total population of the 13 countries, while Fiji and the Solomon Islands combined represent 60%. The second column shows that Tokelau, Solomon Islands, Samoa, FSM, Tonga and Vanuatu are the least urbanised with a quarter or less of their populations living in urban areas. The most urbanised of the developing countries are Nauru, Palau, Cook Islands and RMI. Column 3 indicates GDP per capita for each country. The lowest producing countries among the 13 are Solomon Islands, Kiribati, Nauru and FSM, while the highest are Cook Islands, Palau and Niue. At well over $14,000 per capita the Cook Islands is the highest ranking, due in part to an extensive reform process begun in the mid-1990s (Cook Islands Government Online, 2011).

per capita are presented in columns 1 and 2, with proportions of government spending on health and the contribution of individuals (out-of-pocket expenditure) presented in columns 3 and 4. Column 1 shows that Fiji (3.8%) has the lowest health expenditure as a percentage of GDP. Niue has the highest health expenditure as a percentage of GDP at almost 18%, and has the highest per capita health expenditure (column 2) at $1,408. Column 4 shows the contribution that out-of-pocket expenditure makes to THE, with Tonga as the highest at almost 28%. Columns 5 to 8 present selected health indicators for each country; again our purpose being to illustrate the differing experiences of participating PICs. Life expectancy varies considerably, ranging from a low of 53 for men and 58 for women in Nauru, to 72 and 74 years in Samoa. The under-5 mortality rate per 1000 live births (column 6) ranges from 7.1 in Cook Islands to 48 in Kiribati. Maternal mortality rates (column 7) also vary considerably, although caution is required when interpreting maternal mortality rates as a small number of deaths in any particular year can significantly affect the annual rate in small populations. Samoa has the lowest rate at 3.0 per 100,000 live births, followed by Fiji at 27.5. Palau has the highest rate at 366.3, followed by RMI and Nauru at 324.15 and 300.0 respectively. Column 8 presents the prevalence of diabetes among the 13 participant countries. Most noteworthy is that Nauru has the highest diabetes prevalence rate at almost 31%. (While our purpose here has been to make country comparisons to demonstrate selected indicator variance across the participating PICs, we also show (in Appendix Table 1) that infant mortality rates, under-5 mortality rates and maternal mortality rates from a variety of sources show little consistency regarding the year to which they refer, and provide few explanations of how the estimates have been derived and adjusted).

Niue and Vanuatu have the smallest proportions of people living in poverty, while Kiribati, Fiji, FSM and the Cook Islands have the largest proportions within the 13 countries. Table 2 shows health expenditures for each country, our purpose being to illustrate that PICs have significantly different levels of commitment to health expenditure. Total health expenditure (THE) as a percentage of GDP and THE

4


Elsewhere a micro-state has been defined as a country with a population under one million (Firth 2005); in which case all Pacific Island countries except PNG could be described as micro-states.

3

Doyle et al.

TABLE 1: SELECTED DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS Urban Population5

GDP6

Basic Needs Poverty Line7

(%)

(USD pc)

(% below)

13,3008

72

$14,322

28.4

(2009)

(2006)

(2008)

(2006) (p)

110,000

22

$2,183

29.9

(2010)

(2010)

(2007)

(2005) h

Population4

Cook Islands

FSM

Fiji

Kiribati

Nauru

Niue

Palau

RMI

Samoa

Solomon Islands

Tokelau

Tonga

Vanuatu

890,000

51

$3,715

34.3

(2010)

(2007)

(2011 est)

(2003) h (p)

100,000

44

$1,536

50.0

(2010)

(2005)

(2011 est)

(1996)

9,771

100

$2,042

(2009)

(2006)

(2007)

1,514

36

$8,216

13.0

(2009)

(2006)

(2006)

(2004)

20,397

77

$8,911

24.9

(2009)

(2005)

(2008)

(2006) (p)

54,065

65

$3,130

20.0

(2009)

(1999)

(2008)

(1999)

182,000

21

$3,293

20.4

(2010)

(2006)

(2002)

(2002) h

n/a

531,000

16

$1,296

22.7

(2010)

(1999)

(2011 est)

(2006) (p)

n/a10

n/a

1,5379

0

(2001)

(2006)

103,000

23

$2,983

22.3

(2010)

(2009)

(2011 est)

(2002)

247,000

24

$2,955

15.9

(2010)

(2009)

(2011 est)

(2006) i (p)

Source: DFaT country fact sheets unless otherwise indicated. URL: http://www.dfat.gov.au/geo/index.html Downloaded 22 March 2011. Source: Secretariat of Pacific Community, PRISM Phase 1 Release. http://www.spc.int/PRISM/urbanrural-growth-a-household-size Downloaded 11 April 2011. 6 Source: DFAT country fact sheets. URL: http://www.dfat.gov.au/geo/index.html Downloaded 22 March 2011. 7 Source: AusAID (2009) Tracking Development and Governance in the Pacific, Annex 2, Table 2, p. 63. (p) = provisional; h indicates an increased percentage from previous estimate; i indicates decrease in percentage from previous estimate. 8 More recently the Cook Islands Statistics Office has estimated the resident population for the September quarter 2010 to be 11,400. URL: http://www. stats.gov.ck/CurReleases/popnestVital.htm Downloaded 17 March 2011. 9 Source: SPC Population characteristics. Info submitted by Tokelau Statistics Office. URL: http://www.spc.int/prism/country/tk/stats/Social/Population/ age_sex_.htm Downloaded 22 March 2011. 10 Latest GDP is $A478 estimated in 1980 Source: Government of Tokelau website URL: http://www.tokelau.org.nz/Tokelau+Government/Economy.html Downloaded 7 April 2011. 4 5


Doyle et al.

5

6


Doyle et al.

68.40 (2008p)

82.70 (2008)

71.00 (2008p)

98.90 (2008p)

78.40

304.00

(2008p)

162.45

(2008p)

136.97

(2008)

707.00

(2008p)

1408.45

(2008p)

957.00

(2008p)

13.60

(2008p)

3.80

(2008p)

15.00

(2008)

15.20

(2008p)

17.90

(2008p)

10.80

(2008p)

(2008p)

67.51

(2008p)

5.26

(2008p)

79.25

(2008p)

96.94

(2008p)

4.06

(2008p)

(2008p)

14.86

(2008p)

27.27

n/a

(2008p)

4.42

(2008p)

10.96

(2008p)

2.80

(2008p)

8.70

(2008p)

0.00

(2008p)

24.48

(2008)

0.99

(2008p)

24.77

(2008p)

4.20

(2008p)

7.69

4

(% of THE)

Out-of-pocket expenditure

(2008 est)

68/70

(2008 est)

67/73

n/a

(2007)

65/67

(2006)

72/74

(2004)

67/71

(2005)

66/72

(2001-06)

67/76

(2008)

53/58

(2008 est)

65/70

(2007)

68/72

(2005-10 est)

68/69

(2009 est)

70/73

5

(male/female)

Life expectancy

(2008)

31.00

(2008)

26.00

n/a

(2007)

37.20

(2003-04)

13.00

(2009)

46.00

(2009)

25.64

–

(2003-07)

37.90

(2008 est)

48.00

(2008)

23.60

(2009)

39.00

(2009)

7.10

6

(per 1000 live births)

Under-5 MR

(2006)

70.04

(2008)

76.10

n/a

(2007)

103.00

(2005-06)

3.00

(2009)

324.15

(2009)

366.30

–

(2002)

300.00

(2005)

158.00

(2008)

27.50

–

–

7

(per 100,000 live births)

Maternal MR

2.4

11.6

8.6

2.3

6.7

9.1

9.1

4.6

30.9

6.6

9.1

5.3

5.7

8

Diabetes prevalence12

12

11

Source: WHO Western Pacific Region (2010), Country Health Information Profiles, 2010 Revision, unless otherwise indicated. Source: International Diabetes Federation, Prevalence Estimates of Diabetes mellitus (DM) 2010 – Western Pacific, Table 1.37 URL: http://www.diabetesatlas.org/content/prevalence-estimates-diabetes-mellitusdm-2010 Downloaded 18 April 2011.

(2008p)

68.70 (2008p)

109.04

4.00

(2008p)

– indicates rate of 0.00; p = provisional; n/a = not available.

Notes

Vanuatu

n/a

n/a

Tonga

93.37

153.86

5.15

(2008p)

n/a

84.80 (2008p)

(2008p)

(2008p)

(2008p)

351.00

13.40

(2008p)

97.20

(2008p)

97.90 (2008p)

(2008)

91.50 (2008p)

457.75

4.30

3

(% of THE)

Govt health expenditure

(2008p)

2

1

Tokelau

Solomon Islands

Samoa

RMI

Palau

Niue

Nauru

Kiribati

Fiji

FSM

Cook Islands

(USD pc)

(% of GDP)

Total health expenditure (THE)

TABLE 2: SELECTED EXPENDITURE AND HEALTH INDICATORS11

SECTION 2. METHODOLOGY

Prior to the February 2011 PHRHA forum participants were provided with an ‘HRH ROADMAP’– a schematic framework of HRH management to assist in the identification of problematic areas. Reproduced below, the guide focuses on three broad areas – entry (preparing the workforce),

workforce (enhancing worker performance), and exit (managing attrition). Within each of these were example categories such as planning, education and recruitment (entry); management & supervision, lifelong learning (existing workforce); migration, health and safety (exit), and so on.

Human resources for health

figure 1: HRH ROADMAP

Entry Preparing the workforce

Planning: Workforce Planning Policy; Information Systems Education: Pre-Service Education; Basic Training Recruitment: Policy; Tools

Workforce Enhancing worker performance

Management and Supervision: Job Descriptions; Tools Compensation: Salary Structure and Level; Payment Mechanisms Regulation and Legislation: Scopes of Practice; Standards and Competencies; Quality Assurance and Improvement Lifelong Learning: In-Service and On-The-Job Training; Continuing Professional Development; Polhn

Exit Managing attrition

Migration: Codes of Practice; Bilateral Arrangements Career Choice: Change of Occupation or Activity Health and Safety: Retirement: Succession Planning


Doyle et al.

7

Rather than forcing responses to the questions of issues, challenges, needs and priorities into given categories, we have focused instead on their substantive content and identified themes as they emerge from the data.

Towards the end of the forum Chan (2011a)13 reported back to participants with a brief impressionistic overview of the country presentations. Elsewhere (2011b)14 he has summarised issues raised at the meeting according to the entry/existing workforce/exit framework suggested by PHRHA. With regard to the present discussion, it is noteworthy that the table he provides shows that at least seven countries felt the need to identify one crucial and fundamental issue not explicitly covered by the framework; that of staff shortages.

Responses within each theme, as well as across themes, have been compared to ensure consistent subject categorisation. Areas and themes, however, are not mutually exclusive and there is considerable overlap between many of them. For example, among its Needs and Priorities responses Vanuatu identified ‘the development of training’. Within our analysis this item has been categorised in the Policy, Management and Information subject area. Nevertheless, there are clear links with the Education and Training area. As noted earlier the data have been derived from each participant’s PowerPoint presentation. Not surprisingly, this has occasionally resulted in fragmented and cryptic responses. Data have been excluded from the analysis where the meaning is not clear.

In regard to the approach adopted in this paper, we have taken our cue from the participants. First, we have made no assumptions about the adequacy of workforce numbers or otherwise, and as a consequence, second, have temporarily set aside the suggested HRH framework. Rather than forcing responses15 to the questions of issues, challenges, needs and priorities into given categories, we have focused instead on their substantive content and identified themes as they emerge from the data. Adopting this approach has broadened the scope of the analysis and allowed for in-depth discussion of issues and needs to be based on country responses. Analysis of the data began by grouping responses into broad subject areas (for example, workforce, education and training, migration). Themes within each area were then identified (for example, within the subject area of workforce themes such as staff shortage, recruitment, and so on). They were then aggregated and ranked to indicate which were of most concern overall. Patterns and thematic trends were also identified in this way within the Needs and Priorities responses. Chan, Eric (2011a) Reporting Back, paper presented at meeting Draft Framework for Action on HRH 2011-2015, 10 February 2011, Nadi, Fiji. Powerpoint presentation. 14 Chan, Eric (2011b) Draft Framework for Action on HRH 2011-2015, 10 February 2011, Nadi, Fiji. Powerpoint presentation. 15 The term response is used throughout this paper to refer to participants’ identification of issues, challenges, needs and priorities as specified in their PowerPoint presentations. 13

8


Doyle et al.

SECTION 3. PERCEIVED HRH ISSUES AND CHALLENGES Table 3 and Appendix Table 2 have been compiled from the 13 country reports presented at the forum. Table 3 presents a summary of country contributions, while Appendix Table 2 provides more detail. Participants had been asked to nominate at least five HRH issues and five HRH challenges that were currently being experienced. Given that the notions of issue and challenge are overlapping and that formal definitions of each were not provided by PHRHA, for ease of reading the participants’ perceptions have been collapsed into one table and grouped according to broad subject focus. The following five areas of concern emerged: health workforce; HRH policy, management and information; education and training; public service conditions of employment; and emigration.

Health workforce One of the most nominated areas of issues and challenges was that of the health workforce (column 1), with all countries nominating at least one sub-topic within this area (see

Appendix Table 2). Of most concern to participants was current shortages of skilled, qualified and experienced health workers (nominated by seven countries), followed by the retention of health workers (nominated by six countries), the recruitment of health workers and an ageing workforce and population (both nominated by four countries). Kiribati cited current staff shortages resulting in 53 unfilled positions within its nursing service. Niue also referred to shortages of not only locally trained nurses and doctors, but also pharmacists, radiographers, physiotherapists and laboratory workers. The remaining areas of concern in this domain were: limited finances and funding, skills imbalances, difficulties imposed by geographic distance, heavy workloads, and the negative impact of government reforms on workforce numbers. With regard to the challenge of geographic distance, Kiribati, for example, drew attention to how large geographic distances between islands increased the costs of relocating staff, citing an instance where relocation costs for one staff member and their family amounted to AUD$2,000.

TABLE 3: SUMMARY OF HRH ISSUES AND CHALLENGES Health Workforce

HRH Policy, Management and Information

Education and Training

Public Service Conditions

Emigration

1

2

3

4

5

Cook Islands

ü

ü

ü

ü

FSM

ü

ü

ü

ü

Fiji

ü

ü

ü

ü

Kiribati

ü

ü

ü

ü

Nauru

ü

ü

ü

ü

Niue

ü

ü

ü

ü

Palau

ü

ü

ü

ü

RMI

ü

ü

ü

ü

ü

Samoa

ü

ü

ü

ü

ü

Solomon Islands

ü

ü

ü

ü

ü

Tokelau

ü

ü

ü

ü

ü

Tonga

ü

ü

ü

Vanuatu

ü

ü

ü


ü

Doyle et al.

9

HRH policy, management and information

Public service conditions of employment

Equally nominated were issues concerned with HRH policy, management and information (column 2) with concerns mostly being expressed in terms of ‘lack’ or ‘absence’. Most nominated (9 countries) was the absence of an effective workforce plan or strategy. Closely related to the issue of workforce planning was the need to establish effective information systems, including updating job descriptions and developing performance management systems (nominated by at least three countries).

Working conditions within the public health sector were nominated by nine countries. Attention focussed primarily on the issue of salaries for health workers (nominated by six countries), with concern expressed about current levels of salaries and the need for incentives. RMI, for instance, described its salary structure as ‘ancient and inflexible’. The negative effects of a low retirement age on the health workforce, the absence of incentives, and poor working conditions more generally were also identified.

In addition, issues around exit management, succession planning, research into the most effective use of limited resources, and the lack of trained experienced leadership were also nominated. The absence of, or inadequacy of, standards, regulations and competency frameworks were identified by five countries. Developing health workforce policies and operationalising workforce management strategies are considered difficult to implement, as the participant from the Cook Islands commented, having spent a couple of years developing and drafting a workforce plan, they were denied funding by their own government in 2010 and by NZAID in 2011.

Emigration

Education and training The area of education and training (column 3) was also nominated by all countries (although FSM only briefly referred to this issue with the phrase ‘trained staff’). Six countries (Niue, Kiribati, Vanuatu, RMI, Tokelau and Cook Islands) focused on student numbers and courses currently on offer as areas of concern. Other issues identified included small numbers of people applying to study, low intake numbers, and small numbers of graduating students. Closely related were issues concerned with poor pre-vocation educational preparation in secondary schools (nominated by Nauru, RMI and Samoa), restrictive entry requirements, and length and costs of completing courses. Another group of training issues identified by participants were those concerned with access to education. Absence of local training colleges and institutions, limited access to health courses, limited in-service training and professional development were nominated by six countries. Finally, at least five countries focused on funding and planning of courses and future training as important issues. FSM, for instance, described a dental program as a new program which was in need of both technical and financial support.

10


While all the categories described thus far have been relatively straightforward, the same cannot be said of the final category of emigration. Of the seven countries who nominated emigration, only two indicated the precise nature of their concerns. In the case of Samoa, it was not emigration itself which was seen to be the problem but that the qualifications of Samoans working abroad were not being recognised and that destination countries appear to be ignoring the conditions of bilateral agreements. In the second case, the Solomon Islands, with minimal emigration (Connell 2010) identified the movement of health workers from rural to urban areas (internal migration), difficulties encountered when ‘posting’ people to outlying areas, and attraction ‘to the bright lights’. The contributions of the remaining five countries display varying degrees of ambiguity. First, given that Tokelau does not exhibit a rural/urban distinction and that it has a very small population, it seems reasonable to assume that it is emigration, along with career changes, which is impacting on Tokelaun HRH. Second, despite nominating migration, neither FSM nor Tonga indicated whether their concerns were with out-migration, internal migration, movement from public sector to private sector, or some combination of these different forms of ‘migration’; or indeed, whether, like Samoa, it is not migration itself which is at issue, but a particular aspect of the process. Third, the two remaining countries (Cook Islands and RMI) indicated unambiguously that emigration was an issue they currently face; however, again it cannot be said with absolute certainty what aspect/s of emigration is/are of concern. Nevertheless, it is worth noting, that the Cook Islands referred to ‘competition from highincome countries’, pointing to the disparity between levels of local HRH salaries and those on offer overseas, and its impact on their health sector.

Doyle et al.

SECTION 4. NEEDS AND PRIORITIES

Having described a selection of current HRH situations, obstacles, issues and challenges, each country then identified what they believed was needed to help alleviate problems within their health sector. Participants focussed primarily on two areas – health workforce policy, management and information; and education and training. Twelve of the 13 countries identified at least one aspect of health workforce policy, management and information where it was felt that some sort of action was needed. In one way or another most countries nominated workforce planning as an area requiring attention. This was followed by management needs such as addressing leadership issues, strengthening management skills, and developing policies and procedures (five countries). Similar numbers of participants focussed on stakeholder and donor support, with FSM suggesting the World Health Organization (WHO), Japan International Cooperation Agency (JICA) or PHRHA provide in-service training. Kiribati requested technical assistance with workforce plan analysis, Vanuatu stressed the need for increased political commitment and advocacy, and Niue highlighted the importance of establishing a sustainable funding mechanism. Palau identified their need for an AusAID volunteer for two years to assist in the creation of an HRH office staffed with appropriate personnel. FSM, Samoa and the Solomon Islands focused on the need to develop reliable information systems, while Tonga and Vanuatu sought to revise regulations, develop competencies and standards and establish an accreditation mechanism to facilitate health worker movement. Remaining needs drew attention to raising the age of retirement to 60, reviewing compensation levels, and conducting gap analysis. Slightly fewer (10 countries) nominated education and training as an area of need. Five countries focussed on training in general, drawing attention to such issues as the need to develop programs, to build capacity and to address an ageing workforce. Intake numbers were nominated by three countries, with the Cook Islands wanting to increase the undergraduate nursing intake to 12 per year for five years, and Kiribati hoping to increase its medical assistant intake from 9 to 12. The provision of scholarships, and professional development were each nominated by three countries. Again the Cook Islands focused on maintaining the number of Bachelor of Medicine/ Bachelor of Surgery (MBBS) scholarships at two per year, and the RMI wanting to create a scholarship scheme. Finally, RMI highlighted their need to increase the number of nurses at bachelor and master degree levels.

Participants focussed primarily on two areas – health workforce policy, management and information; and education and training.

The issue of pre-service education was identified (again by three countries) as an important area in need of review. Upgrading skill levels of students leaving high school and revising high school curriculum to reflect HRH course entry requirements were among the needs identified by RMI, Niue and Samoa. Closely related to the issue of prevocational education was that of obtaining support funding for improvement of high school education and training programs as suggested by Kiribati. Not surprisingly, priorities for the PHRHA to assist with tended to mirror the needs previously identified, although greater emphasis was placed on education and training (8 countries) compared to policy, management and information (4 countries). The most distinctive feature, however, was the call for support from PHRHA in obtaining technical assistance (8 countries) and funding (4 countries) in order to fulfil their education and training, and policy, management and information needs. Participants concentrated on the need for support in establishing partnerships, developing networks of local personnel of member countries to assist each other, and establishing links with relevant advisory experts, trainers and resource personnel. Participants also sought assistance in developing training programs, establishing workforce plans, carrying out succession planning and establishing standards and competencies. Despite six participant countries identifying salary levels and/ or structure as an issue of concern, only three (Fiji, Niue and Tokelau) made specific reference to it in their needs and priorities. Given that participants had only a short amount of time allotted in which to outline their concerns and needs, as well as limited space (overheads), it could be that this issue, and the overarching issue of working conditions more generally, were included within other categories (for instance RMI specified the more inclusive need to develop career pathways for each health worker). Similarly, in regard to the issue of migration, only Tonga included it among its needs and priorities, and then only in a very general manner.


Doyle et al.

11

SECTION 5. DISCUSSION

Health sector data for Pacific Island countries are often out-dated, unreliable or simply not available (Feeny & Clarke 2008); a situation which only serves to make the contributions of each country representative, based as they are on personal and first-hand experience, all the more important. Although all health sector characteristics identified do not apply to every country, they nevertheless provide a composite picture which speaks to each country on some level. Thus, we have a health sector characterised by staff shortages, recruitment and retention problems, skill gaps and imbalances, uneven distribution, and an ageing workforce; a health system characterised by insufficient financing (sometimes the result of government reforms or restructuring), out-dated (at best) workforce plans, strategies and policies, inadequate information systems, inadequate standards and competencies, regulations and legislation, and untrained and/or inexperienced leadership and coordination. To this mix can be added disjuncture between pre-service or pre-vocational education levels and those required to enter health training, small student intakes, unattractive salary levels, and few career prospects for the individual health worker. Some countries have also imposed government reforms which have resulted in reduced health expenditures, fewer health workers and deterioration in the provision of health services. Certainly, there are a number of examples of in-country responses to the sorts of problems described above. Vanuatu, for instance, has directed attention to increasing its nursing intake to 60, doubling its intake for nurse aids and increasing opportunities for postgraduate studies overseas. Health partnerships with countries outside the region have been negotiated. For example, Kiribati, Samoa, Tonga and Solomon Islands have established links and bilateral relationships of varying duration with Cuba for the training of medical staff. In regard to education and training there have also been a number of initiatives such as the Pacific Open Learning Health Net (POHLN) which offers online courses to skilled health workers in the Pacific region. In Palau the MoH developed a bridging program to assist high school graduates qualify for entry into health training. Similarly, a bridging course is currently underway in Vanuatu. Within nursing and midwifery education and training, WHO and various Ministries of Health have negotiated a number of partnerships with institutional counterparts in developed countries (for example between the Cook Islands School of Nursing, Auckland Institute of Technology and Manukau

12


Some countries have also imposed government reforms which have resulted in reduced health expenditures, fewer health workers and deterioration in the provision of health services.

Technical Institute; between the Fiji School of Nursing and James Cook University; between the National University of Samoa, Nagano University, University of Technology, Sydney, and Charles Darwin University; between the Tonga Queen Salote School of Nursing and Auckland University of Technology) in order to facilitate the sharing of resources and capacity building. The Health Assistants Training Program, a program equipping indigenous people of RMI with sufficient skills to become mid-level health assistants capable of providing health care in the absence of a doctor, was developed in response to staff shortages in the outer islands of RMI (Keni 2006). In 2007 the Australia-Pacific Technical College was established to provide vocational training at internationally recognised standards across a range of industry sectors, including health and community services (although so far the emphasis has been less on health with certificate and diploma courses focussing on children’s services and community welfare)16. Nevertheless, it is clear from participant responses above, that if workforce numbers are to be significantly increased and working conditions improved, then much more needs to be done to develop workforce plans and accompanying policy, create professional management systems, develop career pathways, and devise appropriate education and training programs. Importantly, developing and maintaining strong leadership in MoH which can reach out and effectively engage key stakeholders outside the health sector (for example, education and finance), obtaining political commitment, and securing financial and technical support, are all high-order priorities for fulfilling these needs. The importance of carrying out workforce planning, especially within the context of international emigration, internal mobility from rural to urban areas, and the movement of skilled health workers from the public to the private sectors, is only strengthened when one is reminded that the most recent and 16

See http://www.aptc.edu.au/courses/health/dipl_community.html.

Doyle et al.

Most discussions of the precise impact of emigration and the nature of its relationship to HRH shortages within Pacific region countries are hampered by the lack of even the most basic data regarding numbers of emigrants, immigrants and returnees, relying instead on ‘back of the envelope’ estimates.

Nevertheless, one thing is certain - the steady loss of skilled health workers through continuing international migration, internal mobility and movement from the public to private health sector places increasing pressure on already limited resources and struggling public health sectors. This is especially so where skilled health workers from other countries who can substitute for those who have emigrated cannot be found (Forcier et al. 2004) and where the loss of only a small number of skilled health workers makes a crucial difference to efficient and effective functioning of a health system (Pak & Tukuitonga 2006).

comprehensive examination of health workforce numbers in the Pacific region was conducted more than 20 years ago (see Rotem & Dewdney 1991, referred to in Connell 2009b.) It is not surprising then that a common feature of the country presentations is the need for workforce plan development; a finding which supports the observation that even though workplans have been developed in some countries, they are unused because they have been neither costed nor funded (Nukuro 2010).

A possible clue as to why emigration has not been nominated is to be found in the comment of a participant from Fiji who noted that they produce 200 nurses per year to compensate for staff losses due to migration and retirement. Such a response clearly indicates that there is the expectation that a certain proportion of nursing graduates will migrate at some stage. Elsewhere, the General Secretary of the Fiji Nursing Association has been quoted saying that to work overseas is regarded as a ‘privilege’ because of the financial and other returns it provides to relatives at home (Lutua 2002 quoted in Connell 2007: 70). There are also examples of countries actively encouraging their citizens to work and train overseas (eg. KANI – Kiribati).

Also noteworthy is the way in which the impact of migration has been viewed by participants. Given the emphasis each country has placed on staff shortages, recruitment and retention problems within their respective health sectors, it is curious that an emphasis of similar magnitude has not been placed on the issue of migration. Although it is a phenomenon thought to be deeply implicated in the development of staff shortages within countries of origin, and particularly so for small countries (Khadria 2010), participants have not given it the attention one might have expected. As noted earlier, seven countries nominated emigration as an issue or challenge, and only one (Tonga) included it among its needs and priorities. This should not be taken to mean, however, that emigration does not impact on the remaining countries. Indeed, the significance of emigration (in all its forms) for the Asia Pacific region, where health systems are often fragile, has been a consistent theme within the literature for some time. (See for instance Iredale et al. 2003, IOM 2010, WPRO 2004). Unfortunately, however, most discussions of the precise impact of emigration and the nature of its relationship to HRH shortages within Pacific region countries are hampered by the lack of even the most basic data regarding numbers of emigrants, immigrants and returnees, relying instead on ‘back of the envelope’ estimates (Connell 2009b).

The question of motivations to migrate is one which has occupied researchers exploring the global migration patterns of people from the Pacific region. (For some recent examples see Barcham et al. 2009; Gibson et al. 2010; Lee 2009, Opeskin & MacDermott 2009.) It is also a topic which is to be found in most discussions of migration patterns of skilled health workers within the Pacific region. (See for instance Brown & Connell 2006, Henderson & Tulloch 2008, Oman 2007, Rokoduru 2008, WPRO 2004.) A full exploration of this literature is well beyond the scope of this paper. What is important to the present discussion, however, is the central place economic considerations occupy (including the family responsibilities and kinship obligations to contribute to household income through remittances) in decisions to migrate. Connell’s extensive and enduring research into migration has led him to conclude that a culture of migration is in evidence within many Pacific Island cultures and that migration, far from being regarded as a problem to be removed, has come to serve a crucial economic role. Indeed, remittances have become an integral component of GDP within a number of PICs (Connell 2009a). Remittances to Tonga, for instance, the leading recipient of remittances, represent approximately 45% of GDP (Lin 2010). Such a sizable proportion reflects


Doyle et al.

13

SECTION 6. POLICY IMPLICATIONS

The migration of health workers is part of a larger exodus (sometimes temporary, sometimes permanent) of skilled and unskilled workers in search of employment.

the important role migration plays in the production of remittance flows and the way in which the ‘transnational corporation of kin’ has become a structural feature of many Pacific Island economies. At the micro level, migrating overseas to secure relatively wellpaid employment has become a purposeful strategy practiced within many families as a means of supplementing household income. At the macro level, economies like Tonga’s have become heavily reliant on the flow of remittances from those who have migrated and are now regarded as remittance economies. In short, the migration of health workers is part of a larger exodus (sometimes temporary, sometimes permanent) of skilled and unskilled workers in search of employment. Having come to play a vital economic role for individuals, households and families, as well as national economies, it is unlikely that international migration will diminish in the near future. That many participants did not identify emigration as a problem, instead focussing on labour market conditions (workforce conditions and salaries, workforce planning and workloads, unfilled positions, inadequate funding, worker shortages and so on), is also consistent with the observation that health worker migration is often a response to difficulties in establishing and maintaining principles of fairness and equity for those working within health systems (Buchan 2008) and to social and economic difficulties encountered outside health systems (OECD 2010). It follows that collaborative efforts by government and stakeholders focussed on recognising the skills of health workers and deploying them efficiently within health systems would go some way towards reducing the negative effects of migration.

14


The perceptions and understandings of participants indicate an acceptance of skilled health worker migration and a strong desire to manage staff shortages, recruitment and retention problems by developing sound policy and appropriate education and training structures either locally or within the Pacific region. They also indicated the need to develop and maintain partnerships which would support the fulfilment of needs and priorities. There are three groups of stakeholders for whom policy implications arise; national governments, regional training institutions, and donors, agencies and international organisations.

National governments National governments have a role to play in developing evidence-informed policies which have the potential to influence the numbers and distribution of HRH within the health system. The crucial issue for national governments is to be proactive in the areas of health workforce planning and production, recruitment and retention, career progression and establishing acceptable terms and conditions of employment. For instance, when posting health workers to rural and remote areas, and to avoid them leaving the service as a consequence, key questions need to be appropriately addressed: Have appropriate incentives been designed by government to help overcome the perceived disadvantages attached to a non-urban posting? Have mechanisms been developed which take into account the financial and physical security of the health worker and their families? Has adequate housing and access to continuing education been provided? These are just some areas where compensatory measures could be developed and implemented by national governments to help offset some of the disincentives associated with working in non-urban areas and to strengthen health workforce retention overall. Policies and initiatives such as these which actively promote and encourage a return to rural areas have the potential not only to impact positively on the distribution of health workers, but to help address equity issues. Disparities between urban and non-urban populations could be reduced as rural populations, traditionally disadvantaged by poorly resourced health services and more recently by internal migration of health workers, have increased access to health care services.

Doyle et al.

Developing bridging courses and outreach programs in schools may go some way towards increasing the skill level of high school graduates and increase their likelihood of gaining entrance to tertiary health professions education.

This is not to suggest a ‘one-size-fits-all’ approach to addressing the challenges of staff shortages, deployment, recruitment and retention. Indeed, building equity and developing human capital within health systems require localised solutions which take local conditions and contexts into account. Nevertheless, national governments have a role (albeit one restricted by limited financial resources, small populations, and economies dependent on overseas aid and remittances) to play in pursuing policies which have the potential to promote and advance HRH. A recent review of HRH migration from six PICs (Samoa, Cook Islands, Fiji, Solomon Islands, Vanuatu and PNG) (Roberts et al. 2011) revealed that none of these countries conduct exit interviews of staff leaving service, nor do they assess the impact of skills migration on services. Accordingly, it is recommended that national governments develop costed workforce plans in conjunction with their Ministries of Finance that include financial incentives for rural placement, career progression options, opportunities for continuing professional development and a system of exit interviews to ascertain the reasons for people leaving public sector service and their home country for alternative careers.

Regional educational institutions The area of pre-vocational education warrants greater attention in many of the smaller PICs, where access to education is often offshore. A number of countries have expressed concern over the small numbers of young people entering health sector training; a situation believed to be largely due to too few high school graduates meeting the standard of science and maths required for entry into training programs17. Developing bridging courses and outreach It is also worth noting that some education systems within Pacific Island countries, like their health system counterparts, are now beginning to experience growing rates of international teacher migration and staff shortages (Voigt-Graf et al. 2007; Iredale et al. 2009).

17

programs in schools may go some way towards increasing the skill level of high school graduates and increase their likelihood of gaining entrance to tertiary health professions education. In addition, the numbers of medical graduates from the Fiji School of Medicine, traditionally the region’s medical graduate supplier, although recently increased, have not been sufficient to contain the emergence of new medical schools within the region, nor to deter PICs from entering into training agreements with Cuba. Managing the return of Cuban trained medical graduates and the integration of graduates of new medical schools into national health systems presents issues of establishing regional standards and internships, and requires planning for funding and resourcing. Accordingly, it is recommended that health professions educational institutions work with national governments to propose and prepare for regional examinations and internship programs that can accommodate graduates from a range of training institutions, including those recruited from Asian countries, many of whom are already working within PIC health systems.

Donor, agencies and international aid organisations With relatively small and in some cases declining health expenditures, it is difficult to see how health workforce recruitment can be adequately increased without significant increases in financing. As Connell (2010) notes, success primarily depends on international agencies and aid donors realising that achieving Millennium Development Goals (MDGs) requires an efficient and productive health workforce. In this sense, health needs to be regarded as a ‘special case’ (p.19) deserving of adequate funding from aid organisations. Furthermore, given the very real limits on the numbers and types of measures Pacific Island governments can initiate to alleviate workforce, policy, education, training and migration challenges, support from the international community is required. There are opportunities for donors to provide technical and/ or financial assistance in a number of areas. HRH data inadequacies across the region have been well documented. Mobility and attrition rates, although fundamental elements required in devising appropriate retention strategies and workforce planning, are largely matters of guesswork. Technical and financial assistance in developing practical methods of recording the internal mobility of skilled health workers (ie movements to and from public to private health sector, rural to urban areas, and movement out of the health sector altogether) and the emigration and return migration of skilled health workers, would provide a sound evidence base


Doyle et al.

15

CONCLUSION

on which to develop well-thought-out workforce plans and recruitment and retention strategies. Accordingly, it is recommended that donors and international agencies provide technical and financial support to assist in building HRH information systems within the Pacific region. In response to the expressed concerns over the quality of secondary school leavers, donors and international agencies could strengthen the potential for national HRH capacity building by supporting secondary education and pre-vocational education systems in providing adequately prepared students for health care education programs.

This analysis has identified common issues and needs, as presented by PHRHA participants, which need to be addressed if health systems are to be strengthened through HRH strategies. While the issues and contexts identified varied from country to country, broad agreement was achieved on measures and strategies which would alleviate shortages of trained and experienced health workers and reduce the exit of health workers from the health sector.

A proposed initiative for donors support could focus on developing connections between the Pacific Island diaspora in Australia and New Zealand by establishing registers of ‘deployable’ health workers willing to contribute to health systems in their home country on short, medium or longer term assignments. Current and reliable information on the Pacific Island health diaspora populations would provide some of the necessary input required to develop realistic re-engagement strategies and mechanisms designed to help ease staff shortages within PICs. To expand the capacity and potential for Pacific regional health professions training will require substantial support from donors to meet the costs of travel, student allowances and course fees.

16


Doyle et al.

REFERENCES

Australian Agency for International Development (AusAID) 2009, Tracking Development and Governance in the Pacific, AusAID, Canberra. Barcham, M, Scheyvens, R & Overton, J 2009, ‘New Polynesian triangle: rethinking Polynesian migration and development in the Pacific’, Asia Pacific Viewpoint, 50 (3), December, pp 322-337. Brown, R & Connell, J 2006, ‘Occupation-specific analysis of migration and remittance behaviour: Pacific Island nurses in Australia and New Zealand’, Asia Pacific Viewpoint, 47 (1), pp 135-150. Buchan, J 2008, How can the migration of health service professionals be managed so as to reduce any negative effects on supply?, Policy Brief, written for the WHO European Ministerial Conference on Health Systems, 25-27 June, 2008, Tallinn, Estonia, WHO.

Feeny, S & Clarke, M 2008, ‘Achieving the Millennium Development Goals in the Asia-Pacific region: the role of international assistance’, Asia Pacific Viewpoint, 49 (2) August, pp 198-212. Firth, S G 2005, Impact of Globalization on the Pacific islands, Briefing paper, 2nd South-East Asia and the Pacific Subregional Tripartite Forum on Decent Work, ILO, 5-8 April, Melbourne. Forcier, M B, Simoens, S & Giuffrida, A 2004, ‘Impact, regulation and health policy implications of physician migration in OECD countries’, Human Resources for Health, 2 (12). Gibson, J, Rohorua, H, McKenzie, D & Stillman, S 2010, ‘Information flows and migration: recent survey evidence from the South Pacific’, Asian and Pacific Migration Journal, 19 (3), pp 391-420.

Chan, E 2011a, Reporting Back, paper presented at meeting Draft Framework for Action on HRH 2011-2015, 10 February 2011, Nadi, Fiji. Powerpoint presentation.

Henderson, L N & Tulloch J 2008, ‘Incentives for retaining and motivating health workers in Pacific and Asian countries’, Human Resources for Health, 6 (8), September.

Chan, E 2011b, Draft Framework for Action on HRH 20112015, 10 February 2011, Nadi, Fiji. Powerpoint presentation.

International Organization for Migration (IOM) 2010 World Migration Report 2010, Geneva.

Connell, J 2007, ‘Local skills and global markets? The migration of health workers from Caribbean and Pacific Island States’, Social and Economic Studies, Mar/Jun 2007, 56 (1/2), 67-95.

Iredale, R, Hawksley, C & Castles, S (eds) 2003 ‘Migration in the Asia Pacific: Population, Settlement and Citizenship Issues’, Edward Elgar, Cheltenham, UK.

Connell, J 2009a, ‘‘I never wanted to come home’: skilled health workers in the South Pacific’, in Helene Lee and Steve Tupai Francis (eds), Migration and Transnationalism: Pacific Perspectives, Canberra, ANU E Press, pp. 159-178. Connell, J 2009b, The Global Health Care Chain: From the Pacific to the World, Routledge, New York. Connell, J 2010, Migration of Health Workers in the AsiaPacific Region, Technical report series, Human Resources for Health (HRH) Knowledge Hub, School of Public Health and Community Medicine, University of New South Wales (UNSW), Sydney. Cook Islands Government Online n.d. Viewed 17 March 2011, http://www.cook-islands.gov.ck/cook-islands.php. Docquier, F & Schiff, M 2009, ‘Measuring Skilled Migration Rates: The Case of Small States’, Policy Research Working Paper, WPS4827, The World Bank, January.

Iredale, R, Voigt-Graf, C & Khoo, S E 2009, ‘Teacher migration to and from Australia and New Zealand, and the place of Cook Islands, Fiji and Vanuatu teachers’, Research in Comparative and International Education, 4 (2), pp 125-140. Keni, B H 2006, ‘Training competent and effective Primary Health Care Workers to fill a void in the outer islands health service delivery of the Marshall Islands of Micronesia’, Human Resources for Health, 4 (27), December. Khadria, B 2010, The Future of Health Worker Migration, Background Paper WMR 2010, International Organization for Migration (IOM), Geneva. Lee, H & Francis, S T (eds) 2009 Migration and Transnationalism: Pacific Perspectives, Canberra, ANU E Press. Lin, H H 2010, Determinants of Remittances: Evidence from Tonga, IMF Working Paper, WP/11/18. Lutua, K 2002, ‘Salaries and conditions of Employment for Nurses, Nurse Practitioners and Midwives – a Fijian


Doyle et al.

17

Perspective’, paper presented at 11th South Pacific Nurses Forum, August, Vila. Nukuro, E 2010, ‘Brief overview: Achievements of the Western Pacific Regional Strategy on Human Resources for health (2006-2015)’, paper presented at the 5th AAAH Conference, 3-6 October, Bali. Organization for Economic Cooperation and Development (OECD) 2010, International Migration of Health Workers, Policy Brief, February. Oman, K 2007, Should I migrate or should I remain? : professional satisfaction and career decisions of doctors who have undertaken specialist training in Fiji. PhD thesis, James Cook University. Opeskin, B & MacDermott, T 2009, ‘Resources, population and migration in the Pacific: connecting islands and rim’, Asia Pacific Viewpoint, 50 (3), December, pp 353-373. Pak, S & Tukuitonga, C 2006, Towards Brain Circulation: Building the Health Workforce Capacity in the Pacific Region, November. Robets G, Doyle, J & Biribo, S 2011, Six Country Migration Study, HRH Hub@UNSW, SPHCM, unpublished. Rokoduru, A 2008, ‘Transient greener pastures in managed, temporary labour migration in the Pacific: Fiji nurses in the Marshall Islands’ in John Connell (ed), The International Migration of Health Workers, Routledge, New York, pp 172-181. Rotem, A & Dewdney, J 1991, The Health Workforce, South Pacific Island Nations, University of New South Wales, Kensington, NSW. Voigt-Graf, C, Iredale, R & Khoo, S E 2007,’ Teaching at home or overseas: teacher migration from Fiji and the Cook Islands’, Asian and Pacific Migration Journal, 16 (2), pp 199-224. WHO Regional Office for the Western Pacific (WPRO) 2004 The Migration of Skilled Health Personnel in the Pacific Region: A Summary Report, World Health Organization Regional Office for the Western Pacific, Manila, Philippines.

18


Doyle et al.

APPENDIX 1 TABLE 1: SELECTED INFANT MORTALITY RATES (IMR), UNDER AGE 5 MORTALITY RATES AND MATERNAL MORTALITY RATES (MMR) IMR (per 1000 live births) UNICEF (2009)

WHO (2008)

WB (2009)

UNFPA (2007)

CHIPS (2009)

(1)

(2)

(3)

(4)

(5)

-

16

7.1 13.5

14

Cook islands

13

FSM

32

32

32

33

Fiji

15

16

15

16

Kiribati

37

38

37

46

Nauru

36

–

–

37.9*

–

-

-

(2005)

38 (2005)

19

13.1 (2008)

52.0 (2005)

Niue

–

Palau

13

13

13

-

21.97

RMI

29

30

29

49

34.0

Samoa

21

22

21

22

Solomon Islands

36

30

30

53

–

-

-

-

Tonga

17

17

17

19

Vanuatu

14

27

14

28

Australia

4

4

–

New Zealand

5

5

-

Tokelau

(2005)

4 (2009)

4 (2009)

20,4 (2006)

44.3 (2008)

16.4 (2008)

27.0 (2008)

4.10 (2008)

4.79 (2007)

Notes Column: (1) Source: URL: http://www.unicef.org/infobycountry/index.html). (2) Source: WHO Global Health Observatory. URL: http://apps.who.int/ghodata/?theme=country (3) Infant mortality rate is the number of infants dying before reading one year of age, per 1,000 live births in a given year. Source: Level & Trends in Child Mortality. Report 2010. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA, UNPD) URL: http://data.worldbank.org/indicator (4) Source: UNFPA Country Profiles for Population and Reproductive Health: Policy Developments and Indicators 2009/2010,United National Population Fund and Population Reference Bureau, 2010. URL: http://www.unfpa.org/public/countries (5) Nauru: 2003-07. Source: WHO Western Pacific country health information profiles: 2010 Revision (CHIPS), WHO, 2010.


Doyle et al.

19

Under Age 5 MR (per 1000 live births) UNICEF (2009)

WHO (2008)

WB (2009)

UNFPA (2007)

CHIPS (2009)

(6)

(7)

(8)

(9)

(10)

–

18

7.1 39.0

16

Cook islands

15

FSM

39

39

39

40

Fiji

18

18

18

18

Kiribati

46

48

46

63

Nauru

44

47

–

–

37.9*

Niue

–

24

–

–

–

Palau

15

15

15

-

25.64

RMI

35

36

35

54

46.0

Samoa

25

26

25

27

Solomon Islands

30

36

36

70

–

–

–

–

Tonga

19

19

19

23

Vanuatu

16

33

16

34

Australia

5

5

–

New Zealand

6

6

–

Tokelau

(2005)

5 (2009)

6 (2009)

23.6 (2008)

48.0 (2008)*

13.0 (2003-04)

37.2 (2007)

– 26.0 (2008)

31.0 (2008)

4.92 (2008)

6.05 (2007)

Notes Column: 6) Source: URL: http://www.unicef.org/infobycountry/index.html). (7) Source: WHO Global Health Observatory. URL: http://apps.who.int/ghodata/?theme=country (8) Under-five mortality rate is the probability per 1,000 that a newborn will die before reaching age five, of subject to current age-specific mortality rates. Source: Level & Trends in Child Mortality. Report 2010. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA, UNPD) URL: http://data.worldbank.org/indicator (9) Source: UNFPA Country Profiles for Population and Reproductive Health: Policy Developments and Indicators 2009/2010,United National Population Fund and Population Reference Bureau, 2010. URL: http://www.unfpa.org/public/countries (10) Kiribati: estimate. Nauru: 2003-07 Source: WHO Western Pacific Country health Information Profiles: 2010 Revision (CHIPS), WHO, 2010.

20


Doyle et al.

MMR (per 100,000 live births)

Cook islands FSM Fiji Kiribati

UNICEF

WHO

WB (2008)

UNFPA

CHIPS

Hogan (2008)

(11)

(12)

(13)

(14)

(15)

(16)

–

–

–

–

–

–

–

–

6 270

317 (2003)

34

31

26

(2007)

56

158 (2005)

300

210

27.5

85

[55-720] (2005)

(2008)

[32-194]

–

–

–

–

Nauru

–

Niue

–

–

–

–

Palau

–

–

–

–

74

–

RMI Samoa Solomon Islands Tokelau Tonga Vanuatu Australia New Zealand

29

(2002)

3 (2006)

140

100

– – 100

140

– 37 (2007)

150

70 (2006)

8

8

(2008 adj)

[6-10] 2008)

14

14

(2008 adj)

[12-15] (2008)

–

158.0 (2005)

300.0 (2002)

– 366.3 (2009)

324.15 (2009)

– – – – –

–

3.0

104

[8-30] (1995)

(2005-06)

[39-236]

22

103.0

284

[65-580] (2005)

(2007)

[102-638]

–

–

–

–

–

–

(2008)

–

127 [48-279]

– 8 14

[16-65] (1995)

– –

76.1

113

(2008)

[42-250]

70.04

178

(2006)

[66-400]

8.4

5

(2003-05)

[4-6]

11.61

8

(2006)

[6-11]

Notes Column: (11) Rates (2005-09) as reported by country. Not adjusted by UNICEF for underreporting and misclassification. Adjusted rates are available for only two countries, Fiji and Solomon Islands; 26 and 100 respectively. Source: URL: http://www.unicef.org/infobycountry/index.html). (12) Country reported estimates. Interagency estimates are available for only two countries, Fiji and Solomon Islands; 26 [14-48] (2007) and 100 [44-240] (2008) respectively. Australia, New Zealand – interagency estimate. Source: WHO Global Health Observatory. URL: http://apps.who.int/ ghodata/?theme=country (13) Modelled estimate. Maternal Mortality ratio is the number of women who die during pregnancy and childbirth, per 100,000 live births. The data are estimated with a regression model using information on fertility, birth attendants, and HIV prevalence. Source: Level & Trends in Child Mortality. Report 2010. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA, UNPD) URL: http:// data.worldbank.org/indicator) (14) Source: UNFPA Country Profiles for Population and Reproductive Health: Policy Developments and Indicators 2009/2010,United National Population Fund and Population Reference Bureau, 2010. URL: http://www.unfpa.org/public/countries (15) Source: WHO Western Pacific Country health Information Profiles: 2010 Revision (CHIPS), WHO, 2010. (16) Source: Hogan, M. C., Foreman, J. J., Naghavi, M., Ahn, S. Y., Wang, M., Makela, S. M., Lopez, A. D., Lozano, R. & Murray, C. J. (2010) “Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5” Lancet 375(9726): 1609 – 1623.


Doyle et al.

21

22


Doyle et al.

Update legislation for Health Practitioners Competence Assurance Act covering registration, monitoring, credentialing and disciplinary processes for all health practitioners

Establish Health Professionals Council

Lack of funding for MoH Workforce Development Plan 2010-2020

Limited financial resources

HW

Geographic dispersal of islands – high relocation costs

health worker

MoH

Ministry of Health

High staff turnover: high cost of relieving staff (maternity leave, retirement, long leave)

Limited/declining budget for Nursing Services

Nursing workload (eg. nurse-patient ratios)

Policy

Research – academic; how to use resources, time and space

Succession planning – lack of continuity as trained/qualified replacement staff not available

Shortage of nursing staff

How can degreed nurses be best utilised?

Must have knowledge and attributes

Retention of trained staff

Shortage of health staff

(3)


Limited intakes into health courses – classroom too small – dormitory refurbishment required

Training trainers (mentors/ couches)

Education specific to HR development

Training

Trained staff

Increase focus on training with specialist visits

Nursing education and training to be strengthened

Small numbers completing Lack of HRH ... planning/ professional training investment/professional development

Geographic dispersal of small islands Lack HRH policy – transport and communication difficult

Recruitment: difficulty recruiting for outer islands

Ageing

(2)

(1)

Acronyms HRH human resources for health

Kiribati

Fiji

of Micronesia

Federated States

Cook Islands

Policy, Management and Information

Health Workforce

TABLE 2: HRH ISSUES AND CHALLENGES BY COUNTRY

APPENDIX 2

Low retirement age (50)

Salaries structured according to grades – no consideration of merit for nursing – no incentives

(4)


Migration

Migration: outward/global: young HWs (competition from highincome countries)

(5)

Emigration


Doyle et al.

23

Difficulties recruiting interested overseas personnel

No common understanding of and attitudes towards work performance due to age gaps between staff (i.e. young vs old)

Understaffed

Retention of staff

Getting the right person to do the job

High medical staff turnover

Retention: unable to retain skilled workers leading to brain & skills drain

Generalist versus specialist skills?

Ongoing recruitment from overseas

Ageing population

Ageing workforce

Shortage of trained local doctors, nurses, paramedics (pharmacy, radiography, laboratory, physiotherapy)

Shortage of experienced personnel

Shortage of qualified personnel

Retention: turnover of staff (e.g.expat, maternity leave cover)

Shortage of HR: government reform (budget)

Lack of skilled local personnel (paramedics, medical, nurses)

Lack of communication between Department and national training, unavailability of national HRH plan

NZ citizens

Clinical activity vs maintaining competency

High patient expectations (technology/internet/referral to centres/small community)

No standards or quality assurance. Requires regulations

“Employers fail to recognise and acknowledge work done”

Non-medical staff in authoritative positions; little understanding of Health Dept and services – not seen as a priority

Poor diversity in health services provided

Employment authority

Limited success of succession planning

Ineffective HRH plan

Care of equipment overseas dependent

Leadership: lack of trained experienced leaders

Infrastructure – lack of support for training, limitation of internet access and computers (e.g. POLHN)

(2)

(1)

Acronyms CME Continuing medical education HR human resources HRH human resources for health POLHN Pacific Open Learning Health Network

Niue

Nauru


Health Workforce

No funding for future training

Slow intake from high school for health training

Poor support for CME in all areas

Limited training opportunities for staff

“Long gaps in training for new trainees to fill future position”

No key financial incentives to retain health staff

Level of remuneration unattractive – difficult to keep and retain trained local staff long-term

Remuneration capped

Poor education preparation at pre-vocation level Continuing education – donor dependent (multiple providers)

Salaries (physician, graduate physiotherapist)

(4)


No training institution, academic prerequisite

(3)

Education and Training (5)

Emigration

24


Doyle et al.

Private health sector growing and stretching available HRH

Traditional HW see column (2)

Ageing (especially nurses & midwives)

Shortage of HRH (especially nurses, midwives, doctors, dentists)

Shortage of local health care professionals

Skill imbalance (will be addressed through the College of Health)

Workforce development (through College of Health)

Acronyms CsoP Codes of Practice HRH human resources for health HW health worker

19

18

AusAID volunteer to begin in March 2011. AusAID volunteer to assist with this task. 20 AusAID volunteer to work with MoH. 21 Healthy workplace initiative commenced late 2010.

Samoa

Marshall Islands

Republic of the

Palau

(1)

Health Workforce

Managing exits: shortage of qualified staff - succession planning challenging

Traditional HWs (inclusion, recognition, credentialing, monitoring) - establish standards for safety of practice

Slow production of HRH to feed or replace services

Information system

No established plan regarding training doctors and other professionals

Lack strategic plan20

Lack formalised HRH plan19

Decision-making process

Policy development18

(2)


Pre-service education: quality vs access issues (university entry requirements restrictive/length of study too long?/too costly for some

No well-qualified science teachers in elementary and middle schools

Inadequate funding for planning relevant training programs

Relatively small intake numbers into health courses

Lack of access to medical and allied health education (besides nursing school and health practitioner training on site)

Level of science and maths for students graduating from both public and private schools

Limited education and training (distance, off island)

(3)


Compensation – relativities in salary structure and levels not reflective of true value of HRH

Salary structure and levels unattractive

“ancient and inflexible salary structure” for MOH professional staff

Minimal incentives

Low salaries

Poor work environment and service conditions21

Service development

(4)


CsoP/bilateral agreements do not appear to be observed/ recognised

Qualifications not recognised in destination countries

Migration “slow but steady migration” (esp nurses and doctors)

Outward migration: professionals and wel--trained seeking opportunities overseas (USA)

(5)

Emigration


Doyle et al.

25

Recruitment of locum health staff with knowledge of local protocols

High demand of health service vs population – 2013 first group of Cuban doctors

Nursing supply increasing, but less being absorbed into public sector

Freeze on recruitment

Budget constraints limiting training opportunities

Robust and effective succession planning

Lack of health succession plan or effective mechanism to ensure provision of health staff at all levels and in all services

Maintain links between national and local levels to ensure quality health service

Establish continuous Professional Development Program linking into clinical governance framework

Robust and effective workforce planning

Limited numbers school leavers choosing to train in health field – competing study opportunities from other areas of public service.

Training does not link to HR department

(3)


Regulation of HWs in accordance with clinical governance policies and guidelines

Upgrade health infrastructure in provinces and outer rural areas

Poor timekeeping, attendance/ absence records

Lack of performance management systems

Work activities unstructured

Job descriptions outdated

(2)

(1)

Very long process of recruitment: (55 steps)

Acronyms HR human resources HW health worker

Tokelau

Solomon Islands


Health Workforce

Salary structure and compensation levels

“Retirement low and dissenters, accommodations, pay/pension and social”

(4)


Migration (resulting in staff shortages)

Migration of HWs

Migration: “to the bright lights”

“Posting”: movement of HWs from rural to urban areas

(5)

Emigration

26


Doyle et al.

Limited space for training

Nursing program22: limited places within nursing program and other training programs

Increasing population demands that the MoH increase training programs (rather than merely replacing aging workforce)

In-service and on-the-job training

Continue professional development

Acronyms HR human resources HRH human resources for health

(3)


For example, recently the general nursing program had an intake of 30 despite receiving close to 500 applications..

22

human resources – understaffed

“Aging and redundant workforce that National strategic planning required needs to be replaced by a modern to help meet national staffing targets workforce”

Vanuatu

Effective performance management system to measure staff performance

HR Management and Policy (new act brought about changes)

Capacity levels (finance and HR)

Competencies and standards

HRH Information System

Workforce planning/projections (career paths, professional management system, succession planning)

Staff turnover as result of migration

(2)

(1)

Tonga


Health Workforce (4)


Address migration issues

(5)

Emigration

This page has been left intentionally blank.

This page has been left intentionally blank.

The Knowledge Hubs for Health Initiative The Human Resources for Health Knowledge Hub is one of four hubs established by AusAID in 2008 as part of the Australian Government’s commitment to meeting the Millennium Development Goals and improving health in the Asia and Pacific regions. All four Hubs share the common goal of expanding the expertise and knowledge base in order to help inform and guide health policy.

Human Resource for Health Knowledge Hub, University of New South Wales Some of the key thematic areas for this Hub include governance, leadership and management; maternal, neonatal and reproductive health workforce; public health emergencies; and migration. www.hrhhub.unsw.edu.au Health Information Systems Knowledge Hub, University of Queensland Aims to facilitate the development and integration of health information systems in the broader health system strengthening agenda as well as increase local capacity to ensure that cost-effective, timely, reliable and relevant information is available, and used, to better inform health development policies. www.uq.edu.au/hishub Health Finance and Health Policy Knowledge Hub, The Nossal Institute for Global Health (University of Melbourne) Aims to support regional, national and international partners to develop effective evidence-informed national policy-making, particularly in the field of health finance and health systems. Key thematic areas for this Hub include comparative analysis of health finance interventions and health system outcomes; the role of non-state providers of health care; and health policy development in the Pacific. www.ni.unimelb.edu.au Compass: Women’s and Children’s Health Knowledge Hub, Compass is a partnership between the Centre for International Child Health, University of Melbourne, Menzies School of Health Research and Burnet Institute’s Centre for International Health. Aims to enhance the quality and effectiveness of WCH interventions and focuses on supporting the Millennium Development Goals 4 and 5 – improved maternal and child health and universal access to reproductive health. Key thematic areas for this Hub include regional strategies for child survival; strengthening health systems for maternal and newborn health; adolescent reproductive health; and nutrition. www.wchknowledgehub.com.au

Human Resources for Health Hub Send us your email and be the first to receive copies of future publications. We also welcome your questions and feedback.

HRH Hub @ UNSW School of Public Health and Community Medicine Samuels Building, Level 2, Room 209 The University of New South Wales Sydney, NSW, 2052 Australia T +61 2 9385 8464 F +61 2 9385 1104 [email protected] www.hrhhub.unsw.edu.au