(WP)HRD/PIC/HRH/3.3/001 English only

Report series number: RS/2oo7/GE/65(FIJ)

REPORT

INFORMAL CONSULTATION ON HUMAN RESOURCES FOR HEALTH FOR PACIFIC ISLAND COUNTRIES

Convened by:

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

Suva, Fiji 10-12 December 2007

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

April ~008

WHOIWPRO LIBRARY MANILA. PHILI?PI;";ES

08

NOTE

The views expressed in this report are those of the participants in the Informal Consultation on Human Resources for Health for Pacific Island Countries and do not necessarily reflect the policies of the Organization.

This report has been prepared by the World Health Organization Regional Office for the Westel11 Pacific for governments of Member States in the Region and for those who participated in the . Informal Consultation on Human Resources for Health for Pacific Island Countries, which was held in Suva, Fiji from 10 to 12 December 2007.

SUMMARY

The ministries of health and the governments of the Pacific island countries and areas (PICs) widely recognize the central role played by human resources for health and have taken strategic measures to strengthen their national health workforce capacities and to address the varied health workforce issues and challenges their countries are facing, with support from WHO, development partners, donors, institutions, organizations and agencies.

An Informal Consultation on Human Resources for Health for Pacific Island Countries was held in Suva, Fiji, from 10-12 December 2007. The objectives of the Consultation were:

(1) to review the human resources for health (HRH) situation in Pacific island countries, based on key reports/documents and identify key areas that could be addressed through a coordinated, partnership approach, within the overall context of health system strengthening;

(2) to share and map current and future partners' support for strengthening the HRH capacity ofPICs, identify and align areas for collaboration and identify the gaps; and

(3) to recommend steps and mechanisms to further harmonize and coordinate HRH programmes in PICs.

More than 40 participants from Pacific island countries and areas, development partners/donors, health training institutions, professional associations/alliances and United Nations agencies, including WHO, attended the Consultation. The key activities involved technical presentations, group work and plenary sessions that included an overview of HRH situation and key initiatives in the Pacific. The participants agreed on a set of priority actions to be taken with respect to health workforce planning and management; education and training; and governance and leadership. They also recognized the benefits and value of aIL key stakeholders taking actions together in a cohesive manner and the need to have a strategic framework, with guiding principles, and to establish a Pacific Human Resources for Health Alliance (PHRHA).

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1.1 1.2 1.3 1.4

CONTENTS Page

INTRODUCTION .................................................................................. 1

g~~~~;e:~~;;~.:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::: ; Organization of the Consultation ............... , .................................................. 2 Appointment of Chairperson, Vice-Chairperson and Rapporteurs ........................... 3

2. PROCEEDINGS ....................................................................................... 3

2.1 Presentations on HRH situation in the Pacific and in the Region ............................ 3 2.2 Group work outcomes for session 1 ................................................ , ............. 4 2.3 Overview of HRH situation, group work and discussion ...................................... 5 2.4 Strengthening health systems for health outcomes and partnerships for HRH ............. 6 2.5 Strategic coordination framework for strengthening HRH capacity

in the Pacific ......................................................................................... 7 2.6 Group work on approaches to coordination of HRH programmes

in the Pacific ......................................................................................... 8

3. CONCLUSIONS ...................................................................................... 9

4. RECOMMENDA TrONS .......................................................................................... 10

ANNEXES:

ANNEX 1 - LIST OF PARTICIPANTS, TEMPORARY ADVISERS, ORGANIZATIONS/INSTITUTIONS AND SECRETARIAT ................... 11

ANNEX 2 - DAILY AGENDA ...................................................................... 17

ANNEX 3 - MOVING FORWARD: A PARTNERSHIP APPROACH ....................... 19 TO HUMAN RESOURCES FOR HEALTH IN THE PACIFIC ISLAND COUNTRIES

Keywon:!s

Health personnel/Human resources / Capacity building / Pacific islands

1. INTRODUCTION

Human resources for health (HRH) is widely recognized, including in the Pacific island countries and areas (PIC), for the central role it plays in enhancing better health system performance, improving the quality of health care, contributing to the achievement of the health­related Millennium Development Goals and in the scaling up of health interventions. In this

1 regard, the Ministers of Health of the PICs have committed themselves and their governments to taking strategic measures to strengthen their national health workforce capacities and to address the varied health workforce issues and challenges that their countries face.

The key actions the Ministers have agreed to undertake include, among others: collation and use of reliable HRH data, evidence and information to inform policy, planning and decision­making; strengthening of effective health workforce planning and management, including managing the migration of skilled health personnel; retention of health workers and improved performance through better remuneration and use of incentives; and scaling up of the education and training of health workers to meet health workforce shortages.

Aside from WHO, many other development partners, donors, institutions, organizations and agencies have been or are planning to support PICs in their efforts to strengthen their health workforce and health system capacities. To enhance its impact and effectiveness, it is essential for such support to be better coordinated as well as aligned to meet the goals and objectives of national HRH programmes, with governments taking the leadership role.

Equally important is the empowerment of PICs to take the lead role and for partners to align and streamline their aid procedures in the spirit of the Rome, Paris and Pacific Declarations on development aid harmonization and effectivenessc. The recent reports3 of two key partners engaged in HRH in the Pacific have recommended the development of a common HRH database and information-sharing, in addition to regional approaches for the recruitment and rotation/sharing of highly skilled professionals among countries.

The Informal Consultation on Human Resources for Health for Pacific Island Countries served as a forum for dialogue between the governments ofPICs, partners and WHO on how to better coordinate and harmonize support for HRH, within the context of strengthening health system performance. More than forty participants, representing Pacific island countries and areas, development partners / donors, health training institutions, professional associations/alliances and United Nations agencies, including WHO, attended the Informal

I Samoa Commitment: Achieving Healthy Islands (Conclusions and Recommendations). World Health Organization 2005~

Vanuatu Commitment. World Health Organization Western Pacific Region (2007)

, to the 2003 Rome Declaration. donors ipartners commit to simplifYing and harmonizing aid procedures. and the 2005 Palis

Declaration includes partner countries' ownership; donor support alignment; managing for results; and mutual accountability. The

Pacific Aid Effectiveness Principles, endorsed at the Pacific Island Countries and Development Partners meeting in Palau (July 2007)

were derived from the Paris Declaration - Attachment A: Document-PlFS(07)PICK.05, Pacific Island Forum Secretariat

3 Pak, S. Tukuitonga, C. Towards Brain Circulation.' Building the Health Workforce Capacity in the Pacific Region. 2006

(unpublished document); Pacific Senior Health Officials Network: Health workforce project - Draft final Report (September 2(06)

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Consultation (Annex 1). The main expected outcomes were: (1) broad consensus on the principles for aligning, harmonizing and coordinating support for HRH for PICs; (2) an agreed coordination mechanism; and (3) a strategic framework for a partnership approach.

1.1 Objectives

The objectives of the Informal Consultation were:

(1) to review the human resources for health (HRH) situation in Pacific island countries, based on key reports/documents and identify key areas that could be addressed through a coordinated, partnership approach, within the overall context of health system strengthening;

(2) to share and map current and future partners' support for strengthening the HRH capacity ofPICs, identify and align areas for collaboration and identify the gaps; and

(3) to recommend steps and mechanisms to further harmonize and coordinate HRH programmes in PICs.

1.2 Opening remarks

Dr Lepani Waqatakirewa, Permanent Secretary, Ministry of Health, Fiji, delivered the welcome remarks on behalf of the Minister of Health and stressed the need for close cross­sectoral collaboration between ministries of health and other key stakeholders influencing HRH, such as ministries of education and finance, and public service commissions (PSC). The major points he mentioned included the linkage between HRH and financial planning; the need for better management and optimal utilization of the health workforce through task-sharing or multi­skilling; development of mentored leadership; and looking after the welfare and interests of health workers through improved working conditions and enhanced professional development and safety at work.

Dr Chen Ken, WHO Representative for the South Pacific, welcomed the participants and partners to the Consultation on behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific. He stressed that HRH has always been a priority for WHO, representing the largest portion of WHO financial support to PICs, and that the Consultation had been convened to develop an outline for a strategic framework or network in consultation with key stakeholders, based on the decisions and recommendations from the Ministers of Health meetings in Samoa (2005) and Vanuatu (2007). He also stressed that the shortage of health workers in the Pacific was negatively impacting current health workers (overworked and demoralized) and health services and outcomes, including limiting access to quality health care and contributing to increased waiting times and subsequent public dissatisfaction and loss of confidence in national health services. He called on countries and partners to work together in a coordinated and cohesive manner to strengthen the health workforce capacity ofPICs within the context of ~trengthening health systems, and wished everyone a productive and enjoyable meeting.

1.3 Organization of the Consultation

The key activities of the Consultation involved technical presentations, group work, and plenary sessions (see Annex 2 - Daily Agenda). Introductory plenary session presentations included an overview ofHRH situation and key initiatives in the Pacific (see Annex 3 - Moving Forward: A partnership approach to human resources for health in the Pacific Island countries)

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and at global and regional levels; preceding government commitments on HRH; reports from countries and partners /institutions and alliances; concept papers on a Strategic coordination framework and a Pacific coordination body for HRH; and Strengthening health systems to improve outcomes and partnerships in HRH.

Two group-work sessions were convened. For the first, participants were divided into three working groups, each addressing one of the following core areas, workfor~e platlhing and management; education and training (scaling up production of health workers); and governance and regulation. Under their respective core areas, the groups focused their discussions and reached conclusions on the priority HRH areas (key actions and outcomes) that require strengthening, areas that require better partnership and collaboration, the specific support and collaboration needed to meet the needs and gaps in HRH in the Pacific, and the major impediments to effective partnership and cooperation that need to be addressed. The second group work session was on approaches to coordination of efforts/programmes on HRH in the Pacific, with a focus on an appropriate framework and mechanism (including a vision, mission, membership, scope /structure /linkages and secretariat), as well as identification of the major stakeholders and key principles for effective partnership and coordination of HRH initiatives in the Pacific.

1.4 Appointment of Chairperson, Vice-Chairperson and Rapporteurs

Dr Lepani Waqatakirewa (Fiji) and Ms Temarama Rou-Ariki Anguna (Cook Islands) were appointed Chairperson and Vice-Chairperson of the meeting, respectively. Dr Marcus Sarno (Federated States of Micronesia) and Mrs Irene Horai Titek (Vanuatu) were appointed Rapporteurs.

2. PROCEEDINGS

2.1 Presentations on HRH situation in the Pacific and in the Region

Dr Ezekiel Nukuro, Regional Adviser for Human Resources Development, WHO Western Pacific Regional Office, presented a brief overview of the global and regional HRH situation/challenges and responses. The key issues/challenges include: weaknesses in leadership and commitment; underinvestment in health systems and HRH; inadequate capacity in countries to train, retain, manage and sustain an adequate health workforce, resulting in shortages of health workers, low salaries and poor incentives and working conditions; and out-migration. He also discussed the key components of the global and regional response frameworks and strategies that are aimed at key result areas, such as demand, supply and governance/management.

Dr Marcus Sarno, Assistant Secretary for Health, Federated States of Micronesia, presented a summary of the recommendations and commitments made by the Ministers of Health for PICs, to be undertaken by their governments with the support of donors, development partners, agencies and organizations, to respond to the major health workforce needs and challenges in the Pacific region, such as increased production of workers and continuing education, migration of health workers and remunerations and incentives.

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Professor Lorraine Ferguson and Dr Elizabeth Halcomb, temporary advisers for the Consultation, presented the priorities of and challengies posed by the current HRH situation, as well as needs and gaps in efforts to strengthen health workforce capacity in the Pacific region. Issues include: supporting health workers on the job, providing quality education, strengthening leadership and management in health services, using online and distance education effectively, and, more importantly, obtaining political commitment. Countries must have ownership ofthe solutions to the challenges facing them, while Ministry of Health leadership must have the commitment to deliver on their promises. Shortages of skills and a lack of funding are two of the biggest challenges to be addressed. Improving health services will require investment by governments in their health systems; the current level of investment is not sufficient. It also will require more partnerships, increased harmonization and further alignment. Priority areas for increased collaboration include: financing the health workforce, HRH information systems, workforce planning and capacity development, pre-service and continuing education, workforce considerations, performance management, and leadership governance and regulation. Professor Ferguson and Dr Halcomb concluded that key factors include country ownership; effective leadership, with vision and good management and governance practices; and effective partnerships.

Country representatives, partners, agencies and institutions then gave their reports, with presentations on the issues faced, interventions supported, and gaps identified. Common gaps that can best be addressed through cross-country collaboration include: a lack of data for evidence-based decision-making; insufficient production of health workers; retention of health workers in the face of migration pressures; inadequate or lack of continuing education; improving working conditions; multi-skilling and scaling up of health workers; lack of capacity to increase the number of health workers being trained to meet health needs; and additional support from PSCs and ministries of finance and education.

2.2 Group work outcomes for session 1

The group on 'health workforce planning and management' identified the lack of essential knowledge and evidence, and inconsistent and incomplete health workforce data, as well as a need for support from other key national authorities that influences policies and decisions on key aspects ofHRH, such as ministries of finance, education and planning and PSC, as important issues. The group recommended the establishment of both an HRH help desk for PICs and an information clearing house to support uniformity of data.

With regards to 'education and training of health workers', the group prioritized the need to increase the training of competent key categories of clinical health worker (doctors, nurses, midwives, dentists and pharmacists), paramedics, public health and community/primary health care workers, multi-skilled workers and health managers. Attention should be paid to strengthening of local and regional institutions with competent faculty, improving the quality and standards of education and continuing professional development, and considering standardization of curricula to enable cross-border recognition of qualifications and a possible regional mechanism for quality control, standard-setting and accreditation/credentialing, Strong partnerships and the engagement of key stakeholders, such as policy-makers and professional associations, as well as institutional twinning, are essential elements. Other measures to be taken include providing improvedlbetter health worker remuneration and conditions to attract intakes into the health sector and strengthening leadership and collaboration among stakeholders.

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The group on HRH 'governance and regulation' identified several areas that need to be addressed at both the national and regional levels. These include: the challenge of migration of skilled health workers; the need for minimum standards for health educators and mechanisms for accreditation of health training institutions; the lack of integrated planning and action; deficiehcies in flRH management and leadership capacity; the need for continuing professiohai educatioh linked to license renewal, and to performance appraisal; and the need for more flexibility in the use of donor support. The challenge of addressing the migration of skilled health workers generated significant discussion. The group agreed to support the use and enforcement of the Pacific Code of Practice. The need to identify and adapt best practice models to address local needs was also highlighted. There was consensus that addressing these priority areas is a complex task requiring the support and collaboration of all stakeholders at both the regional and national levels.

2.3 Overview of HRH situation, grOUP work and discussion (See Figure 1)

A common challenge highlighted in all presentations and group work was the chronic shortage of health professionals, due mainly to inadequate numbers being educated and trained and to retention problems. A common goal is to have an adequate, competent, supported and motivated health workforce to meet population health needs and achieve optimal health outcomes. To achieve this, strategic actions (intensifying and focusing efforts on things that can be done with tangible outcomes and impacts; and acting and working together) are needed with regard to health workforce planning and management, scaling up the production of health professionals and governance and partnerships.

Fig.l: Key common challenge 8t Goal

Common challenge

Chronic shortages of health professionals to meet population

health needs It achieve optimal flealth outcomes,

Inadequate numbers being educated and trained &

Retention problems

Common goal

Adequate, competent, supported It motivated

health professionals to meet population health needs It achieve

o timal health outcomes.

Intensifying & focusing efforts; "Doable" actions for outcomes;

Acting Iworking together

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2.4 Strengthening health systems for health outcomes and partnerships for HRH

Dr Hendrik Bekedam, Director, Division of Health Sector Development, WHO Western Pacific Regional Office, presented key health systems challenges and the rationale for the WHO Action Framework (Everybody's business), with its six building blocks (outlined in Figure 2), the current partnership in 'health landscape' and in HRH, and the role of WHO in these initiatives. Key system challenges include: chronic underinvestment; poor infrastructure; lack of staff; inadequate finance, with out-of-pocket payments pushing millions into poverty; and inequitable distribution and inefficient use of resources. He presented examples of successful initiatives to tackle these challenges through partnerships; improved coordination; increased funding/resources; integration of system strengthening into health intervention and disease programmes, such as HIV / AIDS, TB and malaria; and capacity building.

The key principles of aid effectiveness, partnership and coordination mentioned included: ownership-partner countries set the priorities; alignment-partners align their priorities and use country !regional systems; harmonization-use common arrangements, simplify procedures and share information; and mutual accountability and transparency. With regard to partnerships in HRH, the key areas that need coordination and harmonization are education and training, including sharing of information on regulations, standards, accreditation and quality, curriculum developments, and other subjects; and salaries /incentives of health workers to avoid distortions.

Dr Bekedam then identified the role of WHO as providing leadership, and coordination; engaging in partnerships; providing evidence, policies, technical guidelines and norms; delivering technical support; shaping the research agenda; and monitoring trends.

Fig.2: One framework with six building blocks

Health workforce

Information .. ~~~~~~~~~.~~~~.~~

'-"'~dJcalJlr:,du~~!_tech~oll?Qi~~~! .

Service delivery ~~~ -~ ••......

Improved health (level and equity)

Responsiveness I ., __ "~M_~' __ '"~".~"~'_~~'~~_~_ o •

Social & financial risk protection

.~ .. _ .... _ ... ~ ... c ..

Improved efficiency

He also discussed the potential benefits of a Pacific mechanism for partnership and coordination in HRH that could assist and facilitate achievement ofHR goals at the country level, coordinate efforts, ensure better sharing of scarce resources and harmonize the support of

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development partners. The widespread recognition of the urgent need to address human resources as a critical component of health development provides an opportunity to mobilize support, political commitment and technical expertise. He stressed that, even though countries are facing common issues, the ownership and management of the problems should be based on national agendas and leadership, and it is necessary to consider ways to avoid unnecessary duplication and wastage of scarce resources, to work together and to focus efforts on things that are practical and achievable.

2.5 Strategic coordination framework for strengthening HRH capacity in the Pacific

The rationale and potential benefits, along with the context, scope and components involved in establishing a strategic coordination framework were outlined by Dr Nukuro. The possible benefits of a strategic coordination framework for HRH development include, among others: facilitating 'buy-in' among partners, enhancing the synergy of strategic actions to address common HRH needs among countries, and ensuring that the development of an effective and sustainable health workforce is an integral part of national health development planning and health system strengthening processes; guiding the development and implementation of appropriate Pacific regional HRH initiatives that respond to the priority needs/gaps in HRH programmes in the Pacific; setting out the respective roles of partners in a coordinated approach to enhance programme effectiveness and efficiency; and supporting the monitoring and reporting of the HRH situation and developments in the Pacific region, as well as the outcomes of partners' HRH initiatives and programmes.

The strategic coordination framework should be closely aligned with major health goals (such as the health-related MDGs) and targets ofPICs, based on their health needs and demands. It should be flexible, adaptable and responsive to the changing Pacific health situation, needs, demands and contexts. As outlined in Figure 3, the potential key components/elements of the strategic coordination framework to be further considered are, among others: the aims, goals and objectives; the guiding principles; the key action/outcome areas-based on other factors/contexts, including goals and objectives, while ensuring a consistent and strategic focus for all HRH support; an action plan template/logical framework that includes key action areas/targets, key partners, resources, time-frames and key indicators for monitoring and evaluation; supportive mechanisms for managing the HRH interfaces (between health, public service and [mance); and a regional mechanismlstructure4 to facilitate the implementation, monitoring and evaluation of the strategic coordination framework.

4 This could be similar to the proposed 'Pacific [slands Regional Health Workforce Agency' in the Pacific

Senior Health Officials Network: Health workforce project - Draft Final Report (September 2006)-pages 53-54 or the 'Pacific Human Resources for Health Alliance - PHRHA', proposed at the Pacific HRH Focal Point Networking Workshop - Sept. 2007, Nadi, Fiji.

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Figure 3: OUTLINE - STRATEGIC COORDINATION FRAMEWORK

In~ountry contexts: Ownership & lea~ership Socia-Economic status, HRH Profiles and Capacities, Infrastructures and Technology, HealtbPlanning, Disease Conditions, Political Scenatio, CuIIUtaI Diversity, Geographical Picture, HRH Needs

ORB core areas Jinterphases:

>- Leadership

>- Policy

>- Finance

>- Education

)-.. Partnership·

)- Systems

International Donors and Partners HRH Areas of Interests: Alignment & harmonise Planning and Policy Development, Governance and Management, Training

and Education, Information System, Research and Regulation, Continuing

performance

)-Increased ~t~tial to achieve bealtb OUU:omes

A critical component of the strategic coordination framework, as presented, is its central coordination mechanism, agreed to in the Consultation as the Pacific Human Resources for Health Alliance (PHRHA). The next steps identified are to engage in consultation with all stakeholders to produce a [mal draft of the framework for endorsement and development of a workplan for the Alliance.

2.6 Group work on approaches to coordination of HRH programmes in the Pacific

The working group considered key stakeholders who should be engaged in the regional partnership and their major concerns and interests. The values and principles underpinning effective coordination and collaboration, the best approaches to promote alliances at national and regional levels, and the kind of entity that should steer this effort were also discussed. Finally, the group addressed the functioning of the entity, focusing specifically on its vision, mission, objectives, key functions, guiding principles, membership/composition, institutional linkages, and secretariat.

Several points were stressed concerning the nature of the PHRHA, its scope of work and how it could fit into current management structures of health sectors in the Pacific: it should be complementary to, rather than replace any existing, effective mechanism, either in-country or among countries; its structure and processes should be light, flexible, not very bureaucratic and inclusive; it should be active and sustainable; and it should be linked with existing Pacific regional networks and/or other authoritative bodies in the health sector, including relevant

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organizations and institutions that have influence in HRH and health systems development. Its core members would be all PICs, with key stakeholders and partners as associate members.

While it may not necessarily be a legally constituted body, it should have access to relevant authoritative or decision-making bodies or forums (such as the meetings of Health Ministers for Pacific island countries, Forum leaders meetings or meetings of the WHO Regional Committee for the Western Pacific), in which its recommendations or policy advice could be noted, endorsed or sanctioned.

The guiding principles identified for the strategic coordination framework and the PHRHA include:

• Country ownership and leadership-it should be owned and driven by PICs for the benefit ofPICs and the Pacific region;

• Accountability-it should be_accountable to the Pacific Ministers of Health and to all PICs;

• Sovereignty-the alliance and its work should not infringe upon the national sovereignty of countries to decide on all matters and aspects related to the health system and HRH development and management;

• Realistic-its structure and processes should be light and not very bureaucratic and its workplans need to be realistic, with achievable goals and outcomes;

• Adaptability and flexibility-it should operate in a way that is flexible, adaptable and be responsive to the needs of member countries;

• Sustainability and mutual support-it should acknowledge the contributions and support from development partners and donor agencies in addressing HRH issues in the Pacific and the expected need for continued support in the future; and

• Financial and mutual accountability-all its members (core members and 'externaVex-officio' members) should be accountable to each other for managing aid and achieving resuIis.

3. CONCLUSIONS

The expected outcomes of the informal consultation were to identifY the key areas for action to strengthen the health workforce capacity of Pacific island countries, ascertain the potential partners to be engaged and determine a way for all the partners to work together.

The participants-Pacific island countries and areas, development partners, agencies, institutions and professional associations-agreed on a set of priority actions to be undertaken with respect to health workforce planning and managementj education and training; and governance and leadership. They recognized the benefits and value of all the key stakeholders taking action together in a cohesive manner and also agreed on the need to have a strategic

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framework, with guiding principles, and for establishment of a Pacific Human Resources for Health Alliance (PHRHA).

4. RECOMMENDATIONS

The Consultation made the following recommendations:

(1) The Consultation participants agreed that there is an urgent need to intensify efforts and focus on human resource development in the Pacific.

(2) In recognition ofthe benefits of cross-country collaboration, the Consultation unanimously agreed to establish a Pacific Human Resources for Health Alliance (PHRHA), with links to the Asia-Pacific Action Alliance on Human Resources for Health (AAAH).

(3) In considering the functions ofthe PHRHA, the Consultation stressed the paramount importance of country ownership and leadership in driving the Alliance's agenda and determining its plan of work.

(4) The PHRHA is intended to add value by providing support to countries in their HRH efforts. The Consultation identified the following specific areas of collaboration: capacity development; sharing of information, evidence and good practices; HRH data collection; establishment of an information resource centre; support and advice; advocacy; and monitoring and evaluation.

(5) The Consultation also agreed that:

• WHO should act as interim secretariat for the Alliance and should draft the terms of reference and governance structure for further consideration and endorsement by the countries and partners (March 2008);

• all participants should report the outcomes of the Consultation to their ministries of health and other stakeholders;

• interested members and parties should be encouraged to contribute to the work of the secretariat; and

• Alliance focal points, representing each Ministry of Health, should be identified.

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ANNEX 1

LIST OF PARTICIPANTS, TEMPORARY ADVISERS, ORGANIZATIONS/INSTITUTIONS

COOK ISLANDS

FIJI

KIRIBATI

MARSHALL ISLANDS,

MICRONESIA, FEDERATED STATES OF

NAURU, REPUBLIC OF

PALAU, REPUBLIC OF

SAMOA

AND SECRET ARIA T

1. PARTICIPANTS

Ms Temarama Arou-Ariki Anguna, Human Resources Officer, Ministry of Health, Rarotonga. Fax No. (682) 23109; Tel. No. (682) 29664; E-mail: m.anguna@health.gov.ck

Mrs Maria Matevewa, Director, Corporate Services, Ministry of Health, Suva. Tel. No. (679) 322 1522; E-mail: mmtavewa@govnet.gov.fj

Dr Teraira Bangao, Acting Director of Hospital Services, Ministry of Health, Nawerewere, Bikenibeu. Fax No. (686) 28152; Tel. No. (686) 28100; E-mail: t.bangao@yahoo.com

Ms Erma Wase Myazoe, Director, Human Resources Development, Ministry of Health, P.O. Box 16, Majuro MH 96960. Fax No. (692) 625; Tel No. (692) 625; E-mail: ermawm_s@hotmai1.com

Dr Marcus H. Sarno, Assistant Secretary for Health, Department of Health and Social Affairs, FSM National Government, P.O. Box PS 70, Palikir, FM 96941. Fax No. (691) 320 5263; Tel: (691) 320 2619; E-mail: msamo@fsmhealth.fm

Mrs Marissa Cook, Director of Administration (Health), Ministry of Health, Yaren District, Republic of Nauru. Fax No. (674) 4443851; Tel No. (674) 444 3853; Email: marissa.cooknauru.gov.nr

Ms Patricia Maech, Coordinator, Continuing Education for Nursing, Ministry of Health, P.O. Box 6027, Koror. Fax No. (680) 488 1211; Tel. No.: (680) 488-2552 or 488-2553; E-mail: p_maech@palau-health.net

Ms Sarah Faletoese, Principal Health Planner, Ministry of Health, Private Mail Bag, Apia. Tel. No.: (685) 23974/68116; E-mail: Saraha@health.gov.ws

Annex 1

SOLOMON ISLANDS

TONGA

TUVALU

VANUATU

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Mr Oswald Ramo, Under Secretary (Admin/Finance), Ministry of Health, P.O. Box 349, Honiara. Fax No. (677) 20085; Tel. No.: (677) 28610; E-mail: Oramo@moh.gov.sb

Mr Tu'Akoi'Ahio, Principal Health Administrator, Ministry of Health, P.O. Box 59, Nuku'alofa. Fax No.: (676) 24 291; Tel No.: (676) 21 270 Ext. 1416; E-mail: tahio@health.gov.to

Mr Kakee Pese Kaitu, Permanent Secretary, Ministry of Health, Vaiaku, Funafuti. Fax: (688) 20 832; Tel. No.: (688) 20 404; E-mail: soh@tuvalu.tv

Mrs Irene Horai Titek, Human Resource Manager, Ministry of Health, Private Mail Bag 042, Port Vila. Fax No.: (678) 26113; Tel. No.: (678) 22545

2. TEMPORARY ADVISERS

Dr Lorraine Ferguson, Associate Professor of Nursing, Clinical Leadership and Professional Development, School of Nursing, College of Health and Science, University of West em Sydney, Building ER, Parramatta Campus, Locked Bag 1797, Penrith South DC NSW 1797, Australia. Fax No.: Fax: 61296859343; Tel. No.: 61296859029; E-mail: l.ferguson@uws.edu.au

Dr Lepani Waqatakirewa, Permanent Secretary for Health, Ministry of Health, Dinem House, Toorak, Suva, Fiji. Fax No.: (679) 3 306163; Tel. No.: (679) 3221515.

AMERICAN PACIFIC NURSING LEADERSHIP COUNCIL

AUSTRALIAN AGENCY FOR INTERNATIONAL PEVELOPMENT

3. ORGANIZATIONS/INSTITUTIONS

Mrs Toaga A. Seumalo, President, American Pacific Nursing Leadership Council, LBl Tropical Medical Center, Fagaalu American Samoa 96799. Fax No.: (684) 633-7794; Tel. No.: (684) 633-5995; E-mail: toagaatuatasi@yahoo.com

Dr Ross Sutton, Australian Agency for Development Assistance Tel. No.: +6} 262064283; E-mail: rosssutt@bigpond.net.au

Ms Carrie Ann Best, Second Secretary, Development Cooperation Section, Australian High Commission, Suva. Fax No.: (679) 3382065; Tel. No.: (679) 3382111

II

DIVINE WORD UNIVERSITY

FIJI SCHOOL OF NURSING

FIJI SCHOOL OF MEDICINE

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Annex 1

Mr Kichawen Chakumai, Head, Health Management Department, Divine Word University, P.O. Box 483, Madang, Papua New Guinea. Fax No.: (675) 8522812; Tel. No.: (675) 8522937; E-mail: kchakumai@dwu.ac.pg

Ms Filomena Naidole Mckay, Senior Tutor Sister and Acting Deputy Principal, Fiji School of Nursing, Tamavua, Suva, FijL Fax No.: (679) 3 321013; Te1. No.: (679):3 331499~ E-mail: filo-fsn@yahoo.com

Professor David Brewster, Dean, Fiji School of Medicine, Suva, Fiji. Fax No.: (679) 330 5781; Tel. No.: (679) 3233201; Email: d.brewster@fsm.ac.fj

Professor Jan Pryor, Fiji School of Medicine, Suva, Fiji. Fax No.: (679) 332 1107; Tel. No.: (679) 331 1700; E-mail: j.pryor@fsm.ac.fj

JAPAN INTERNATIONAL Mr Yoshida Ryosuke, Assistant Resident Representative, Japan COOPERATION International Cooperation Agency, 7tll Floor, Dominion House, AGENCY Suva, Fiji. Fax No.: (679) 3 302452; Tel. No.: (679) 3 302522;

E-mail: Yoshida.Ryosuke@jica.gojp

NEW ZEALAND AGENCY FOR INTERNATIONAL DEVELOPMENT

SECRETARIAT OF THE PACIFIC COMMUNITY

Dr Masako Kawamura, Project Formulation Adviser (Health), JlCA Fiji Office, Level 8, Suva Central Building comer of Pratt Street and Renwick Road, Suva, Fiji. Fax No.: (679) 3 302452; Tel. No.: (679) 3 302522; E-mail: Kawamura.Masako@jica.go.jp.

Mr N ariaki Mikuni, Deputy Resident Representative, JICA Fiji Office, Level 8, Suva Central Building comer of Pratt Street and Renwick Road, Suva, Fiji. Fax No.: (679) 3 302452; Tel. No.: (679) 3 302522; E-mail: mikuni.nariaki@jica.go.jp

Mr Dimitri Geide1berg, NZAID Manager (Regional), New Zealand High Commission, P.O. Box 1378, Suva, Fiji. Fax No.: +679 3300040; Tel. No.: +679331 9317; E-mail: dimitri.geilderberg@mfat.govt.nz

Mr Sachida Nand, Programme Administrator, Regional, New Zealand High Commission, P.O. Box 1378, Suva, Fiji. Fax No.: +6793300040; Tel. No.: +679331 9317

Dr Thierry Jubeau, Manager, Public Health Programme, Secretariat of the Pacific Community, 98848 Noumea Cedex, New Caledonia. Fax No.: (687) 26318; Tel. No.: (687) 262000; E-mail: spc@spc.int

Annex 1

SOUTH PACIFIC CHIEF NURSING OFFICERS ASSOCIATION

UNITED NATIONS CHILDREN'S FUNDS

UNITED NATIONS POPULATION FUND

UNIVERSITY OF GUAM

UNIVERSITY OF PAPUA NEW GUINEA

UNIVERSITY OF NEW SOUTH WALES

UNIVERSITY OF TECHNOLOGY SYDNEY

UNIVERSITY OF WESTERN SYDNEY

- 14-

Mrs Pelenatete Stowers, Assistant CEO, Nursing and Midwifery, Ministry of Heath, Apia, Samoa. Fax No.: (685) 26553; Tel. No.: (685) 23330; E-mail: PelenateteS@health.gov.ws

Dr lsiye Ndombi, Representative, United Nations Children's Fund 3rd and 5th Floors, Fiji Development Bank Building, 360 Victoria Parade, Suva, Fiji. Fax No.: (679) 330 1667; Tel. No.: (679) 330 0439; E-mail: Indombi@unicef.org

Dr Robyn Mcintyre, Project Officer, EPI, United Nations Children's Fund, 3rd and 5th Floors, Fiji Development Bank Building, 360 Victoria Parade, Suva, Fiji. Fax No.: (679) 3301667; Tel. No.: (679) 3300439; E-mail: mcintyre@unicef.org

Dr Adriu N aduva, UNFP A Office for the Pacific, 5th Floor, FNPF Place, Suva, Fiji. Fax No.: (679) 331 2785; Tel. No.: (679) 330 8022; E-mail: assifi@unfpa.org

Dr Maria Isabel Salomon, Director, School of Nursing and Health Sciences, University of Guam, P.O. Box 5363 UOG Station, Mangilao, Guam. Fax No.: 1671 734 1203; Tel. No.: 1671 7352653; E-mail: msalomon@uguam.uog.edu; guamdye@yahoo.com

Professor Sir lsi Kevau, Executive Dean, School of Medicine and Health Sciences, University of Papua New Guinea, P.O. Box 5623, Boroko, Papua New Guinea. Fax No.: (675) 325 0809; Tel. No.: (675) 311 2626; E-mail: isi.kevau@gmail.com

Mr Alan Hodgkinson, Associate Dean (Postgraduate Coursework) Faculty of Medicine, School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW 2052, Australia. Fax No.: 61293852517; Tel. No.: (61293851192

Ms Michele Rumsey, Policy, Research and Development Manager Faculty of Nursing, Midwifery and Health, University of Technology, P.O. Box 123, Broadway, NSW 2007, Australia. Fax No.: 61295144835; Tel. No.: 61295144877; Mobile: 0417933519; E-mail: Michele.rumsey@uts.edu.au

Dr Elizabeth Jane Halcomb, Senior Lecturer, University of Western Sydney, Building 7, Campbelltown Campus, Locked Bag 1797, Penrith South DC NSW 1797, Australia. Fax No.: 61246203161; Tel. No.: 61246203344; E-mail: e.halcomb@uws.edu.au

- 15 -

Annex 1

3. SECRETARIAT

Dr Chen Ken, WHO Representative in the South Pacific, WHO Regional Office for the Western Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva; Fiji. Fax No.: (679) 3234177; Te1. No.: (679) 3 234100; E-mail: chenk@sp.wpro.who.int

Dr Hendrik Bekedam, Director, Health Sector Development, WHO Regional Office for the Western Pacific, 1000 United Nations Avenue, Manila, Philippines. Fax No.: (632) 521 1036; Tel. No.: (632) 528 9921; E-mail: bekedamh@wpro.who.int

Dr Ezekiel Nukuro, RegionalAdviser, Human Resources Development, WHO Regional Office for the Western Pacific, 1000 United Nations Avenue, Manila, Philippines. Fax No.: (632) 521 1036; Tel. No.: (632) 528 9816; E-mail: nukuroe@wpro.who.int

Ms Kathleen Fritsch, Regional Adviser in Nursing, WHO Regional Office for the Western Pacific, 1000 United Nations Avenue, Manila, Philippines. Fax No.: (632) 521 1036); Tel. No.: (632) 528 9921; E-mail: fritschk@wpro.who.int

Mr Steven Baxendale, Technical Officer, POLHN Coordinator, WHO Regional Office for the Western Pacific, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Fax No.: (679) 3234177; Tel. No.: (679) 3234100; E-mail: baxendales@sp.wpro.who.int

Professor Arie Rotem, Technical Officer, Human Resources for Health, WHO Regional Office for the Western Pacific, Level 4 Provident Plaza One, Downtown Boulevard, Suva, Fiji. Fax No.: (679) 3234177; Tel. No.: (679) 3 234100

Ms Monica Fong, Technical Officer, Human Resources for Health and Health Systems Research, WHO Regional Office for the Western Pacific, Level 4 Provident Plaza One, Downtown Boulevard, Suva, Fiji. Fax No.: (679) 3234177; Tel. No.: (679) 3 234105; E-mail: fongm@sp.wpro.who.int

Ms Charmina Saili, Technical Officer, Health Systems Strengthening, WHO Regional Office for the Western Pacific, Level 4 Provident Plaza One, Downtown Boulevard, Suva, Fiji. Fax No.: (679) 3234177; Tel. No.: 3234105; E-mail: sailic@sp.wpro.who.int

Dr Rodel Nodora, Technical Officer, HRH Information, Planning and Management, WHO Regional Office for the Western Pacific, 1000 United Nations Avenue, Manila, Philippines. Fax No.: (632) 521 1036; Tel. No.: (632) 528 9029; E-mail: nodorar@wpro.who.int

08:30-09:00

09:00-09:30

INFORMAL CONSULTATION ON HUMAN RESOURCES FOR HEALTH FOR PACIFIC ISLAND COUNTRIES 10-12 December 2007

Registration

Opening ceremony: • Remarks by Fiji government • Keynote address (WHO)

Adoption of the agenda.

Suva, Fiji

Distribution of badges. folders and documents.

(07 December 2007)

Officer (Dr Ezekiel Nukurro)

09:30- 10:00 I Objectives and expected outcomes. Dr Ezekiel Nukuro Chairman

10:30-12:00

13.00-15:00

15:30-17:30

Self-Introductions & announcements.

SESSION 1: HRH Situation & Priorities. 1. Global & Regional levels 2. Pacific Island Countries:

• Pacific Government commitments • Moving Forward- Priority HRH needs and

gaps.

(current and future) done by Countries I Partners in the Pacific & Lessons learned. Areas of Discussion:

• Workforce planning & management • Education and training (Scaling up of

production of health workers) • Governance & partnerships

groups: .. rlomyareas for partnerships and regional collaboration in strengthening HRH capacity in the Pacific:

1. Health workforce planning and management

2. Increased education {training of health workers,

3. HRH Governance

Dr Ezekiel Nukuro

Dr Marcus Sarno Dr Lorraine Ferguson

Pacific Island Countries Development partners Organizations {agencies Institutions{Alliances WHO & UN agencies

Prof. Arie Rotem (working groups facilitator)

To have an overview of HRH initiatives at various levels and gain common knowledge of key HRH developments; what are the priority HRH needs for the Pacific and I Chairman gaps in meeting those needs; and the government oommitrnents for slrenolhenino HRH capacity of the

i. Summary of HRH programmes in the Pacific loutoomes. ii. Awareness about gaps. iii. Generate ideas about Ipw to I Chaii ilion align and ooordinate HRH activities in the Pacific for further discussions in working groups

To identify priority areas Ikey actions in HRH for partnerships and regional oollaboration.

Appointed group chaiTpersons I facilitators

>-~ -~ x N

--J

08:15-08:30

08:30-10:30

11 :00-12:00

13:00-15:30

15:30-16:00

16:00 - 17:30

8.30- 10:00

Recap of day 1 sessions Rapporteur/Secretariat

SESSION 4: Working group presentations and I Group presenters discussions

within the systems strengthening, partnerships and coordination.

• WHO Action Framework on Health Systems Strengthening & Partnerships / I Dr Henk Bekedam coordination in Health

• Concept - Framework for a partnership and coordinated approach in strengthening I Dr Ezekiel Nukuro HRH capacity in the Pacific

SESSION 6: Working groups: 1. Principles for Aligning, harmonizing and

coordinating support for HRH in the Pacific 2. Strategic Framework Outline 3. Pacific coordination mechanism lentity

Break

Continuation of Working Groups.

SESSION 7: Working group presentations

Prof. Arie Rotem (Working groups facilitator)

Group presenters

10:00-10:30 I Break

SESSION 8: Presentation of draft proposed 10:30-12:30 I conclusions and recommendations for

discussions and adoption. Rapporteurs

Reporting back on outcomes of group work - for discussions and achieving consensus.

i) Importance of linkages between HRH, health systems and health outcomes & Lessons learned from International partnerships and aid coordination ii) Explore the relevance Ibenefits of a Framework for strengthened coordination of HRH initiatives.

1) To identify and reach consensus on key principles for partnerships and coordination. 2) Explore the concept of strategic framework & its outline. 3) Consider the structure and draft terms of reference for a coordination mechanism /entity.

Chairman Nice chairperson

Chairman Nice chairperson

Appointed group chairpersons I facilitators

Reporting back on outcomes of group work - for discussions and achieving consensus.

Chairman

Chairman

» ;;;l ;;;l

'" ,~

N

0>

- 19 -

ANNEX 3

MOVING FORWARD:

A PARTNERSHIP APPROACH TO HUMAN RESOURCES FOR HEALTH

IN THE PACIFIC ISLAND COUNTRIES

A Background Paper

Informal Consultation on HRH in Pacific Island Countries

Suva, Fiji

10-12 December 2007

- 20 -

Annex 3

Acknowledgements

This paper was prepared by a team comprising University of Westem Sydney faculty members including Ellizabeth Halcomb, Lorraine Ferguson, Yenna Salamonson, Roslyn Weaver, Karen Hancock, Debra Jackson, Esther Chang, Robert Anders and John Daly; and Kathleen Fritsch, Ezekiel Nukuro, Steve Baxendale, Juliet Fleischl and Rodel Nodora, of the World Health Organization Western Pacific Region.

- 2L -

Annex 3

Table of Contents

1.0 Executive Summary ................ ; ......... ;;;.;; ........................ ;; ...... ; ....... ;.; ................ ; .. ; .........•• ; ....... ;; .... 4 2.0 Introduction .. i.' ..• ~ .•.•....... I ••• i ••••••• I •• , • .; ... j.11 •• iI'"i •••• I.IIIIIIII.i"i.'I.II.ill1U.ii'.I.~i.II,;II'.ii"I •• I.i"I"U~oI'I •• II.IIII'"II,.I'11 B 3.0 Overview of human resources for health situation ..................................................................... 5

3.1 Population health needs ................................................................................... : ............................. 6

Disease burden .......................................................................................................................... .

Capacity for human resources for health planning & management ..................................... 6

3.2 Health workforce recruitment, retention and training ................................................................. 6

Workforce Size, Distribution & Skill Mix .................................................................................... 6

Health Expenditure ..................................................................................................................... 11

Working Conditions .................................................................................................................... 11

Migration ...................................................................................................................................... 11

Education and Training .............................................................................................................. 12

3.3 Health Workforce Governance and Management ........................................................................ 13

Policy & Regulatory Frameworks .............................................................................................. 13

Leadership & Management ........................................................................................................ 14

4.0 Current Human Resources for Health Programs ......................................................................... 14

4.1 Health Service Plannin'g/Management .......................................................................................... 16

4.2 Pre-vocational Education ............................................................................................................... 19

4.3 Post-basic Education ...................................................................................................................... 19

5.0 Summary .......................................................................................................................................... 20

5.1 Recommendations .......................................................................................................................... 20

List of Tables

Table 1. Density of health providers by country(17) .............................................................................. 9

Table 2. Mid-level practitioner titles and training programs(18) ........................................................... 10

Table 3. Current HRH activities in Pacific Island countries ...................... : ......................................... 15

Table 4. Current programs I activities for Health Service Planning & Management ........................ 18

- 22 -

Annex 3

Executive Summary

1. This document is intended to:

a. provide an overview of the current human resources for health (HRH) situation in Pacific Island countries;

b. map current HRH initiatives and programs and delineate potential strategic interventions and guiding principles; and

c. identify core HRH strategic interventions common to all Pacific Island countries

2. The strengthening of HRH in Pacific Island countries has major potential benefits. The evidence illustrates the importance of capacity building, strengthened regional partnerships and infrastructures to meet national health targe~, health-related Millennium Development Goals, as well as to improve health service accessibility and quality in the region.

3. Particularly important areas for intensified collaboration and interventions include: (1) health expenditures, health financing and the cost/benefit analysis of alternative HRH workforce options; (2) HRH information, data and information management systems; (3) capacity for strategic planning and management of the workforce; (4) investments in education, educational programmes and institutional resources, quality and standards, as well as ongoing staff development and skills to meet evolving and future population health needs; (5) workforce recruitment, distribution, composition and skill-mix, including the costs and implications of alternative models of service delivery; (6) performance management and evaluation; working conditions, environments and retention; and (7) leadership development; policy and regulatory frameworks.

4. Currently, there are limited formal opportunities for donor organisations and external partners to develop ongoing collaborative relationships and coordinated approaches to human resources for health development. This has led to duplications in some areas of policy development, service provision, education and training and gaps in others. A key challenge, therefore, is to bring donor organisations and external partners together to share information and develop a common, coordinated and strategic approach to human resources for health development in the Pacific Islands.

5. The establishment of a coordinating body would serve to facilitate partnerships, promote communication between stakeholder groups, and more effectively facilitate the implementation of human resources for health strategic plans, while recognizing the unique needs, geography and cultures of the countries.

6. A number of options for the development of such a body should be considered, building on existing partnerships, networks and alliances. Establishment of a secretariat for the body should be facilitated by WHO, in collaboration with other partners and stakeholders.

7. The functions of a coordinating body, subsequent to the formulation of agreed-upon goals with measurable outcomes and action steps, targeted at identified priority HRH strategic interventions, could include:

a. Establishing mechanisms for data collection and storage of information and an information resource centre to promote information sharing and communication between Pacific Island countries, donor organisations and external partners.

b. Monitoring, reviewing and conducting trend analysis of the human resources for health situation in the Pacific

c. Evaluating current and alternative models of service provision, assessing their effectiveness, accessibility and acceptability, as well as their impact on health outcomes.

- 23 -

Annex 3

d. Considering means of strengthening the education, deployment, supervision, support, retention and professional development of rural and remote health workers, including mid-level practitioners;

e. Facilitating greater coordination and collaboration among educational institutions, national and regional regulatory bodies, education and health commissions and policy-advisory bodies. Cross-border competency validation and registration, continuing professional development requirements and scopes of practice for advanced practice and/or speciality health practitioners are among matters requiring facilitation.

8. It is evident that the development of a more harmonized, coordinated, regional partnership approach to human resources for health would facilitate human resources for health and health system effectiveness, as well as contributing to improved population health outcomes. The establishment of a Pacific Island coordinating body or infrastructure would serve to facilitate partnerships, promote communication between stakeholder groups, as well as more effectively facilitate the implementation of human resources for health strategic plans, while recognizing the unique needs, geography and cultures of the island countries.

INTRODUCTION

9. The health workforce is integral to the performance of the health system, the effective delivery of health interventions, the quality of care provided and the health-related Millennium Development Goals (MDGs)(2). Deficiencies in human resources for health directly impact upon the health of the community<5). The importance of this issue has been recognised by the World Health Organisation (WHO) in terms of making human resources for health a priority area of their work for the next decade(2).

10. This document is intended to:

a. provide an overview of the current human resources for health (HRH) situation in Pacific Island countries with particular attention given to the root of causes of HRH issues, challenges and obstacles impacting the achievement of national health and MDG goals and targets;

b. map current human resources for health initiatives and programs and delineate potential strategic interventions and guiding principles addressing the major gaps requiring further support, collaboration, partnerships; and

c. identify the core HRH strategic HRH interventions common to all Pacific Island countries which would benefit from a regional and partnership approach.

11. Data analysis of the situation is based on: (1) a review of published documents including country reports, project reports, peer-reviewed publications and "grey" literature; (2) a structured questionnaire; and (3) a medline search.

OVERVIEW OF HUMAN RESOURCES FOR HEALTH SITUATION

12. Substantial effort has been invested in workforce planning to strengthen human resources for health in the Western Pacific. Nevertheless, significant barriers remain, including political, social and economic factors, limited funds for health care delivery and the training and ongoing professional development of the health workforce. These pressures can be broadly classified as: (i) the population health needs and the human resources for health capacity of the Pacific Island countries; and (ii) issues related to the health workforce, including recruitment, production, education and training; distribution,

- 24 -Annex 3

composition and skill-mix; and retention and management, including the work environment.

Population health needs

13. Perhaps the most significant challenge facing health services is the rising prevalence of chronic non-communicable diseases (NCDs), including cardiovascular diseases and cancer, which have become the leading cause of death in most Pacific Island countries. Modifiable risk factors are major contributors to the rise in NCDs, including diets high in fats, sugars and salt; reduced physical activity; and high rates of tobacco and alcohol use. Health promotion, prevention, risk reduction and the provision of health services all represent challenges for health systems to adequately address health promotion and lifestyle modification, while meeting the unique needs of those with established chronic illness and functional impairments.

14. Notwithstanding the rise in chronic conditions, communicable.diseases (infectious and parasitic diseases), maternal/perinatal conditions and nutritional disorders still comprise the second largest group of conditions causing death in the Pacific Island countries. While health systems must evolve to cope with the rise in chronic conditions, they must also ensure the continued provision of primary health care services for those with acute conditions, as well as chronic communicable diseases, including HIV/AIDS.

15. Other challenges specific to the Pacific Island countries are the provision of accessible and quality care to remote and vulnerable populations, as well as the provision of specialist health services to a geographically disparate population. Though mental health conditions contribute significantly to the total burden of disease, they remain poorly recognised and addressed in the Pacific Islands. Growing rates of morbidity and disability from neuropsychiatric disorders, drug and alcohol abuse and suicide have been reported across the region; yet mental health services remain underfunded, underdeveloped and understaffed.

16. The lack of accurate data, vital in estimating current and future disease burden and health service needs, hampers health workforce planning. The development of minimum datasets and central data repOSitories would promote the establishment of a robust dataset to support workforce trend analysis and the strategic allocation of limited resources to areas of greatest need.

Capacity for human resource health planning and management

17. It has been recognised that within the Pacific, as in many parts of the world, the "technical capacity in human resource management strategic planning and management is weak". Many Pacific Island countries have underdeveloped data collection and research relating to human resources for health, compounded by the paucity of detailed, up-to-date epidemiological, demographic and social information which impede projections of service needs. Enhancement of the knowledge base related to current human resources and health needs is essential to form a basis of future workforce planning.

He;!lt/! workforce recruitment. retention and training

18. WHO estimates a global shortage of doctors, nurses, midwives, pharmacists,dentists and support workers of around 4 million. The lesser-resourced Pacific Islands are at a disadvantage in competing with wealthier countries in terms of training, recruiting and retaining the skilled health workforces that they need.

Workforce Size, Distribution and Skill Mix

19. A density of 2.5 per 1000 population of doctors, nurses and midwives is required to implement basic essential health interventions and attain the health-related Millennium Development Goals. Table 1 shows a significant variation in the density of health care workers between the Pacific Island countries, with a number of countries falling below or

- 25 ...

Annex 3

close to the recommended minimum density level. Caution must be used in interpreting these data, given the potential for poor data quality and the time period that has elapsed in some cases since the data were collected and reported.

20. While general standards and targets for health workforce density in relation to population are helpful, the workforce numbers and the types of human resources for health required need to be determined by health policy and health facility staffing levels, according to health service demands in individual countries. Breakthroughs in medical technology; population ageing, the rise in non-communicable disease and the increase in chronid and complex conditiohs all impact upon the volume and types of health services required. The health service demands, population distribution, changing technologies, population and epidemiologic trends, as well as health financing factors all affect the distribution, composition, skill-mix and management of the health workforce.

21. Geographical imbalances, topographical challenges and uneven workforce distribution, particularly in underserved rural and remote areas and poor urban areas are common problems in the Pacific Islands, exacerbated by limited workforce sizes in the Pacific Islands.

22. The ageing health workforce in many of the Pacific Island countries poses multiple challenges as older health workers are more likely to be distanced from advances in health service delivery, best practice disease management and developing technologies, posing an urgent need for continuing education. The lack of succession planning to replace this group when they retire further exacerbates the health workforce shortage.

23. Gender also influences workforce participation, recruitment and retention. Though females predominate in the nursing, midwifery and allied professions, the medical professions are largely comprised of men. In addition to their dual roles related to child rearing and family responsibilities, female workers typically have lower status, less remuneration and fewer opportunities to engage in leadership positions than many male health workers regardless of their educational background.

24. Structural and skill imbalances or the lack of appropriate skills to suit local conditions and changing circumstances is a challenge in the Pacific. While acknowledging the uniqueness and diversity of Pacific Island countries, it is important to examine the cverall composition of the health workforce, their roles and their skill-mix in order to identify gaps and strengthen the capacity for provision of quality services, particularly to vulnerable and remote communities.

25. Mid-level practitioners, including nurses, nurse practitioners, midwives, and nurse aides or community health workers provide a significant proportion of health care services throughout the Pacific Islands. They serve as front-line health providers who have received sufficient advanced training to provide primary health care, including the diagnosis and treatment of common health problems; the prOVision of emergency management and referrals of those requiring additional interventions to more advanced facilities. While medical practitioners are usually employed in regional referral hospitals and main population centres, the provision of basic primary health care in less populated areas is largely undertaken by mid-level practitioners.

26. Scaling up and strengthening the role of nurse practitioners is widely regarded as a cost­effective strategy for building health system capacity rather than the continuing reliance on phYSicians. An evaluation of Fijian nurse practitioners in 2001 found them to be playing a key role in the health care system, with positive, cost-effective outcomes in both curative and preventative health care. Evidence from developed countries, such as that in the Cochrane Collaboration review of studies of the substitution of doctors by nurses in primary care suggests that appropriately trained nurses can produce as high quality care and achieve as good patient health outcomes as primary care physicians. Consideration of the future of the nurse practitioner role in relation to health workforce plans and equitable health service provision is vital, as is the further development of

.. 26 .,.

Annex 3

policies guiding the delivery of services by nurse practitioners and the potential career pathways of the nursing/midwifery workforce throughout the Pacific Islands.

Table 1. Density of health providers by country(20) ,

~ '" '" '" '" <Il '" U) "* .~ 'c;; " '" " E £C " Q) C 'c C

'" -5iCl) C U5~ ~ "" '" 0

'" '" ::> .3 Skilled Health Worker rn '" "in 2 " :::I "in '" :::I O·C ""0 ,,'" "0 '" - '" '" 0 - ~- ro C £IUC "in .sl§ :=- .0 :::I "iii :::I IU E 0> "iii :::I - u.. D.. 'ffi "iii C c: >

Category ~ (ij~~ -'" ·c '" U Z '" 0 .... 0 :::I c:

Q)t:~ 0 '" .- -E s:: .<:; Z D.. C/) E 0 l- I- ro ·c ~::;;;

'" ~£ 8 "'- c f!! ~ -§ I- >

~ -go I!! '" Q) t.)z ::;;; Z u.. u.. rn

Year 2003 1999 2003 2005 2003/4 2000/4 2004 2000 2004 2002 2006 98103-5 2005 2005 NlA, 200213 N/A 2004 Population 65500 80362 20200 114100 832450 254600 93100 61218 10100 230789 1730 19907 182700 478000 153(1 , 101870 9600 215540

:,', ""> " ....... ,':":", ........•.. , , , ,,'.i,'(· '<), Medicine ..• '.:' ......... ' ••••.• ,,' '. '.' , ...

.. '.' , "':. ", .... , .' '. ..,

Total DoctOls 49 31 27 62 339 447 20 24 7 476 4 25 52 89 l 43 4 29 Rate per 10 000 Pop'n 7.83 4.47 14.67 5.43 4.04 17.80 N/A 4.63 4,95 22.04 23.12 12.31 2.74 1.86 2O'.ID' 3.90 4.18 1.35 "'.<::,:'.,,"';,.:. '., .•.... ,.,',";:,,' ,"', ······Nurslng '. . •....• ,., •. :.. •..•.••...• ": ' .. " ...... ',.. . . . ' .. ....... , ..... "" , ..

Total Nurses 127 123 60 229 1648" 824 270 152 33 1128 13 111 136 628 10; 341 30 362 -Rate per 10 000 Pop'n 20.29 17.74 32,60 20.07 19,88 35,90 26.50 29,34 47.52 52,25 75.14 55.76 7.47 12.97 66.7 33.70 31.38 14.48

I~""··" . ""', , . . ...•...... ',., ,i".:: . . ,'/, ' ..' )', ,'. '.. '; Midwives ... , .. . ,.,'<., .. , .. , ',:. .: , . . . ' ..

Total Midwives 1 14 15 20 NJA 93 32 N/A 2 83 2 1 37 74 3 21 10 50

Rate per 10 000 Pop'n 0.16 2,02 8.15 ' 1.75 NJA 15:80 3.60 N/A 1.98 3,81 11.56 0,56 2,03 1,55 20-0i , 2.08 10.46 2.32 I" .... ' .... ':,. .. ............ '.' .. ,. ',').':.,' ,,",'<:,,'. ,::., .'<""1,'.;" :, Wentistry ".' ......,;.,'.: "'. .... : ..... ..... .... , ..

•

' . ,. . .

Total Dentists 15 3 18 13 56 113 3 4 1 126 3 2 6 52 l 13 2 3

Rate per 10 000 Pop'n 2,40 0.43 9,78 1.14 N/A 4,10 0.30 0.77 0,99 5.84 17,34 1.10 0.33 1.09 2!l1ID 227 2,09 N/A i'C: .. ,.,," ;,> .',.. .,' ·.'t, • .. ' .•. , ." ...• '.'.' ......• , 'i'j:G" ,".', ·;'i ..... ',",'., .. , .. " .. ' "': <:ii;',· " '>l '.'.

'>:'''",'''.. '..-'" ' •• . ...... , ....

". . .....

Total Pharmacists 2 4 2 16 87 100 2 2 4 97 1 1 3 53 0: 4 2 5

Rate per 10 000 Pop'n 0.32 0.58 1.09 1.40 NJA 4,0 0.20 0,39 4,95 4.49 5.78 0,55 0,33 1.10 0: 0.40 2.09 N/A

'\\/,:"".'"..: :...' >, ii, .::·:'!~iS,/: ';; iOtherpararnooicai (e:g.medicalassislant, technicians)" '.' .• ,....... .,). .... . ,:" .:'. . •..• ',' .. '.' .•.• ". .. '.' .' .,i ...... , .... • • . ' .

Total Paramedical 146 20 20 325 355 NJA 16 53 13 N/A 4 13 101 493 t 26 5 N/A

Rate per 10 000 Pop'n 23,32 2.88 10,87 28.48 4,27 N/A 1.80 10,23 12,87 N/A 23,12 7,20 5,53 10,31 6,67 2.57 5.23 N/A 1·;'(,-:::\.",':<·.·· ' .. ::.2",.,/ ·,,".",'.i'Y:; . ",', , ' ',., Othe!l;tealth personnel(e:g: heatth inspector, traditional workers j •. ' .... ,:,;:'.' .. .... '.' .

.. ..... . .

Total Other 13 .14 14 183 963 NJA 10 N/A 156 N/A 4 6 35 N/A 1 22 23 51

Rate per 10 000 Pop'n 2.08 2.02 7.61 1 16.04 11.584 1 N/A 1.10 1 N/A 1 154.46 NJA 1 23.12 1 3.30 2,90 1 N/A 1 6,67 1 2.18 1 24.06 I 2,37 I

c ;:; (~ j'\

:",0')

N -.I

_. 28 --

Annex 3

27. A key challenge regarding mid-level health practitioners is the differences in roles, scopes of practice, education/training and backgrounds of the various workers in different countries. Such disparities preclude comparisons between the various models of care in terms of clinical outcomes and cost-effectiveness. Table 2 outlines the varying mid-level health worker and nurse practitioner titles, training programs and reasons for attrition. A key priority in addressing these variations includes the further development and strengthening of legislation with clearly defined scopes of practice and competency statements for all levels of health providers, including those with advanced practice education and competencies.

28. Another key challenge is matching the skills of health professionals with specific needs of the local community, in particular the balance of curative versus preventative services. According to Pak and Tukuitonga, services for health promotiQn and disease prevention are under- developed in the Western Pacific region. While the aim is to provide universal access to primary health care, low investment in such services, compared to high cost curative services, means that availability is inconsistent and quality of care is variable. Given that Tukuitonga estimates that 80% of health events and their sequelae can be satisfactorily addressed at primary care level, deficiencies in the accessibility and quality of primary (health) care services are likely to have a significant impact on health outcomes. The recent outbreaks of communicable diseases such as severe acute respiratory syndrome and avian influenza highlighted deficiencies in the skill mix in terms of a lack of epidemiologists, nurses, public health workers and general physicians(2). Other issues identified included inadequate infection control and environmental policies and legislation; a lack of technology and logistics for diagnosis and treatment; and inadequacies in crisis communication(2).

Table 2. Mid-level practitioner titles and training programs(l5)

Nurse practitioner

Medical assistant

Clinical nurse consultant

Medex

Health officer

Health assistant

Nurses aides

Year program initiated

Program duration (years)

Total program graduates

% graduates presently employed

Further educationllraining

Migration

Death

Transfer to administrative post

Dismissal

Resignation

'MA training ceased In 1984

... .. ."

0 " 0 .l!! .., .!!!

X

1990

6

=S ....

X

X

1975(MA)' 1998 (NP)

1 (NP)

61 MAs 10 NPs

64% MAs 100%NPs

X

X

X

,.. = .. .. " .. .. ." 0 ~ -g ~

.r::; " ~ .. E ~:ii

.. ..e..5!:! '" 0 .. '" -

X

X

X

X

X

X

1978 Mid-1970s 1993

1.5 1.5 (HA)

46 76-80 37

83% 88% 95%

X X

X X

X X

X

~ .. CI

" " 0 " I- ~

X

X

1977 1983

3 10 months

34 44

79% 91%

X

X

X

X

X

- 29 .-

Annex 3

30. Well-designed research is urgently required to evaluate the various models of service provision and human resource configurations utilised in the Pacific Islands, to determine the relative efficacy of these models in terms of health outcomes, cost-effectiveness and provider/community satisfaction. Enhanced regional networking and communication between providers and policy makers regarding effective strategies to manage human resources and skill mix also have the potential to improve service delivery.

Health Expenditure

31. Wages, salaries and allowances of health workers hi the Western Pacific represent approximately 45% of general government health expenditures, as compared to 42.3% in Europe and 49.8% in the Americas. Data accuracy, as well as the.lack of private health workforce data limits firm conclusions which can be drawn. However, given the significant expenditure on the health workforce, there still remains little evidence to compare and analyze the effectiveness of various models of j;:are. Chen et al. describe current spending patterns on human resources as being ''fragmented and inefficient," emphasizing that "to invest more strategically, donor coordination and policy coherence must be greatly improved-changing attitudes about health workers, not as a burden but as a crucial investment, harmonising the workforce across competing categorical programmes, and ensuring fiscal policies that support workforce improvements".

Working Conditions -.

32. Issues of poor employment conditions and working environments throughout the PaCific Islands make the retention of staff an ongoing challenge. The multitude of factors impacting working conditions includes:

• Low pay and limited incentives;

• Lack of appropriate job descriptions, performance assessments and career

paths;

•. Excessive workloads;

• Ineffective staff rostering systems and task allocation;

• Inadequate supervision or management support and frequent changes in staff

organisation and reporting lines;

• Understaffing and lack of funding for positions;

• Poor facilities and lack of equipment/supplies;

• Absence of regular continuing professional education;

• Lack of professional autonomy;

• Absence of gender equity; and

• Lack of transparent mechanisms for performance management; promotion and

rewards.

33. These issues clearly need to be addressed to enhance motivation and satisfaction of the existing health workforce, as well as to promote the future recruitment and retention of suitably qualified staff.

Annex 3 ·30 -

Migration

34. Migration of health care workers is a significant issue for the Pacific Island countries, just as it is globally. The movement of health care workers away from the Pacifib Islands to more developed countries experiencing shortages of health workers, and offering better remuneration and working conditions is a growing problem and a trend likely to continue. Additionally, a number of students are entering the health education system with the intention of migrating and seeking p'rosperity overseas. While some educational institutions have been established to by produce graduates 'for export', a number of lesser-resourced Pacific Island countries have become "unwilling donors to the wealthy countries to which their health personnel have migrated".

35. Factors reported in the literature as contributing to migration are largely related to health system and economic conditions within Pacific Island countries, including: a lack of funding for health resulting in lower salaries; poor working conditions and infrastructure; lack of training and career structure; political instability and social factors. However, objective measures of the impact of migration on Pacific Islanti countries are not readily available. Well-designed, independent research continues to be needed to enable health ministries to accurately identify and prioritise factors contributing to the outward migration of skilled health workers.

36. There are many challenges in addressing or managing the ongoing problem of skilled health worker migration. To date there has been no coordinated strategy implemented that has reduced migration rates, with few countries directly. seeking to address the issue. Action needs to be taken at a country level as events beyond the control of the health system, such as political instability, are likely to accelerate emigration rates. Further, the rights of individuals to migrate and seek greater life opportunities overseas must be weighed against the needs of the health system to retain skilled workers. Traditional policy measures aiming to simply restrict migration of health care workers have been found to be ineffective. Countries need to develop policies to implement the Pacific Code of Practice.

37. As it is likely that at least some degree of migration is inevitable, strategies to manage . migration may assist in encouraging workers to either stay within or return to the Pacific

Islands. For example, one potential strategy could be to enable the circulation of skilled health workers within and between Pacific Island countries. Such a system requires a regional approach, with a common commitment by stakeholders and partnerships between health systems to encourage rotation. A central co-ordinating body, representing all Pacific Island countries, is needed to facilitate these rotations in a harmonious manner and identify opportunities for professional development and sharing of worker expertise.

Education and training

38. Given that nurses represent the largest group of health care workers in the Pacific Islands, strengthening nursing and midwifery education is a clear priority. One of the current problems is substantial variation in entry-to practice or initial nursing and midwifery education among Pacific Island countries. In the mapping exercise of nursing education in Pacific Island countries, Usher et al. recommended the development of !3xpert 'hubs', or well-establlshed Schools of Nursing to support smaller Pacific Island countries in strengthening nursing and midwifery education and to facilitate more effective resource-sharing. The potential support provided identified 'hubs' could include training stUdents from other islands, providing student and faculty exchanges, and collaborating with other regional and partner institutions to further develop and standardise curricula. If successful, such a collaborative model could be transferred to other disciplines.

39. Despite the Significant investments in education, training and staff development by governments, WHO, donor agencies and other sectors, the return on these investments is unclear. Although a large number of meetings and workshops are undertaken on various issues, including capacity-building for various disease-specific interventions, as

_. 31 .

Aimex: 3

well as leadership or networking, there appears to be a lack of harmonisation and coordination of these events as well as a lack of evaluation of the impact of such trainings on service and health outcomes. The practical constraints in implementing and maintaining effective training strategies identified by the Pacific Island Health Workforce project include: (i) insufficient national funding; (ii) lack of adequately-resourced training facilities and programmes in some countries; (iii) substantial reliance on training programmes in countries outside the region and the frequent loss oftrained health workers to these countries; and (iv) difficulties in the management of training programmes.

40. In the past, the only way for health professionals to participate in continuing education had been through fellowships and attachments at institutions in other' countries. Significant improvements in coordination and the use of information and communication technologies now provide mechanisms to increase the impact of training and development interventions in a cost-effective manner. Open and multi-modal distance learning, can reduce geographical isolation and allow workers to rapidly access knowledge and evidence, enabling discussions and consultations with personnel in other countries. While some progress has been made in developing and delivering open learning, major impediments include the limited availability and accessibility of equipment (e.g. computers), the high cost and limited availability of internet access, and the level of computer literacy in the workforce. It will likely take time for information technology to be utilised to its full potential.

41. It is evident that greater analysis of educational (pre-vocational and postgraduate) and training programmes throughout the Pacific Islands is required. This analysis should provide the evidence to develop strategies to improve co-ordination and harmonisation to reduce duplication, share resources and experiences, and strengthen educational standards and quality.

Health Workforce Governance and Management

Policy and Regulatory Frameworks

42. Workforce policy and legislative frameworks must be underpinned by strong leadership, good governance a'nd management structures and reliable workforce information. To be effective, strategic planning and decision~making about the numbers and types of health care workers, deployment, skill-mix, and training/ongoing development needs must be evidence-based, using up-to-date workforce data collection and analysis systems. This requires tne establishment of human resource policies and information systems at both country and regional levels essential to track, coordinate, review, monitor and manage human resources for health within each country. The data provide important inputs to the strategic planning process, as the numbers and types of human resources required to address the changing patterns of disease need to be accurately projected, and the education funding and planning adjusted to ensure adequate intakes and outputs of all types of health care professionals over the longer term, rather than simply reacting to short-term crises.

43. While most Pacific Island countries have regulatory frameworks related to the level of training required and the roles and responsibilities undertaken by health professionals, there is often a lack of statutory requirements for the ongoing or continuing professional development and currency of practice to maintain registration or licensure as a health professional. The lack of opportunities for ongoing development and career enhancement may well contribute to the outward migration of health professionals.

44. An emerging issue related to policy and regulation oUhe health workforce is the need to engage both the private and public sectors in the development of policy and regulatory frameworks. The development of recognised competencies, task substitution and delegated authority can optimise the utilisation of the available skill mix and promote efficient use of limited human resources. Although core nursing and midwifery

- 32

Annex 3

competencies have been formulated and agreed upon by regulatory bodies in the Western Pacific and Southeast Asian Regions, dialogue betvveen Pacific Island countries and educational institutions relating to the development of agreed essential, core curricllia for health workers ha's been limited. Strategically, there is a need to review and strengthen legislative frameworks and training and development plans related to human resources for health. Additionally, there is a need to develop coordinated and consistent policies and plans across both private and public sector organisations involved in planning, educating/training, developing and retaining human resources for health.

. Leadership and management

45. Leadership and governance approaches to improving human resources for health need to be multidimensional and carried out in consultation with a broad range of health and non-health, government and non-government stakeholders. Atcording to Chen etal. such approaches need to include "adequate financing, strong leadership and political commitment" and the stakeholders should include "finance, health and education ministries, academic leaders, professional associations, labou·r unions, educational institutions and non-government organizations".

46. The Western Pacific Regional Strategy on Human Resources for Health 2D06-2015 recognises "a crucial need for strategic and comprehensive workforce planning linked to budget and management planning cycles". Workforce development strategies need to take a long-term view and include what Chen et al. call "five key dimensions - engaging leaders and stakeholders, planning human investments, managing for performance, developing enabling policies and building capacity while monitoring results". While there are a number of regional and country"specific workforce strategies and plans related to human resources for health in the Pacific, some countries have not been able to implement those plans. or effectively coordinate the efforts of the partners and stakeholders to achieve the goals and objectives of those plans.

47. Improving managerial. competence by providing targeted leadership development and management training, mentorship and supportive netvvorksat all levels of the health care system is important·for improving the recruitment, retention, motivation and competence of the health workforce as well as the quality of care provided.

48. According to the Pacific Senior Health Officials Netvvork, improving governance structureS is crucial to health 'sector management, both within individual Pacific Island countries and regionally, if health workforce issues are to be addressed strategically for the longer term. .

49. The Pacific Plan recommends the concept of "regionalism" as a way of strengthening regional cooperation and support for many aspects of regional development. The Plan makes reference for the collection of health statistics and health workforce data, health worker recruitment and the investigation of regional approaches to technical and vocational training programs aimed at a standardised approach to programmes and portability of technIcal qualifications. While it Is recognised that the PacIfic Islands are a very diverse group of sovereign countries that need human resource for health . strategies to address the specific health care needs of their own populations, collaboration and sharing of information; knowledge, experience and resources are Important if health workforce issues and the Health of the populations are to be improved. This regional collaboration could· include health workforce information sharing (including vacancy and recruitment Information), networks of skilled health professionals;

. sharing of human resource policy and planning processes and potential best practices focused on successful incentives, improved workplace environments, as well as effective skill-mix options.

. 33·

Annex 3 PRESSING HUMAN RESOURCES FOR HEALTH PROBLEMS OBSTACLES AND DEVELOPMENT NEEDS "'" ."

50. The current HRH issues analyzed are consistent with the most pressing human. resource needs identified by stakeholder survey respondents:

• Strengthening of human resources for health, including the d~velopmef)t and management of the workforce, mechanisms to atlClress workforce needs in the face of significant nutnbers oT pending retirements iii ctltlcalroles With limited succession planning;

• Strategically planned education and training - including accessible resources and the development of curricula that meet population health needs and cultural contexts;

• Computer and English language literacy for health workers to increase the accessibility of online health resources;

.. Centralisation of basic education and resources across countries to utilise expertise, reduce duplication, maximise the outcomes from donor/external partner inputs and improve the quality of education and training;

.. Recruitment and retention of the health workforce, with particular consideration given ·to the skill mix needed to address community needs;

• Adoption of more flexible working arrangements and role SUbstitution;

• Leadership and management both in the clinical setting and in human resource planning;

• Innovative strategies to improve working conditions;

• Greater clarity in job descriptions to streamline service delivery, reduce duplication and identify gaps;

• Enhanced regional co-operation in all aspects of human resources for health; "

• The development of coordinated strategies to promote workforce mobility within the region, as a means of addressing the issue of migration;

• Evaluation of various models of care using different skill mixes to examine effects on c1inical"outcomes and cost-effectiveness; and

• The development of cost-effective capacity building that produces measurable outcomes.

51. When asked to look forward, several respondents cited "effective leadership with vision and good management and governan~ practices" as key factors in determining the human resources for health situation in the next decade. Respondents say there would be clear benefits by organisations, such as WHO, taking on more proactive leadership roles within the region. Respondl?nts also indicated that both donor organisations/external partners and Pacific Island countries needed to be involved in developing strategic plans for human resources for health development in the region.

52. Table 3 provides examples of some of the types of human resources for health activities or programmes undertaken by survey respondents.

. 34 ..

Anne~ 1 . . Table 3. Examples of current HRH activities in Pacific Island countries

Organization

AAAH - Asia Pacific Action Alliance on H RH (Thailand)

Asian Development Bank

Auckland University ofTechnology

Australian Govemment (AusAID & Department of Health and Ageing)

Fiji School of Medicine

James Cook University

Nauru

UniversITy of the South Pacific (Fiji)

UniversITy of Technology (Sydney)

Type of Activities or Programs

Training I Workshops Capacity building for HRH system planning

Networking

Intersectorial human resource planning/management and training

Curriculum development for the School of Nursing in Tonga Currently reviewing and nedeveloping educational material for the Solomon Islands

Support of the Pacific Senior Health Officials Network The PSHON Health Workforce Project (September 2006)

The Tonga/Australia Health Workforce Planning Tools Partnership Funding to the Department of Health and Ageing for the Pacific Senior Health Officials

Network Funding to the Fiji School of Medicine

Funding through the Royal Australasian College of Surgeons medical specialist visits and in­country training COUIS'S,. and allied health training in hospttal equipment maintenance and

repair

Training and Staff Development

Nurse education - post registration courses (BNS, Mental Heatth, Intensive Care, Coronary Care, Peri-operative Nursing certificate level courses)

Consultancy for Scope of Nursing Practice in Fiji Consultancy for Clinical Govemance/Risk Management for the Fiji Ministry of Health

On Site Health -Educator, access to Pacific Health Open Learning Network, access to Internet for all staff.

Assistance with relocation for expatriate staff, provision of accommodation including provision of utilities at no charge, transport

Scholarship programs for trainees to sludy health related fields, ego medicine, nursing, physiotherapy, radiology

Training and reseanch Workforce management

Recruitment and planning consultancies

Development of nursing and midwifery minimum dataset in partnership with the WHO Western Pacific Region and a Pacific Island working group

Various consultancies related to HRH

4.1 Health service planning and management

53. Improving managerial competence by providing targeted leadership development and management training .. mentorship and supportive networks at all levels of the health system is important for improving the recruitment, retention, motivation and competence of the health workforce,as well as the quality of servIces provIded. The Pacific Senior Health Offlclal$ N@twC)rk recC)snlsell th~t Improving gOVfjrnance structyres is erucial ta the long term fI1~naaemef\t Elf the Mealtheal'e sector, both within individual Pacific Islang countries and regionally.

54. A number of current programmes were identified that specifically target the need for improved health service planning and management in the Pacific Island countries. While this programme targets a key regional need, closer links to the health system are required to improve the applicability of this education to ihehealth sector.

55. The Pacific Senior Health Officials Ne.twork Policy Partnerships Initiative tries to bridge the gaps between increased discussion regarding workforce planning and action within the health setting. This initiative involves health planners from Australia and Tonga working to improve workforce policy and planning. Other activities related to health service planning and management focus on the development of partnerships to

I I

II

35

Annex 3

strengthen regional planning and management capacity. Both the Asia-Pacific Action Alliance on Human Resources for Health and the human resources for health committee at the Fiji School of Medicine seek to develop a network for workforce planning and improved communication. The challenge is to ensure that their activities have a direct impact on the health system that improves capacity or health outcomes.

56. The American Pacific Nurse Leaders Council (APNlG) and the South Pacific Chief Nursing Officers Alliance (8PCNOA) play Important roles In addressing nursing and midwifery contributions to health systems and population health outcomes.

57. In September 2007, a workshop of national HRH focal points of Pacific island countries (funded by WHO and convened by FSMed) recommend the establishment of a mechanism (initially named as Pacific Human Resources for Health Alliance) for addressing common HRH issues of the Pacific. The alliance aims to oversee the implementation of human resources ~or health development strategies. While such an aim has significant potential to improve human resources for health development, the current terms of reference of this alliance do not describe engagement of external partners and donor agencies. Such engagement would strengthen the alliance's ability to harmonise human resources for health programmes in the region.

Table 4: Examples of current health service planning and management programmes I activities >

i Program Name Program Aims Type of support Funded by Strengths Weaknesses Ways to improve Sustainablnty strategies 1.0>

Asia-Pacific Action Alliance Strengthened HRH planning & Advocacy for health workforce Rockefeller Non-govemmental Not a funding agency Active involvement Ownership by members on Human Resources for management capacity toward investment & development, Foundation of Its members & Heal1h adequate, equitable, eflldent & Support human resources WHO multi-stakeholders Small secretariat partners in the Partnerships with all

effective HRH & health system information system CIDA region stakeholders for health equity & quality development, promote GHWA flexible work plan to promote improved in the Asia,Pacific knowledge sharing, & technical European actions by its members region coordination Commission

Policy Partnerships To partner ofllcers from the Under the HRH - Tongal Australian Flexible Activities are detennined Pacific to Pacific Supports capadty Initiative (PPI), PSHON Pacific with ofllcBlS from Australia Healtl1 Workforce Department of by PSHON members partnerships development wl1h Pacific

Australia & thePSHON to Partnership Australia Health and Aging Targets priority areas Ministries of Health. support themwlth.inproving Department of Health & Ageing supports outcome achievement Unm PPI activities can health policy & planning within is providing support to the AusAlD Include partnership Improves approaches to their Ministry in an area of Prlndple Health Planning Builds local capacity between Pacific Island health policy planning & agreed priority. The focus of Officer, Tonga Ministry of Health

Acllvi1ies are endorsed by PSHON countries, support can only development

one of these partneillhips is to develop health workforce be provided in areas within HRH - TongaJAuslralja Health planning tools, with a focus on & reporled to the PSHON the scope of our Has high level Workforce Planning Tools succession planning. provides opportunities for partners Departmenfs technical endorsement & Partnership (Current) to then support other countries to expert/se. involvement

undertake similar activities

HRH Committee at the Fiji Create a regional network for Improved planning for workforce WHO Regional focal points Empty planning exercise Still early days N/A School of Medicine workforce planning, discuss issues. with no impact t.>

HRH issues. 0-

Resource limitations of the School

PacifIC Human Resources To strengiilen human Monitor human resources for WHO Regional engagement Still in transitional period Still early days N/A for Health Alliance resources for health planning health situation, coordinate

and managementoapacity knowledge generation, act as a Need to gain support of resource centre, assist in external partners I donor capacity building, coordinate agencies and identify resources

General Education Leadership & management- Increase in number of qualified Self-funded IntemationaJly recognised & suits May not be fully orienlaled Greater Regional needs in their (University of the South across the boarci;staff individuals -programs up to Public Service lhe needs of the Pac~ic region to health workers collaboration with strategic plans - as well Pacific) retention & better salaries & masters level, project Commission health sector as countries are

working condillons management, MBA, leadership Donor agencies programmes members of the & governance & public University administration & management

- 31 .

Annex 3

Pre-service. pre-registration health professional education

58. It has been reported that the Pacific Islands generally have an undersupply of graduates to meet health service needs. Budgetary restraints significantly impact both institutional capacity and standards of education. This clearly has the potential to impact the quality of policies developed to support health workers.

59. The Nauru Department of Health, recognizing that many of their schoolleavers lac~ the skills necessary for tertiary study and the need for recruitment of potential students to health-related higher education programmes, has developed a 12-month programme in which students gain skills in mathematics and science while also gaining experience in a health setting. This type of initiative increases entry to the health workforce. However, good evaluation has to be made to draw conclusions regarding its effectiveness.

60. The Fiji School of Nursing, in partnership with James Cook Univ~rsity, has developed a contemporary, evidence-based curriculum for its nursing students. In addition to the review of the curriculum, this collaborative project has provided an opportunity for educators at the Fiji School of Nursing to develop their own teaching and assessment skills. Resources to support learning and teaching, including information technology and textbooks, have also been identified and mobilised. It has only been implemented in 2007 and is yet to be evaluated.

61. The College of Micronesia is currently working towards establishing its own nursing pre­registration program in an attempt to reduce the difficulties associated with sending locals to other Islands to undertake their nursing education. While the benefits of conducting such a programme in Micronesia have been clearly established, it is unclear whether the planned programme development has sufficiently been linked with other Schools of Nursing in the Northern Pacific Islands.

62. The Fiji School of Medicine plays a significant tole in providing pre-registration and postgraduate medical education in the Pacific. However, institutional and capacity issues impact its ability to playa greater role in human resources for health development.

63. The data presented do not fully reflect the overall current health professional education situation in the Pacific Islands. A regional nursing and midwifery education and regulatory mapping project is underway, which aims to strengthen and maintain up-to­date country data; and support mechanisms for more effective resource sharing, institutional and faculty development, as well as curricular standardization. An infrastructure is envisioned which will enable the ongoing collection and maintenance of up-to-date health professional educational and workforce data; closer communication, shared teaching experiences, resources and courses, as well as more efficient means of addressing educational development needs, academic quality and standards.

Post-basic and post-graduate education

64. The data identify areas of duplication, significant gaps in current programmes, as well as potential areas for more efficient resource-sharing. It is difficult to obtain accurate data about such programmes as donor agencies report that such funding is often provided under broader support programs that fund development in fields other than health and information available may not specify the extent of support for health specific activities. The impact and outcomes of such programmes on professional development, service delivery and health outcomes has not been adequately evaluated.

65. OngOing collaboration between the Fiji School of Nursing and James Cook University and the Queen Salote School of Nursing (Tonga) and Auckland University of Technology require ongoing evaluation to determine their impact on nursing practice and sustainability.

66. A recent initiative offering significant potential is the development of a credentialing programme for nurses and midwives, with an initial programme for credentialing

- 3S .

Annex 3

midwives undertaken in September 2006 at the National University of Samoa. The process of credentialing provides an opportunity to demonstrate that clinicians have defined levels of education/training, experience and competence. While evaluation data collection is ongoing, successful implementation of midwifery credentialing has the potential to serve as a model for the further development of credentialing programmes in the Region. Greater emphasis on a regional partnership approach by both Pacific Island countries and external institutions may assist in reducing duplications, minimising gaps and strengthening educational opportunities for nurses and midwives across the Pacific.

67. Another important open-learning education programme is the Pacific Open Learning Health Net (POLHN). As a vehicle for online and distance learning, information technology has great potential in terms of cost-effectiveness and overcoming the high cost of providing traditional face-to-face teaching. The POLHN is4 0ne example of how information technology can increase opportunities for both continuing professional education and access to the latest health literature and best-practice repositories. Despite its potential, significant barriers such as the limited availability of hardware and software; limited computer literacy of health workers, the need for appropriate course content, as well as inadequate telecommunications bandwidth, need to be addressed before its potential can be fully realized.

68. The issues presented regarding post-basic education once again highlight the potentially significant role that could be played by improved coordination of human resources for health education programmes and greater collaboration between Pacific Island countries and external partners I donor organisations.

CONCLUSIONS

69. Analysis of the reports and literature reviewed, as well as survey data received, demonstrated a high degree of coherence between priority issues reported in the literature and those experienced currently in the Pacific Islands. Although significant work is in progress throughout the region, attention needs to be paid to the priority human resources for health needs and challenges in the Pacific Islands.

70. The strengthening of human resources for health in Pacific Island countries has major potential benefits for improved health outcomes. The evidence illustrates the importance of capacity building, as well as strengthened regional partnerships and infrastructures to more efficiently and effectively meet national health targets, health-related Millennium Development Goals, as well as to improve health service accessibility and quality in the region.

71. Important areas for intensified collaboration and interventions include: (1) health expenditures, health financing and the cost/benefit analYSis of alternative HRH workforce options; (2) HRH information, data and information management systems; (3) capacity for strategic planning and management of the workforce; (4) investments in education, educational programme and institutional resources, quality and standards, as well as ongoing staff development and skills to meet evolving and future population health needs; (5) workforce recruitment, distribution, composition and skill-mix, including the costs and implications of alternative models of service delivery; (6) performance management and evaluation; working conditions and environments and retention; and (7) leadership development; policy and regulatory frameworks.

RECOMMENDATIONS

72. It is evident that the development of a more harmonized, coordinated, regional partnership approach would strengthen the human resources for health capacity and health system effectiveness, as well as contributing to improved population health outcomes. The establishment of a Pacific coordinating body would serve to facilitate partnerships, promote communication between stakeholder groups, and more effectively

- 39 -

Annex 3

facilitate the implementation of human resources for health strategic plans, while recognizing the unique needs, geography and cultures of the island countries.

73. A number of options for the development of such a body could be considered, building on existing partnerships developed through the Asia-Pacific Action Alliance on Human Resources, the proposed Pacific Human Resources for Health Alliance and other networks and alitances. Establishment of a secretariat for the body could be facilitated by WHO, in collaboration with other partners and stakeholders. The effectiveness and ?utcomes of such a body would be facilitated through membership representing both an i5perational group from Pacific Island countries, regional organizations and networks, and a technical partners group comprising external partners and donor organizations . .

74. The functions of a coordinating body, subsequentto the formulation of agreed-upon goals with measurable outcomes and action steps, targeted at identified priority HRH strategic interventions, could include:

a. Establishing mechanisms for timely and accurate data collection and storage of information concerning disease burden; educational programs, workforce characteristics and regulatory profiles. The coordinating body could subsequently work as an information resource centre, promoting information sharing and communication between Pacific Island countries, donor organisations and external partners.

b. Monitoring, review and trend analysis of the Pacific human resources for health situation, including support to address workforce supply, composition and distribution, in particular, the geographical imbalance of the workforce, as well as coordinating mechanisms to address gaps in the its skill composition.

c. Evaluation of current and alternative models of service provision, assessing their effectiveness, accessibility and acceptability, as well as impact on health outcomes. Evaluation data could inform the planning of future health services.

d. Considering means of strengthening the education, deployment, supervision, support, retention and professional development of rural and remote health workers, including mid-level practitioners;

e. FaCilitating greater coordination and collaboration among educational institutions, national and regional regulatory bodies, education and health commissions and/or policy-advisory bodies to establish mechanisms for core curricular standards, course and programme recognition and/or accreditation, strengthened academic quality, innovation and interdisciplinary collaboration. Cross-border competency validation and registration, continuing professional development requirements and scopes of practice for advanced practice and/or speciality health practitioners are among matters requiring facilitation.

7&. The above recommendations, when implemented, provide the basis for coordinating HRH activities in the Pacific region. This coordination will reduce inefficiency and improve human resource development and management.