Mapping Human Resources for Health
Profiles from 15 Pacific Island Countries
Report to the Pacific Human Resources for Health Alliance From the Human Resources for Health Knowledge Hub April 2009
www.sphcm.unsw.edu.au
Contents
Acknowledgements ...... 3 Executive Summary ...... 8 Background ...... 11 Section 1: Human Resources for Health Country Maps ...... 14 Cook Islands...... 15 Federated States of Micronesia ...... 19 Fiji ...... 24 Kiribati ...... 27 Niue ...... 35 Palau ...... 39 Papua New Guinea ...... 42 Republic of the Marshall Islands ...... 45 Samoa ...... 48 Solomon Islands ...... 52 Tokelau ...... 55 Tonga ...... 59 Tuvalu ...... 65 Vanuatu ...... 68 Section 2: In-Country and Regional Education Institutions ...... 71 Section 3: External Partners Providing Assistance in HRH ...... 84 Discussion ...... 96 Conclusion and Recommendations ...... 98 References ...... 99 Appendices ...... 100 Appendix 1: Terms of Reference ...... 101 Appendix 2: Survey Questionnaire Instrument ...... 102
2 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Acknowledgements
The HRH Hub@UNSW wishes to thank all of the people of Pacific Health Ministries who have helped to progress this document. Thank you for your support, your time, and your valuable contributions. The HRH Hub particularly wishes to acknowledge the guiding support of Dr Ken Chen, Dr Juliet Fleischl, and Ms Monica Fong from the World Health Organization, Suva, Fiji. Special thanks to the project team in developing the mapping profiles: . Ms Jacqui Davison . Ms Michele Vanderlanh Smith . Associate Professor Rohan Jayasuriya . Associate Professor John Hall . Dr Augustine Asante (Ph.D) . Mr Alan Hodgkinson We also wish to thank Ms Lorraine Kerse, who provided technical review assistance, and would like to acknowledge the assistance provided by Ms Michelle Imison, Dr Angela Dawson (Ph.D), Ms Vanessa Traynor and Ms Waireti Amai.
If you would like to discuss any of the information in this report or find out more about the HRH Hub then please contact: Associate Professor John Hall, Director, email: [email protected] or telephone: 61 2 9385 8464 Vanessa Traynor, Manager, email: [email protected] or telephone: 61 2 9385 8459 For copies of the report contact Waireti Amai via email: [email protected] or telephone 61 2 9385 8464 or why not download a copy from our website: http://www.sphcm.med.unsw.edu.au/SPHCMWeb.nsf/page/HRHHub
The Human Resources for Health Knowledge Hub is funded through a grant from the Australian Agency for International Development (AusAID) under the Strategic Partnerships Initiative.
3 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Acronyms
AusAID Australian Agency for International Development
ADB Asian Development Bank
ADS Australian Development Scholarships
ARDA Anglican Relief Development Agency
BE Bachelor of Education
B Med Bachelor of Medicine
BN Bachelor of Nursing
CBR Certificate in Community Based Rehabilitation
CDC Centre for Disease Control and Prevention
CDU Charles Darwin University (Australia)
CEO Chief Executive Officer
Cert Certificate
CHIPs Community health Information Profiles
CHE Commission for Higher Education
CN Community Nursing
CPE Continuing Professional Education
CWM Colonial War Memorial Hospital
DAC Development Assistance Committee
DFaT Department of Foreign Affairs and Trade (Australia)
DfID Department for International Development (UK)
DHA Demographic Health Survey
DHS Department of Health Services
Dip Diploma
DoH Department of Health
DOTs Directly Observed Treatment, Short
DPH Diploma Public Health
EHW Environmental health Worker
EN Enrolled Nurse
4 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries FSM Federated States of Micronesia
FSMed Fiji School of Medicine
FSoN Fiji School of Nursing
FTE Full Time Equivalent
GDP Gross National Product
Gvt Government
HSIP Health Sector Improvement Program
HR Human Resources
HRH Human Resources for Health
HRD Human Resource Development
IMCI Integrated Management of Childhood Illness
INTV Institute National de Technologie de Vanua
IT Information Technology
JCU James Cook University (Australia)
JICA Japan International Cooperation Agency
KANI Kiribati-Australia Nursing Initiative
KANGO Kiribati Association of NGOs
KIR-EU Kiribati European Union Health Improvement Project
KSoN Kiribati School of Nursing
LDCs Least Developed Countries
LPNs Licensed Practical Nurses
MBA Master of Business Administration
MBBS Bachelor of Medicine, Bachelor of Surgery
MCH Maternal and Child Health
MDG Millennium Development Goal
M Med Master of medicine
MoE Ministry of Education
MoH Ministry of Health
MoU Memorandum of Understanding
MTS Medical Treatment Scheme
5 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries NA Nurse Anaesthetist
NCDs Non-Communicable Diseases
NDoH National Department of Health
NZRDS New Zealand Regional Development Scholarships
NGO Non government organization
NP Nurse Practitioner
NSA Non State Actors
NUS National University of Samoa
NZAID New Zealand Agency for International Development
NZ New Zealand
OGI Outer Gilbert Islands
OUMS Oceania University of Medicine Samoa
PacLII Pacific Islands Legal Information Institute
PBL Problem based Learning
PCC Palau Community College
PHC Primary Health Care
PHN Public Health Nursing
PHRHA Pacific Human Resources for Health Alliance
PICs Pacific Island Countries and Territories
PIP Pacific Islands Project (AusAID)
PIHOA Pacific Health Officers Association
PMU Project Management Unit
PNG Papua New Guinea
POLHN Pacific Open Learning Health Network
POHW Primary Oral Health workers
PPP Purchasing Power Parity
PPHSN Training in Communicable Disease Surveillance
PPTC Pacific Paramedic Training Centre (New Zealand)
PREPP Training on pandemic preparedness and outbreak investigation.
RAMSI Regional Assistance to the Solomon Islands
6 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries RMI Republic of the Marshall Islands
ROC Republic of China
RN Registered Nurse
SICHE Solomon Islands College of Higher Education
SIS Small Island States
SPC Secretariat of the Pacific Community (New Caledonia, Fiji)
SWAp Sector Wide Approach
UoA University of Auckland ( New Zealand)
UoG University of Guam
UoO University of Otago (New Zealand)
UN United Nations
UNFPA United Nations Population Fund
UNICEF United Nations Children's Fund
UNSW University of New South Wales (Australia)
UPNG University of Papua New Guinea
USA United States of America
USAID United States Agency for International Development
USP University of South Pacific
UTS University of Technology (Australia)
UT University of Technology (New Zealand)
VMSS Visiting Medical Specialists Scheme (NZAID Project)
WB World Bank
WHO World Health Organization
WPRO Western Pacific Regional Office (World Health Organization)
7 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Executive Summary
Human Resources for Health (HRH) are central to the performance of health systems. Limited HRH has been identified as a major obstacle to achieving the health-related MDGs. Health Ministers of Pacific Island Countries have committed themselves and their governments to implementing strategic measures to strengthen their national HRH capacities and address the varied health workforce challenges they face. The Pacific Human Resources for Health Alliance (PHRHA) is the regional body mandated to identify and implement strategies to strengthen HRH capacities in the Pacific. It brings together national governments, international agencies and other stakeholders in the health sector to address HRH issues of common concern in a unified manner. In their July 2008 meeting, the PHRHA member countries identified strengthening HRH data collection and information management systems as priority areas requiring collaboration. Consequently, the PHRHA secretariat in conjunction with WHO Western Pacific office contracted the Human Resources for Health Knowledge Hub at the University of New South Wales (HRH Hub@UNSW) to undertake a rapid mapping of HRH resources in Pacific Island countries. As specified in the Terms of Reference, the mapping exercise was to generate baseline data on the current HRH situation in the region, information on in-country and external education institutions involved in HRH development, and data on external partners providing HRH-related assistance. The study was undertaken between November 2008 and March 2009 using semi-structured questionnaire to gather data from PHRHA member countries. The data collection was undertaken mainly through telephone interviews and email communications. Fifteen (15) Pacific Island countries, all members of the PHRHA, participated in the study: Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Nauru, Niue, Palau, Papua New Guinea, Republic of the Marshall Islands, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu. Additional data was gathered from secondary sources to supplement the primary data obtained through the questionnaire. The key findings of the study include the following: 1. Variations in workforce data availability 2. Lack of disaggregated workforce data 3. Varied HRH data repositories 4. Limited continuing education and training resources 5. Limited coordination among external partners engaged in HRH support
8 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Variations in the availability of workforce data Marked variations exist in the availability of workforce data across the 15 countries studied. Countries like Tonga, PNG and Cook Islands had detailed workforce data including numbers of health personnel disaggregated by gender and age. By contrast, the majority of the countries had limited workforce data readily accessible. Data on recruitment and retention including incentive schemes designed to retain personnel were unavailable in many countries. Varied HRH data repositories Almost all the countries studied had varied HRH data repositories. The Ministries of Health had information on the number of personnel (nurses, doctors, dentist, etc.) currently working in the government health sector but knew very little about the education and training institutions and the annual turnover of health personnel of these institutions. Such information was largely held at the Ministries of Education and the various medical and nursing training institutions. Information on current vacancies was generally limited in all the countries. Lack of disaggregated workforce data There were significant gaps with regards to disaggregated data. Only five (Tonga, PNG, Cook Islands, Nauru and Niue) of the 15 countries studied had disaggregated workforce data by gender, age or nationality. Such disaggregated information is essential for effective workforce planning including planning for education and training. Limited continuing education and training development Limited continuing education, training and development of health professionals emerged as a key issue in the Pacific. There were wide variations across Pacific Island countries in terms of the existence and appropriateness of health worker education and training, as well as their type, frequency, coverage and quality. Limited coordination among external partners engaged in HRH support To enhance the impact and effectiveness of donor support to the PICs, it is essential that the support to be better coordinated as well as aligned to meet the goals and objectives of national HRH programmes /strategies of each country, with government taking the lead. Conclusion and Recommendations Most Pacific Island Countries have attempted to enhance their national health information systems, often with the support of partner agencies (i.e. SPC, WHO). However, the findings of this mapping exercise demonstrate that significant deficiencies in the collection, analysis, management and application of HRH data persist in many PICs. Additionally, there appears to be no systematic way of linking HRH information to policy-making at the national level. The main factors underpinning these deficiencies as evident in the study include: . Weak organizational support for data collection systems . Lack of standardization and coherence in attempts to improve health information systems . Decentralised/autonomous/fragmented systems in some countries . Limited capacity for data management and use of workforce data to guide policy making at the national level . Lack of coordination among external partners supporting HRH development
9 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries
Although not directly evident from the study, other factors such as inadequate collaboration between the Ministry of Health and other Ministries such as Education, Finance and the Public Services Commission appear to also constrain HRH data collection and management in the Pacific. On the basis of the above findings the following recommendations have been made:
RECOMMENDATION 1: That support be provided to countries to develop a standard and coherent system of health workforce information gathering. This should include a system of disaggregating workforce data by gender, age and nationality RECOMMENDATION 2: That countries be supported to develop one centralised HRH data repository that brings together data on all aspects of HRH including data on education and training resources as well as donor support for HRH development. RECOMMENDATION 3: That greater attention be paid to providing continuing education and training services/resources that contribute to the goals of building capacity and capability in HRH in the region. It is crucial that external donors support this engage adequately with Pacific Island Health Ministries in order to identify accurately their education and training needs. RECOMMENDATION 4: That donor support to be better coordinated as well as aligned to meet the goals and objectives of national HRH programmes/strategies, with government taking the leadership role. The primary value of this approach, builds on the efforts of The Pacific Plan, which provides a contextual framework for implementation of the key health Millennium Development Goals.
10 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Background
Human Resources for Health (HRH) play a pivotal role in strengthening health systems. Limited HRH is widely recognised as an impediment to achieving the health-related Millennium Development Goals (MDGs) (WHO 2006; UN 2008). Health Minsters of Pacific Island Countries have committed themselves and their governments to implementing strategic measures to strengthen their national HRH capacities and address the varied health workforce challenges they face. The key areas the ministers have agreed to focus attention include collation and use of reliable HRH data to inform policy, strengthening of effective health workforce planning and management systems, and scaling up education and training of the health workforce to meet current shortages. The Pacific Human Resources for Health Alliance (PHRHA) is the regional body dedicated to identifying and implementing strategic measures to strengthen HRH capacities in the Pacific region. It brings together national governments, international agencies and other stakeholders in the health sector. In July 2008 the PHRHA member countries identified HRH information management systems as a key priority area where collaboration is required to strengthen national health systems and accelerate progress towards achieving the health-related MDGs (Minutes of PHRHA Meeting 2008). The PHRHA Secretariat in conjunction with the WHO Western Pacific office drafted a Terms of Reference (refer to Appendix 1) establishing the basis for country resource maps that will identify gaps in the basic HRH data and tools used by regional Ministries of Health. The PHRHA and WHO envisaged that the country maps will be developed into comprehensive HRH profiles that could be used across the region to guide policy makers, development partners and other stakeholders identify key areas where investments in HRH are required. The University of New South Wales Human Resources for Health Knowledge Hub (HRH Hub@unsw) was contracted to undertake, between November 2008 and March 2009, HRH resource mapping that will produce baseline data on current HRH situation in the PHRHA member countries. This report presents HRH maps based on situation analysis in fifteen Pacific Island countries (Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Republic of Marshall Islands, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Islands, Tonga, Tuvalu, Tokelau, Vanuatu). The findings are presented in three inter-related sections: . SECTION 1 Baseline data on current HRH situation across the region – Country . SECTION 2 In-country and external education institutions assisting in HRH development . SECTION 3 External partners providing HRH assistance
11 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Method A pragmatic and flexible approach was adopted for this study. Previous Hub work including a literature review of HRH profiling methodology provided a foundation for this task. The timeframe and resources allocated to this study for the PHRHA required that data be collected from Ministries of health via telephone, fax and email. A questionnaire tool was deemed most appropriate. Data was collected over a 3 month period and compiled in an excel spreadsheet. Additional supportive data was collected in some cases. Progress was monitored through regular team meetings and the report was collaboratively complied. The Questionnaire The semi-structured questionnaire developed for this study was designed to capture quantitative workforce data as well as narratives concerning retention and incentives, legislation related to practice, workforce planning initiatives, education and training and donor activity. This covers the three components of the study specified in the Terms of Reference: baseline information on current HRH situation, information on education and training resources, and external partners providing assistance in HRH development. The questionnaire was 10 pages long and had three workforce tables, a training activity table, and external partners providing HRH assistance (Appendix 3). The questionnaire was developed using standard occupational cadres and indicators specified by WHO and reviewed by technical experts and modified accordingly before use. Data collection The questionnaire was primarily administered through telephone interviews and email exchanges with PHRHA Country Focal Points and representatives of the Ministries of Health (see list of participants – Appendix 2). The list of PHRHA Country Focal Points was provided by WHO (Suva). The questionnaire was initially distributed to the Focal Points, together with an explanatory letter from the HRH Hub. Follow-up telephone interviews were then conducted to complete the questionnaire. Some participants chose to complete the questionnaire independently and returned by email, rather than completing it over phone. In such instances, follow up calls were made to clarify the responses provided. In addition to the primary data gathered through the questionnaire, data were also collated from secondary sources. These were mainly data on education and training resources available in-country and externally. The four main documents from which these data were collated are: . Human Resources for Health in Pacific Island Countries – A Situational Analysis, University of Western Sydney 2007 . Situational analysis of mental health needs and resources in Pacific Island Countries, University of Auckland NZ, 2005 . HRH Training in Pacific Island Countries-PNG, Samoa, and Fiji. Asia-Pacific Action Alliance on Human Resource for Health, 2008 . Expanding the Professional Healthcare Education Resources in Pacific Countries, Hezel Associates, 2001 Data were also collated from a CD Rom provided to the HRH Hub by WHO (Suva) containing various documents of recent studies on HRH in the Pacific region. Data to address the third component of the study i.e. donors involved in HR capacity building and donor fund flows, was
12 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries obtained from the country questionnaires (as outlined above), and through contact with development agencies – AusAID, NZAID, SPC, WHO etc, either directly of via their websites. The data (both primary and secondary) were gathered over the period of four weeks. In line with the Terms of Reference (TOR) of the contract, the data were not analysed. Data collation and presentation The questionnaire data was compiled into an excel spreadsheet and then checked against the questionnaire. The quantitative data was presented in a series of tables for presentation in this report and additional information sourced from documents listed above were added to the narrative.
13 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries
Results Section 1: HRH Country Maps
14 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Cook Islands
Cook Islands has a population of 21 000, spread across 15 islands and atolls with a total land area of 241 square kilometres. About 90% of people in the territory are Cook Island Maoris and the country is predominantly Christian. Cook Islands is a self-governing parliamentary democracy in „free association‟ with New Zealand. The Cook Islands has limited natural resources and a shortage of skilled labour due to the continuous emigration of skilled workers to New Zealand. Isolation and a dependence on government-generated economic activity and employment provide further constraints on development. Cook Islands‟ relatively high income per person (in 2005 the estimated GDP per capita (PPP) was $9100) reflects the impact of expatriate residents, close alignment to New Zealand remuneration scales and the tourist-based economy of Rarotonga. Disparities between the Main Island and outer islands in relation to access to healthcare reflect differences in the health workforce. During recent years, the Ministry of Health has concentrated on providing sufficient general practitioners to provide health services in the outer islands. Whilst four islands (Pukapuka, Penrhyn, Mitioro and Rakahanga) have health officers they do not have a resident doctor. Workforce Data Table 1a describes the distribution of the health workforce by occupation and gender and includes the number of non-nationals in each occupational category. Gender specific data is current for 2009. Data on midwives and nursing personnel is aggregated. Table 1.a Distribution of health workforce occupation by gender and number of non-nationals
Occupation Number male female Total non-nationals Physicians 17 7 24 10 Nursing and Midwifery Personnel 3 113 116 8 Dentists 4 0 4 0 Dental technicians/assistants 6 9 15 0 Pharmacists 1 0 1 1 Pharmaceutical technicians/assistants 4 3 7 0 Laboratory scientists 2 4 6 0 Laboratory technicians/assistants 0 1 1 0 Radiographers 2 0 2 1 Environmental Health Workers 0 1 1 0 Public Health Workers 19 3 22 0 Community health workers 2 7 9 0 Medical Assistants 1 1 2 0 Personal Care Workers - - - - Other health workers 29 43 72 1 Health management workers 5 13 18 0 TOTAL 95 205 300 21
15 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries It was reported that expatriates (non-Cook Islander residents) working with the MoH, were most likely to be senior medical officers and nurses, predominantly from Fiji. The current anaesthetist is from the Solomon Islands. Table 1.b describes the distribution of the health workforce by occupation and age group. Over half of the workforce (59.8%) fell in the 30-49 years age group, 18.6% in the 0- 29 group and 21.6% were in the 50+ group. Table 1.b Distribution of health workforce occupation by age group
Occupation Age group (in years) Number 0-29 30-49 50+ Total Physicians 3 12 8 23 Nursing and Midwifery Personnel 22 67 27 116 Dentists - 1 3 4 Dental technicians/assistants 7 9 0 16 Pharmacists 0 0 1 1 Pharmaceutical technicians/assistants 3 4 0 7 Laboratory scientists 0 5 1 6 Laboratory technicians/assistants 1 0 0 1 Radiographers 1 1 0 2 Environmental Health Workers 0 1 0 1 Public Health Workers 7 12 3 22 Community health workers 0 8 1 9 Medical Assistants 0 2 0 2 Personal Care Workers - - - - Other health workers 9 48 15 72 Health management workers 3 10 6 19 TOTAL 56 180 65 301
The current vacancy rate (March 2009) is 5.3% of the total health workforce (n=301), or 16 full time equivalent (FTE) positions - 6 physicians, 5 nurses, 1 dentist, 1 theatre technician, 1 Environmental Health Officer, 2 support staff. Workforce Retention and Incentives The key incentive provided for health workers is training support. This includes payment of full salary for training under 12 months (or a base salary level if training is over 12 months) for Ministry of Health employees. Following graduation, employees receive an increase in their salary increment level. Reimbursement of course fees, for those not on a scholarship, is available if employees graduate with at least a „B‟ grade average and the course is deemed relevant to their area of work. Professional Registration and Legislation No national legislation outlining scopes of practice for health workers is currently in place, however health workforce standards are contained in the draft national HRH Plan. It is expected that the
16 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries standards will be finalised once the plan itself is endorsed. A Nursing Code of Practice already existed, but it was unlikely to be a legislated code. Professional registration is under review. The Medical and Dental Board of the Cook Islands currently registers physicians and dentists only, while the Cook Islands Nursing Council registers professional nurses and midwifes. The MoH has sought approval from NZAID to fund a consultant to assist in the establishment of an overarching Health Professionals‟ Council, which will include all health professionals. Planning A ten year Human Resources for Health Development Plan has been developed and will be endorsed by the Minister of Health by June 2009 for implementation from July 2009. The MoH also meets with the following central agencies to improve yearly health sector planning: . National Human Resources Department to determine numbers for in-country scholarships, short-term training attachments, Government scholarship recipients, student assistance fund eligibility . Public Service Commission to discuss employee numbers and job sizing for future year(s) . Ministry of Finance & Economic Management regarding payroll, bulk funding, capital expenditure items and yearly budgets Current Donor Support HRH-related support includes: . WHO Fellowships (2009 biennium) – MBBS, Pharmacy Technician, Bachelor of Dentistry, Masters in Surgery, Medical Intern trainee at CWM; Primary Oral Health workers (POHW) . POHLN – distance online learning . Pacific Paramedical Training Center in Wellington, NZ – upgrading the skills of 2 or 3 laboratory scientists . UNFPA – Midwifery Certificate, Reproductive Health (WHO) . Cook Islands Nursing School – Diploma in Nursing . NZAID In Country Training – Nurse Practitioner Training Program . NZAID Scholarships – Dietetics & Nutrition . NZAID short-term training attachment - Ophthalmology . Cook Islands Government Scholarship Scheme – USP courses (finance, management including MBA) . Fred Hollows Foundation – Diploma in Ophthalmology Education, Training and Development Activities The Cook Islands School of Nursing offers a 3 year Diploma in Nursing, funded by the Cook Islands Government, which provides Registered Nurses for the country. There are approximately 20 prospective applicants per year, with 12 nurses graduating in 2008. There is also a Nurse Practitioner course based at the Nursing School for graduate nurses, which is funded by NZAID. This 9-month course produces local graduates with on-the-job training at the central hospital (and on selected outer islands) with a theoretical underpinning. There is also a local, 1 year Dental Training program, which produces Dental Practitioners. Curriculum review dates or modes of teaching of these courses are not known. MBBS, Bachelor of Pharmacy, and Bachelor of Dentistry courses are run through the Fiji School of Medicine, while the Pacific Paramedic Training Centre (PPTC)s used to up skill laboratory
17 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries scientists, usually in 1 to 3 months courses. WHO and NZAID provide support for Cook Island trainees at these institutions, respectively. Sources of Data Initial data regarding planning, legislation and professional registration was collected via a self- completed questionnaire which was emailed to key informants, and follow-up information was collected via telephone. Workforce data was retrieved from the Cook Islands Health Information System, March 2009, whilst demographic and economic data were sourced from the AusAID country program website for Cook Islands and the DFAT Country Information websites [9 March 2009].
18 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Federated States of Micronesia
The Federated States of Micronesia (FSM) consists of 607 mountainous volcanic islands and coral atolls in four major island groups across 1 million square miles in the northern Pacific Ocean. FSM‟s scattered population numbers about 120 000 (2008) and is composed largely of ethnic Micronesians. The country‟s age profile is very young, with the median age of both men and women around 20 years. Growing urbanisation and a decline in subsistence production have increased the population density in each of its four state capitals - Chuuk, Kosrae, Pohnpei and Yap. Whilst the population shows continuing susceptibility to both communicable and non-communicable diseases, citizens enjoy a relatively high level of health care in comparison to the rest of the Pacific region. Large-scale unemployment and reliance on US aid, the levels of which are decreasing under the terms of the Compact of Free Association with the USA, are the two greatest economic vulnerabilities. The Division of Health of the National Department of Health, Education and Social Affairs does not have a direct role in the provision of health services. The Department of Health Services (DHS) in each of the four States has primary responsibility for curative, preventive and public health services. This responsibility includes the main hospital, peripheral health centres and dispensaries (primary health centres). Only residents of urban centres have direct access to the main hospital in each State, with transportation issues often preventing residents who live on the outer islands from accessing hospital care. Workforce Data Table 1.a on the following page reports available data on the distribution of the health workforce by occupation. Neither gender nor age-specific data was available. Data on the number of non-nationals for each occupational group was also unavailable at the time of data collection, however it should be noted that there is a decreasing reliance on US doctors and specialists as more FSM-born doctor‟s graduate and are employed by the FSM government (WPRO CHIPS 2008 FSM).
19 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1.a Distribution of health workforce by occupation
Number Occupation male female total non- nationals Physicians - - 64 - Nursing Personnel - - 264 - Midwifery Personnel - - 16 - Dentists - - 14 - Dental technicians/assistants - - 26 - Pharmacists - - 0 - Pharmaceutical technicians/assistants - - 16 - Laboratory scientists - - 0 - Laboratory technicians/assistants - - 33 - Radiographers - - 16 - Environmental Health Workers - - 40 - Public Health Workers - - 393 - Community health workers - - 31 - Medical Assistants - - 8 - Personal Care Workers - - 0 - Other health workers - - 93 - Health management workers - - 43 - TOTAL - - 1057 -
Whilst data on current vacancy rates are not available, the number of expected vacancies in each cadre for the next 7 years are described in Table 1.b on the following page. These expected vacancies are derived from the FSM Health Workforce Development Plan 2000-2019.
20 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1.b Number of expected vacancies for the next 7 years
Occupation Number Vacancies Physicians 10 Nursing Personnel 40 Midwifery Personnel 12 Dentists 4 Dental technicians/assistants 8 Pharmacists 8 Pharmaceutical technicians/assistants 0 Laboratory scientists 8 Laboratory technicians/assistants 0 Radiographers 8 Environmental Health Workers 8 Public Health Workers 8 Community health workers 20 Medical Assistants 4 Personal Care Workers 20 Other health workers 20 Health management workers 4
Workforce Retention and Incentives The following incentives and conditions are available for public sector employees in the FSM Division of Health or State-based Divisions of Health: (i) an employment MOU that guarantees a job immediately after completing their training; (ii) increased annual leave and home leave (as compared with other public sector employees; (iii) merit-based increment increases; (iv) increased professional development or continuing education (short courses or workshops) as compared with other public sector employees. Professional Registration and Legislation The FSM Legislative Code (1997) and its amendments, provides for the licensing of medical officers, dentists, optometrists and pharmacists (FSM Code 1997 § 201-213). Nevertheless, the FSM informant advised there is a range of licensing mechanisms operating in FSM, possibly due to the FSM Compact of Free Association with the USA. The informant listed the current licensing boards below.
21 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 2. Workforce Occupation by Registration Board
Occupation Registration Board System of governance/ delegated authority for registration Physicians Yes/Licensure Board Medical Association/PBMA Nursing and Midwifery Personnel Yes/Licensure Board APNLC/FSM Nursing Act Pharmaceutical Personnel Licensure for Importation* International Treaty on CS Dentistry Personnel Yes Dental Association Laboratory Health Workers Yes PACT Environment and public health workers Yes EPA/SPREP Other Health Workers Yes Public Service System Community & traditional health workers Yes Public Service System Health management and support workers Yes Public Service System
Planning FSM utilises a range of planning tools, in particular the FSM Health Sector Strategic Development Plan, the WPRO Regional Strategy on HRH 2006-2015, the Nahlap Action Plan, Licensure Development Plan, COM-FSM Public Health Program Proposal, COM-FSM Nursing Program Proposal and PACT Plan for Continuing Education Program. In addition, consultation around the development of a FSM HRH Development Plan has recently been supported by the Pacific Health Officers Association (PIHOA) through the World Health Organization. Regular meetings are held between the FSM Department of Health and Social Affairs and other agencies, including Financial Year Budgetary meetings with Department of Finance and FSM Congress, annual budget review with the Executive Budget Review Committee, Cabinet meetings on National Health issues on a periodic basis and annual Audit Finding meetings with the Public Auditor. Current Donor Support
HRH-related support includes: . WHO Fellowships (2009 biennium) – At various countries, including Japan, Malaysia, Korea, Philippines etc . POHLN – distance learning . AusAID - support a selection of students at Fiji School of Medicine, especially from Kosrae State FM (3-4 students currently in Fiji School of Medicine studying MBBS, pharmacy, nursing) Education, Training and Development Activities Local on-the-job training exists for health assistants for dispensaries (rural health centre) in remote villages and outer islands, community health DOTs workers (for TB and Leprosy), community mental health outreach workers (counsellors) and program coordinators and managers. The majority of the health workforce are trained at the following regional institutions: University of Hawaii, Fiji School of Medicine, New Zealand universities, University of Guam, various universities in the USA mainland, CDC, Atlanta, Palau Community College, Republic of Palau and Republic of Marshall Islands Nursing School. The Department of Health and Social Affairs have put forward a proposal to
22 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries initiate two health practitioner training programs at the College of Micronesia located in FSM. This proposal is drawn from the current National Health Sector Plan and the four state health plans. A Certificate in Public Health to train public health workers is the most advanced, where it is proposed that the College could manage a yearly intake of 30 students funded by donors, government traineeships, WHO and individuals themselves. A similar local nursing program proposal is at an early stage of development. Sources of Data Workforce data was provided by the FSM Department of Health and Social Affairs, demographic and economic data was sourced from the DFAT and AusAID Country Information websites [9 March 2009] and health systems data from WHO/WPRO 2008 CHIPs for Micronesia, available at http://www.wpro.who.int/countries/2008/mic/. All other data reported here was collected via telephone interview with key informants with email follow up where required. The Medical Licensing section of the 1997 FSM Legislative Code is Title 41. Public Health, Safety and Welfare - Chapter 2 Health Services Personnel (§201-213) and can be accessed via PacLii or directly via http://fsmlaw.org./fsm/code/index.htm
23 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Fiji
Fiji comprises 332 islands and coral atolls, about 110 of them inhabited, located in the South Pacific Ocean. It has a population estimated at 931 741 (July, 2008), just over half of whom are Fijian and around a third of whom are Indian. Fiji enjoys a relatively high income level compared with neighbouring Pacific island countries (in 2008 the per capita GDP was estimated at $3,700), a skilled and educated workforce and a well-developed private sector. It is not aid-dependent (total donor aid to Fiji is around 2.4 per cent of GDP) and tourism, sugar, clothing and mining are among its main export industries. Though access to health and education is reasonably good by Pacific standards, the quality of services is poor, particularly outside urban areas (AusAID, Fiji Country Profile). Health sector reform during the early 2000‟s led to the restructuring of health management services with a move to decentralised health service delivery. Health services are delivered through 900 village clinics, 124 nursing stations, three area hospitals, 76 health centres, 19 sub-divisional medical centres and three divisional hospitals and three speciality hospitals, with TB, leprosy and medical rehabilitation units at Tamavua Hospital and St Giles Mental Hospital. Increasing demand for services has led to an expansion in the number of private general practitioners and specialists practising in Fiji under the Fiji Medical Council. Despite MoH commitment to the promotion of a healthy population and a well-financed health system, maintenance of health infrastructure remains a challenge and the non-communicable disease burden in Fiji continues to grow (WPRO Fiji 2008 CHIPs). Workforce Data Table 1a on the following page describes the distribution of the health workforce and number of vacancies by occupation. Gender specific and age specific data is unavailable. Vacancy rates vary widely across occupational categories, with the highest evident in the Health Management category (21%, n=70) and the lowest amongst Environmental Health Workers (0.8%, n=1).
24 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1a. Distribution of health workforce and number of vacancies by occupation
Occupation Number filled vacancies positions positions (%) available Physicians 372 24 (6.1%) 396 Nursing and Midwifery Personnel 1957 147 (7.0%) 2104 Dentists and Dental technicians/assistants 171 30 (14.9%) 201 Pharmacists and Pharmaceutical technicians/assistants 76 8 (9.5%) 84 Laboratory scientists - - - Laboratory technicians/assistants 125 9 (6.7%) 134 Radiographers (incl. x-ray technicians) 56 9 (13.8%) 65 Environmental Health Workers 118 1 (0.8%) 119 Public Health Workers - - - Community health workers - - - Medical Assistants - - - Personal Care Workers - - - Other health workers (incl. social welfare, domestic, bio- 124 21 (14.5%) 145 medical technicians, OT, physio and dieticians) Health management workers (Exec., IT, Admin, Finance etc) 264 70 (21.0%) 334
TOTAL 3263 319 (8.9%) 3582
Workforce Retention and Incentives Medical, nursing and allied health professionals employed by the public sector in Fiji are eligible for a „country allowance‟ if they work in a rural area. Doctors are also offered an on-call allowance if they work in a rural or remote area. In these locations housing is also provided. Public and private sector doctors are allowed to undertake locum work, with some doing up to 20 hours per week in hospitals. One of the most significant issues facing Fiji‟s health workforce is the emigration of skilled health professionals from the public sector to the private sector, tourism operations or other countries in the region. The Ministry of Health has developed a strategic plan focussed on retention strategies to (S.Tagilaga, 2005). Professional Registration and Legislation The Fiji Medical Council regulates all doctors and dental officers who work in-country. The Nurses, Midwives and Nurse Practitioners Board deals with nursing registration, under the Nurses and Midwives Act (1982). The Nurses Board provides a framework of practice, but this is not legally binding. Allied health workers have their own individual association which functions like a union, and are not covered by any legislation. A bill to support the registration of pharmacists, the Pharmacy Professions Bill (2006), has been drafted, but is yet to be endorsed by Cabinet. Laboratory technicians and other support personnel have a Code of Conduct from the Public Service Commission, whilst traditional practitioners are not governed by any legislation. Planning Fiji has a National Health Workforce Plan - 1997-2012. The plan is yet to be fully implemented due to resource constraints and has been under review for some time. The Ministry of Health's National
25 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Strategic Plan 2007-2011 has a specific theme on the retention of skilled workforce with calls for the “Development and retention of a valued, committed and skilled workforce to enhance the delivery of quality health services” (2007). The MoH meets regularly with other Ministries - Health and Finance meet around June each year to plan the following year's budget. The Corporate Services Division meets with the MoH‟s Deputy Secretary, the Public Service Commission and Finance, specifically regarding HRH. Current Donor Support WHO support to the Ministry of Health in developing biennial budgets. In the latest round, the Ministry has requested technical assistance in the development of policy, staffing, planning, etc. Clinical training - Several Medical officers and nurses are currently training overseas - some are studying paediatrics with AusAID support, some are undergoing management training with Korean assistance. Education, Training and Development Activities Fiji is a major regional training provider in the South Pacific, helping to meet not only its own human resource training needs but also those of its neighbours. Nurses are trained locally at either the Fiji School of Nursing (a government institution which offers a three-year diploma program) or the Sangam Nurse Training School (which produced its first cohort of 48 graduates last year). In addition, nurses can complete a Bachelor‟s or Masters Degree through James Cook University. Midwives also train through the Nursing School, as well as in Tonga and Western Samoa. Many NGOs provide assistance for community health worker training and the MoH trains village health workers. Undergraduate training for medical officers is offered at the Fiji School of Medicine (FSMed), which also provides instruction for dieticians, physiotherapists, laboratory technicians and radiographers. In May 2009 the FSMed will undertake a regional consultation and needs analysis process with various stakeholder groups. The Umanand Prasad School of Medicine at the University of Fiji is based in Lautoka and is in the second year of offering a six year undergraduate entry medical program. Its first intake in 2008 was 40 students. The MBBS course is based on a traditional curriculum with the pre clinical sciences taught in the early years before moving onto the clinical sciences in the latter years of the program. The main teaching hospital is Lautoka Hospital which had previously been a FSMed teaching hospital. All students in the program have been offered scholarships by the Fiji Government. Information on other local training programs for Community Health Workers, Public Health Officers, Nurse Assistants is unavailable. Sources of Data Workforce data was sourced from the Health Planning and Infrastructure Development department, Fiji Ministry of Health. Gender and age-specific was unavailable at the time of collection. Information on planning, legislation, professional registration and training was collected via telephone interview, with follow-up information via email Demographic and economic data was sourced from the DFAT and AusAID Country Information websites [March 11 2009]. Health situation and system information was obtained from the WPRO CHIPS 2008 Fiji profile, accessed at http://www.wpro.who.int/countries/2008/fij/national_health_priorities.htm Fiji Medical and Dental Practitioners Act 1978 accessed Pacific Islands Legal Information Institute on 20 March 2009 at http://www.paclii.org/fj/legis/consol_act/madpa281/ Fiji Nurses and Midwifes Act (amended 1982) was also accessed at PacLII http://www.paclii.org/fj/legis/consol_act/nama223/
26 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Kiribati
Kiribati is composed of three island groups in the Pacific Ocean that straddle the Equator. It is made up of 33 mostly low-lying coral atolls surrounded by extensive reefs, of which 21 are inhabited. The low level of some of the islands makes them sensitive to changes in sea level and vulnerable to cyclones. Kiribati gained its independence from the UK in 1970 and is now governed by a 46-seat unicameral parliament. In July 2008, Kiribati‟s population was estimated at around 110 000, 99% of them Micronesian with a median age 20.6 years and life expectancy of about 63 years. Kiribati has few natural resources and is one of the least developed Pacific Islands, with GDP per capita estimated at $3700 per person (2008). Economic development is constrained by a shortage of skilled workers, weak infrastructure and remoteness from international markets. Private sector initiatives and a financial sector are in their early stages. Foreign financial aid from the EU, UK, US, Japan, Australia, New Zealand, Canada, UN agencies and Taiwan accounts for 20-25% of GDP. Kiribati receives around $15 million annually for the government budget from an Australian trust fund and another $5 million as remittances for seamen on merchant ships abroad. Kiribati is still categorised as a Least Developed Country (LDC) by the UNDP. Kiribati has a well-established health system - a national referral hospital in South Tarawa, a surgical and maternity level hospital on Kiritimati Island and two smaller basic hospitals, followed by a primary health care network that consists of 92 health centres of varying capacity and usually headed by a medical assistant/nurse. There has been a steady improvement in key health indicators over the last decade, however the country faces the double burden of disease, with high rates of communicable disease (especially TB and diarrhoeal disease) accompanied by increasing rates of non-communicable disease. A parallel traditional health system exists offered by traditional healers, providing pregnancy and childbirth services, local medicines and massage. Most of the population use both formal and traditional health services. Workforce Data Table 1. Details the distribution of the health workforce by occupation for the year 2008. Gender and age specific data was unavailable.
Table 1 Distribution of health workforce by occupation 2008 Occupation Number of staff Physicians 25 Nurses and Midwives (Health Assistants incl.) 361 Dentists and technicians 18 Pharmacists and technicians 22 Environmental & public health workers (health promotion) 13 Laboratory technicians 27 Other health workers 34 Community health workers 0 Administrative and support staff 32 Nursing School staff (lecturers etc) 20 TOTAL 552
27 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Workforce Retention and Incentives Data not reported/unavailable Professional Registration and Legislation The Kiribati Medical Council and Nursing Council act as controlling authorities for the registration and discipline of medical practitioners; dentist; nurses and members of para-medical services, and for connected purposes. The principle objective of this Act is to enact one comprehensive Medical Services Act which governs and controls all medical services in Kiribati. Planning The Ministry of Health works within a comprehensive framework for policies, plans and legislation, the implementation and enforcement of which is variable. The Government has introduced an annual performance-based planning process that requires all line ministries to develop annual output-based operational plans known as Ministry Operational Plans (MOPs). The strategic objectives set out in the national Development Plan for the period 2008-2011 guide the formulation of the Ministry of health‟s annual operational plans. The overall goal of the Ministry of Health, as stated in the National Development Plan 2004-2007, is “Continuous improvement in the provision and delivery of preventative and curative health services and equitable distribution of the benefits attained nationwide through effective and efficient allocation of scarce resources and good governance (accountability and transparency)”. The Ministry is in the process of completing its sector wide plan for the period 2008 to 2011) to focus its attention and coordinate donor support to achieve this goal. Current Donor Support The Ministry of Health receives significant technical and financial support from development partners. WHO provides funding and technical support to: epidemic alert and response; HIV care and treatment; health promotion, including tobacco control; environmental health; essential health technologies and medicines; health information; and health system development. UNFPA supports reproductive health activities and UNICEF supports the expanded programme on immunization, nutrition and infant feeding, and IMCI. The South Pacific Community supports the control of tuberculosis, HIV/STIs, noncommunicable diseases, disease surveillance and pandemic preparedness. Considerable support is also provided by the Australian Agency for International Development, the New Zealand Agency for International Development, and the governments of Cuba and Taiwan (China). Like other countries in Oceania, Kiribati is a beneficiary of Cuban medical aid and resources. There are currently sixteen doctors providing specialised medical care in Kiribati, with sixteen more scheduled to join them [1]. Cubans have also offered training to I-Kiribati doctors [2]. Cuban doctors have reportedly provided a dramatic improvement to the field of medical care in Kiribati, reducing the child mortality rate in the country by 80%.[3] As of September 2008, twenty I-Kiribati were studying medicine in Cuba, their expenses paid for by Cuba, and more may join them as Cuba increases the number of scholarships provided to Pacific Islander medical students.[4]
28 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Kiribati-Australia Nursing Initiative (KANI) The KANI is a 5-year pilot, Australian Government Funded, program designed to contribute to Kiribati government‟s effort to address rapid growing population, urbanization and youth unemployment through emigration of skilled labour and advancement of nursing care services. The objectives of the KANI therefore is to: . Educate and skill the I-Kiribati youth to gain Australian and International employment in the nursing sector . Upgrade nursing education in Kiribati to reduce the cost and period required to gain internationally accepted qualification offshore The European Union (EU) has allocated Euro 8.8 million for the project “Improvement of Health Services on the Outer Islands” The grant is divided into two parts. Euro 7.7 million is to be provided through FSM for the KIR-EU Health Project. An amount of Euro 880,000 has also been allocated to Non-State Actors (NSA) and will be managed through the Kiribati Association of NGOs (KANGO). The overall objective of the Project is to improve the living conditions on the Outer Gilbert Islands (OGI) in a sustainable manner, through increased access to primary health care (PHC). The Project purpose is to provide Kiribati inhabitants, in the OGI, with improved quality of PHC services with a view to increasing acceptance and utilization of health facilities. Education, Training and Development Activities The Ministry of Health has a workforce training plan to guide the awarding of overseas fellowships, but there is not systematic process in place to ensure the ongoing competency of health workers, and no routine clinical supervision or support. Absenteeism and attrition is through to impact on productivity, and staff motivation is reported to be a human resource management problem. The nursing staff in Kiribati has lately received training in priority areas as identified by a situation analysis conducted on serving staff and sanctioned by the Ministry of Health & Medical Services through funding of the Health Improvement project by the European Union. The training is provided by the Fiji School of Medicine and the University of the South Pacific as well as locally facilitated ones as detailed below: IMCI . Post basic Public Health . Post basic Midwifery . Fiji School of Medicine RHTP . Primary Trauma Care . Health Service Management . Post Graduate Certificate in Health Service Management . Post Graduate Diploma in Public Health University of the South Pacific . Post Graduate Certificate in Tertiary Teaching
29 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Sources of Data Demographic and economic information was sourced from DFAT and AusAID Country Profiles. Kiribati health system and disease burden information is sourced from WPRO CHIPS 2008 for Kiribati, accessed at http://www.wpro.who.int/countries/2008/kir/national_health_priorities.htm
1. "Six More Cuban Physicians To Serve In Kiribati”, Pacific Magazine, October 1, 2007 2. "Kiribati discusses medical training with Cuba,” Radio New Zealand International, September 6, 2006 3. "Cuban doctors reduce Kiribati infant mortality rate by 80 percent", Radio New Zealand International, July 19, 2008 4. "Small Island States and Global Challenges", Cuban News Agency, September 30, 2008
30 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Nauru
Nauru is a single-island nation with an estimated population of 13 770 (July 2008). Fifty eight per cent are Nauruan. The country gained independence in 1968 following a period of rule under a UN trusteeship. Nauru‟s primary export is phosphate but these deposits are now significantly depleted, and maybe completely exhausted by 2010. Most commodities are imported, mainly from Australia. Income from phosphate mining is directed to the country‟s trust funds, which were established as a means of anticipating and managing the predicted decline in mining. These funds however have now been heavily drawn down. As a result the government has been forced to freeze wages and reduce public service staffing. Nauru lost further revenue in 2008 with the closure of Australia‟s refugee processing centre, making it heavily dependent on imports and foreign aid. The decline in Nauru‟s economy over the past 15 years has had a impact on population health. The Nauru National Development Strategy (2005-2025) states that: Decreasing financial resources has led to a sharp drop in the provision of basic health services. Policies, programs and projects are inadequate and regulations are largely ineffective. Limited programs to prevent malnutrition exist and implementation is weak. There are limited standards and epidemiological information available. Limited funding is available for preventative and curative services. Public resources do not achieve intended goals; especially community education. A growing proportion of the population cannot afford the financial burdens of illnesses including the care of women and children. (p. 19) Nauru is reported to have the poorest health indicators for NCDs (cardiovascular disease, diabetes, cancer and respiratory diseases) in the Pacific region. Other health-related development priorities for Nauru are stated as the provision of a reliable supply of clean water, governance and policy reforms, and improved human resource development. The key vehicle for health care service delivery remains the Nauru General Hospital. Workforce Data Gender disaggregated data for Nauru, dated 2009, is available and provided below.
31 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1.a. Distribution of health workforce occupation by gender and number of non-nationals Occupation Number male female total non-nationals Physicians 9 1 10 9 Nursing and Midwifery Personnel 5 94 99 7 Dentists 1 - 1 1 Dental technicians/assistants 2 - 2 - Pharmacists - - 0 - Pharmaceutical technicians/assistants 4 3 7 - Laboratory scientists - - 0 - Laboratory technicians/assistants 2 3 5 - Radiographers 1 1 2 2 Environmental Health Workers 5 - 5 1 Public Health Workers 2 3 5 - Community health workers - - 3 - Medical Assistants - - - - Personal Care Workers - - - - Other health workers 9 7 16 1 Health management workers 3 12 15 3 TOTAL 43 124 170 24
The workforce data for Nauru demonstrates a reliance on highly skilled staff from other countries. This includes physicians, radiographers, dentists and pharmacists. These non-nationals are predominantly from Fiji, Tuvalu, Tonga and Burma. There have been long-term difficulties filling the pharmacist position on Nauru. In contrast most nurses and health management workers are Nauruan. The workforce is predominantly female.
Table 1.b Distribution of health workforce occupation by age group Occupation Number male female total non-nationals Physicians 17 7 24 10 Nursing and Midwifery Personnel 3 113 116 8 Dentists 4 0 4 0 Dental technicians/assistants 6 9 15 0 Pharmacists 1 0 1 1 Pharmaceutical technicians/assistants 4 3 7 0 Laboratory scientists 2 4 6 0 Laboratory technicians/assistants 0 1 1 0 Radiographers 2 0 2 1 Environmental Health Workers 0 1 1 0 Public Health Workers 19 3 22 0 Community health workers 2 7 9 0 Medical Assistants 1 1 2 0 Personal Care Workers - - - -
32 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Occupation Number male female total non-nationals Other health workers 29 43 72 1 Health management workers 5 13 18 0 TOTAL 95 205 300 21
The majority of nurses, physicians, laboratory workers and health management workers are in the middle age bracket, while the radiographers are both recently qualified. Despite the number of unreported ages 45% of staff across all groups are aged between 30-49 years. The recorded vacancies in the health workforce in March 2009 included four physicians, one dentist, three pharmacists, four health management workers and four other health workers. No nursing or midwifery personnel positions are currently vacant. Workforce Retention and Incentives The Nauruan MoH reported that expatriate health professionals (doctors, nurses and allied health staff) are on a higher salary scale than other expatriates in other departments, and are paid tax-free. Housing and electricity are provided free of charge. Professional Registration and Legislation Medical officers (in 1999), nurses and midwives (in 2000) and pharmacists (in 2001) are all registered under the Health Practitioners Act of Nauru (1999). The Republic of Nauru Health Practitioners Registration Board is appointed and approved by Cabinet. No other health professions are required to be registered. No scopes of practice currently exist; however the Ministry of Health is at the moment drafting its first: a National Nursing Scope of Practice. Locally-trained Nurse Aides and District Public Health Officers have a competency-based assessment. Planning The following HRH plans are used by the Ministry of Health: . Nauru Workforce Planning Report, June 2004, prepared by AusHealth International, July 2004 and companion Workforce Implementation Report, August 2008 . Nauru National Sustainable Development Strategy (NNSDS) 2005-2015 . MoH Organisational Reform Report, October 2008 . The Ministry of Health meets regularly with the Department of Finance and international donors, however not all these meetings are formal events. A report regarding staff training is delivered to the donor agencies on a three-monthly basis Current Donor Support AusAID is the key donor partner to Nauru who currently support undergraduate training for Nauruans in the region. This includes: . Undergraduate regional training support at USP in Preliminary (nursing) and Foundational (laboratory, dental, pharmacy) courses. Five nursing trainees (three-year training) are currently studying at the Kiribati School of Nursing (KSoN), and midwifery trainees are studying at the Fiji School Nursing (FSoN)
33 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries . Australian Regional Development Scholarships, there are currently four Nauruan recipients in nursing (three-year training at FSoN) one in radiologist (three- year training,) and one for medicine (six-year training in FSMed). Education, Training and Development Activities There are two cadres in the health sector trained locally on Nauru. They are: . Nurse Aides – this is a hospital-based in-country training program which includes classroom session to complete 16 modules, self-learning packages, lectures, clinical competency assessment and written assessment. This is AusAID-funded. Nurse Aides who wish to continue further training at a regional Nursing School must apply to enter the University of the South Pacific centre (in Nauru) to complete Preliminary Courses first. Both AusAID and the Government of Nauru fund this training. . District Public Health Workers - a similar in-country training program, combining lectures, self-learning packages, competency assessment and written assessment AusAID-funded. . Funding support for Nauruan trainees either comes from the Government of Nauru itself, or WHO or AusAID. Sources of Data Descriptive data contained in this map is based on email responses provided by the Nauruan Ministry of Health. The Republic of Nauru Health Practitioners Act (1999) can be found online at PacLII: http://www.paclii.org/nr/legis/num_act/hpa1999223/
34 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Niue
Niue is one of the world‟s largest coral islands. The population of the island has fallen from a peak of 5200 in 1966 to an estimated 1444 in 2008. There is substantial emigration to New Zealand, 2400 km to the southwest. Niue is a self-governing parliamentary democracy in free association with New Zealand. Its citizens also hold New Zealand passports. The economy is based on tourism, agriculture and light industry involving the processing of passion fruit, lime oil, honey, and coconut cream. Grants from New Zealand are used to pay wages to public employees. Economic aid from New Zealand in 2002 was US$2.6 million. Niue suffered a devastating cyclone in January 2004, which decimated nascent economic programs. While in the process of rebuilding, Niue has been dependent on foreign aid. Despite the difficult financial situation of the Niue government, the GDP per capita is quite high – US$5800 (2003 estimate) – literacy is 100% and the population health situation is indicative of a developed country. National health priorities are focused on public health prevention strategies to reduce risk factors associated with causes of morbidity/mortality and lifestyle diseases. Niue's estimated total health expenditure in 2006 was US$ 1.9 million, with per capita total health expenditure of US$974. The major health service facility is the new Niue Foou Hospital, rebuilt with NZAID, European Union and WHO support in 2005 following the cyclone. Most of the health workforce is based at this facility with regular village visits made by community health nurses and public health officers. (WPRO CHIPS 2008 Niue). Workforce Data As can be seen in table 1.a below the health workforce is made up of predominantly female Niuen staff. Table 1.a Distribution of health workforce occupation by gender and number of non-nationals
Occupation Number male female total non-nationals Physicians 1 2 3 1 Nursing Personnel 1 13 14 0 Midwifery Personnel 0 2 2 0 Dentists 2 0 2 0 Dental technicians/assistants 1 1 2 0 Pharmacists 1 0 1 0 Pharmaceutical technicians/assistants 0 0 0 0 Laboratory scientists 0 0 0 0 Laboratory technicians/assistants 1 0 1 1 Radiographers 1 0 1 0 Environmental Health Workers 2 0 2 0 Public Health Workers 1 2 3 0 Community health workers 0 0 0 0 Medical Assistants 0 0 0 0 Personal Care Workers - - - - Other health workers/Caregivers 0 7 7 0 Health management workers 1 2 3 0 TOTAL 12 29 41 2
35 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1.b describes the distribution of the health workforce by age. The majority of the workforce are over 30 years of age with just over 10% under 30 years. Table 1.b Distribution of health workforce occupation by age group
Occupation Age group (yrs) Number 0-29 30-49 50+ not spec. Total Physicians 0 2 1 - 3 Nursing Personnel 4 3 7 - 14 Midwifery Personnel 0 1 1 - 2 Dentists 1 0 1 - 2 Dental technicians/assistants 0 1 1 - 2 Pharmacists 0 1 0 - 1 Pharmaceutical technicians/assistants 0 0 0 - 0 Laboratory scientists 0 0 0 - 0 Laboratory technicians/assistants 0 1 0 - 1 Radiographers 0 0 1 - 1 Environmental Health Workers 0 2 0 - 2 Public Health Workers 0 2 1 - 3 Community health workers 0 0 0 - 0 Medical Assistants 0 0 0 - 0 Personal Care Workers - - - - - Other health workers 0 4 3 - 7 Health management workers - 2 1 - 3 TOTAL 5 19 17 - 41
Table 2 describes the number of vacancies across the health workforce. The majority of workforce vacancies fall in the nursing area with other vacancies in specialist areas. Table 2 Number of vacancies by health workforce occupation group (as at March 2009)
Occupation Number of Vacancies Physicians 2 Nursing Personnel 5 Midwifery Personnel 2 Dentists 2 Dental technicians/assistants 2 Pharmacists - Pharmaceutical technicians/assistants 1 Laboratory scientists - Laboratory technicians/assistants - Radiographers - Environmental Health Workers - Public Health Workers - Community health workers - Medical Assistants - Personal Care Workers - Other health workers - Health management workers - TOTAL 14
36 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Workforce Retention and Incentives No data reported/available. Professional Registration and Legislation Niue does not have an authorised Board of Registration for the health professions. All health workers are registered in the country in which they trained. Neither is there a legislated scope of practice for health workers. However, as public servants all health workers are covered by the Public Service Regulations and any individual employment contracts. There are no current occupational standards or workforce competencies in use in Niue. Planning There is a Department Human Resource Plan and Department Corporate Plan and Annual Report that all incorporate HRH. The National Training Council, which has overall responsibility for national Human Resources, also has a HRH development plan. There is a Mental Health workforce plan for health workers still in draft and yet to be finalised; this forms part of the Pacific Mental Health Network (PIMHNet) work undertaken in 2008. Meetings to plan the yearly budget and other matters of importance, including training needs, are held approximately twice a year between the Departments of Health and Finance. Similarly, a meeting between the Director/Manager of Health and the National Training Council are held 2-3 times a year to discuss departmental training needs. Current Donor Support HRH-related support includes: . WHO Fellowships (2009 biennium) – for base-level nursing degree at FSoN numbers of trainee nurses not stated. One doctor was funded in 2007 to commence post-graduate anaesthetics training at FSMed. . Republic of China – funding was provided for one trainee in dentistry, commencing training in 2007 at FSMed. . NZAID – one undergraduate medicine trainee commenced training at Otago University, NZ, in 2006. One radiographer commenced training at Auckland University, NZ in 2008 (also supported by the Niue Government). Two nurses also commenced their foundation and degree program in 2007 in NZ (name of university not stated) Education, Training and Development Activities For the following occupations training is provided by senior staff in the relevant section on-the-job: Nurse Aides and caregivers, Environmental Health Assistants and drivers and staff nurses. The remainder of the health workforce is trained in the region, primarily in Fiji and New Zealand, as per the following table. The Health Department was unable to recruit school leavers for training as dental technicians, laboratory technicians and nursing in 2007-2009, despite funding being available. Low levels of achievement in science subjects and low numbers of high school students choosing science are the major factors for trainees not being eligible for nurse training at FSoN. Sources of Data Descriptive data was collected via an email questionnaire from the Niue Department of Health. Demographic and economic data was sourced from the DFAT and AusAID Country Information
37 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries websites [15th March 2009]. Health Systems data was retrieved from WHO/WPRO 2008 CHIPs for Niue available at http://www.wpro.who.int/countries/2008/niu/national_health_priorities.htm
38 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Palau
This North Pacific island group consists of about 300 islands ranging from its mountainous main island, Babelthuap, to low, coral islands fringed by large barrier reefs. Palau has a population of 21 093 people (July 2008 estimate) who are a diverse mix of Palauan (Micronesian with Malayan and Melanesian admixtures), Filipino, Chinese and other Asian nationalities. Palau ratified a Compact of Free Association with the US in 1993, bringing independence into law, after three decades as part of the UN Trust Territory of the Pacific. The Palauan economy consists primarily of tourism, subsistence agriculture and fishing. The government is the major employer. Financial assistance is provided by the US. The population has a GDP per capita income of US$8 100 (2008 estimate) which is 50% higher than that of the Philippines and much of Micronesia, that is a per capita. Plans for expansion in the tourist sector have been greatly bolstered by the expansion of air travel in the Pacific, the rising prosperity of leading East Asian countries, and the willingness of foreigners to finance infrastructure development. Business and tourist arrivals numbered 85 000 in 2007. A number of key government health priorities have been identified, including addressing the burden of non-communicable diseases, solid and liquid waste management, human resources in health; and improvement of legal frameworks for health in Palau. The current health service is centralised on the Belau National Hospital on Koror. Four community health centres, and several primary healthcare centres, support this health structure. The transition of the national disease burden from communicable to non-communicable diseases continues. Of the reported ten leading causes of death, eight were due to non-communicable diseases related to lifestyle-associated risk factors, and are therefore preventable (WPRO CHIPS for Palau 2008). Workforce Data
Table 1 Distribution of health workforce occupation by national and number of non-nationals Occupation Number of staff (1998)
National Expatriate Total Physicians 19 7 26 Nurses and Midwives (incl. Health Assistants) 106 7 113 Dentists and technicians 21 3 24 Pharmacists and technicians 13 1 14 Environmental & public health workers (health promotion) 8 0 8 Laboratory technicians 12 1 13 Other health workers (incl. Counsellors, Social workers) 7 0 7 Community health workers 0 Administrative and support staff 106 2 108 TOTAL 292 21 313
The above data shows that the majority of the workforce are Nationals, the largest number of expatriate workers are physicians who make up just under half of the countries doctors.
39 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Workforce Retention and Incentives Doctors and nurses receive a 20% loading on top of their salaries when on call, and there is a 15% bonus for nurses who work night shifts. Environmental health workers and those who travel to the field to deal with disease outbreaks for example may also receive this incentive. Some cadres receive housing as part of their salary package. Professional Registration and Legislation The Board of Health Professions by law licenses those who seek to practice (doctors, allied and environmental health professionals; and, possibly, nutritionists, although this was unconfirmed). Licenses are renewed every three years. There are plans to license health administrators and support providers. Doctors are required by the Board to undertake Continuing Professional Education (CPE); the Board specifies type and quantity. Providing CPE is a challenge and consists of distance education and face to face workshops across different specialties. Those who have occasions to travel off-island usually combine their travel with some kind of CPE. There is a need to for relationships with various higher education providers especially in radiology and laboratory technology and to make different types of training available in country. The recently elected Ministry of health is currently discussing Strategic Plans, standards of care and frameworks. There is new policy direction which focuses on the accountability of the health workforce. The status of Codes of Practice is ambiguous. The transition state of the MoH has meant a number of policies and codes of practice are being reviewed to determine legality. There is much discussion on the division of labour between occupations and any new codes of practice will need to reflect flexibility in the workforce. For example, due to low fertility there is reduced demand for trained midwives and nurse practitioners would be able to cover these positions. Nurses in Palau have their own standards, produced by the MoH and the Nursing Association. They are in draft form and require further work to improve their functionality. Then they need to be streamlined and implemented across the health services. Other cadres are now interested in producing similar standards, and that nursing is leading the way. The Palau Medical Society is the body most aligned with Doctors in the country. There is a plan to develop a local College of Health whereby the performance of all those who work for the MoH (not including administration, records management, procurement, IT) can be assessed according to the overall goals of MoH. Planning A strategic planning process is underway for HRH with a target of completion at the end of the 2009. The reclassification of personnel is being undertaken through dialogue between the Public Service Commission and all Ministries Nurses have met with the Public Service Commission in the last year, and are working with the Pacific Islands Health Officers Association (PIHOA). There are efforts by the Micronesian members of the PIHOA to develop a HRH plan which will also target allied health personnel. Current Donor Support Current donor initiatives in HRH are listed below: . USAID funding has previously been provided through Fiji for training in health management, nutrition, epidemiology and administration, but the last cohort was in 2006. Program is currently on hold
40 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries . WHO provides a biennial budget; One fellow has finished at the FSMed and one will commence midwifery training next month, with another to commence in 2010 (for a seven- month training course) Education, Training and Development Activities There are a number of local training initiatives in Palau. There are efforts at present to improve the basic Public Health degrees in local two-year colleges. The Palau Community College started such a process last year. The MoH is now trying to review the course to enable problem-based learning, in line with the Strategic Plan. This is not yet quite in place as they are working with limited resources. There is currently ad hoc training for pharmacy technicians, laboratory technicians and similar cadres, the need now being to compensate for this training and to work out how to formalise and extend it. One of the training and development challenges faced by Palau is that young people do not choose medicine or nursing after high school partly as their maths and science is not strong enough and tourism presents an attractive employment alternative. A Health Academy is planned, involving local government high schools (which cover 85% of Palau‟s students), working collaboratively with the MoH to encourage young people into health professions. The MoH has just made two short DVDs, funded by WHO, promoting nursing and the allied health professions, which are to be shown on TV. Local doctors are trained at the Fiji School of Medicine. The preference is for regional training in Fiji or the Philippines, as the trainees are more likely to return to Palau. There is a nursing program in the local college that needs to be strengthened. A bridging program works with local colleges, encouraging nurses to become RNs to get Nursing Assistants into in-house training and Licensed Practical Nurses (LPNs - a level below the RN) to work full-time and study in order to qualify as RNs. The nursing administration made a policy decision to have trainees go through local colleges as LPNs rather than as nursing assistants. Full-time students can are eligible for US federal funds to pay for full-time education in a local college. Local midwives train in Fiji as there are insufficient numbers and insufficient deliveries every year in Palau to give trainees the exposure they require. There are discussions at present on developing a community health course in the local colleges; as students move through the course, the hope is that they will branch of into specialisations. The aim is to continue moving people up through development and merit, as well as increasing numbers. There is no formal training supplied by the MoH for traditional practitioners. There is an official acknowledgement of traditional practice, and the idea of not mixing traditional and „Western‟ medicines is well-established. Sources of Data Workforce data was collected from the Ministry of Health. Information on Palau‟s health structure is sourced from WPRO CHIPs 2008 for Palau, found at http://www.wpro.who.int/countries/2008/bla/
41 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Papua New Guinea
The largest country in the Pacific in terms of both landmass and population, Papua New Guinea supports an estimated 6.1 million people and their more than 800 indigenous languages. The vast majority of Papua New Guineans live in rural areas across the populous mountainous highland provinces and the remote islands between the Coral Sea and the South Pacific Ocean. The lack of sustained local infrastructure, including health services, has meant a population shift towards the urban areas where poverty, violence, and unemployment are prevalent. PNG‟s GDP has risen sharply by more than 4% over the past 5 years to US$1,027 per capita, however around 40% of the country‟s population live in poverty and experience one of the lowest life expectancy and highest infant and maternal mortality rates in the Pacific region. PNG‟s population growth of about 2.7% per year and high rate of reported HIV cases (the highest in the region) are driving up competition for scarce government resources. Health services in PNG are provided by both the government and the private sector. The private sector includes a large number of church-based providers, a small modern private-for-profit sector, commercial–based providers such as the mines, and an undocumented number of traditional healers. In some provinces church-based providers account for about 80% of health services. Within the public sector, management responsibility for hospitals and rural health services at the provincial level is divided. The National Department of Health (NDoH) manages the 19 provincial hospitals, while all other services (health centres and sub-centres, rural hospitals and aid posts, collectively known as “rural health services”) are managed by the provincial and local governments. There is some support for a proposal to create a unified provincial health system with a single provincial health authority responsible for both hospital and rural health services, headed by a provincial director of health who would report to both the national and provincial governments. To date this has been implemented in four provinces. Difficulties in maintaining rural health infrastructure, regular break downs in the supply chain of pharmaceuticals, shortages of nurses and community health workers and the remote locations of many services have combined to result in a weakening health system (WPRO, CHIPS, and PNG 2008). Workforce Data Table 1.a describes the distribution of the health workforce by occupation and gender whilst Table 1.b sets out workforce distribution by age group. Available data has been categorised into the following six cadres: Community Health Workers, Nursing Officers, Medical Officers, Health Extension Officers, Allied Health and Support Staff, Other and Unknown. Workforce vacancy data was not available at the time of data collection.
42 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1.a Distribution of health workforce occupation by gender
Occupation Per cent Number Male Female Unknown Total Medical Officers 81.5 16.0 2.5 333 Nursing Officers 21.0 78.0 1 2844 Medical Assistants 72.0 26.5 1.5 718 Community health workers 45.5 52.0 2.5 3883 Allied Health 45.5 52.5 2.0 409 Other health workers 84.0 9.5 6.5 579 Health Support Workers 59.0 36.0 5.0 1821 Unknown 49.0 28.0 23.0 555 TOTAL 10809
Table 1.b Distribution of health workforce occupation by age group
Occupation Age group (yrs) Per cent Number not 0-29 30-39 40-49 50-55 56+ Total specified Physicians 4.2 30.6 27.9 12.3 4.5 20.4 333 Nursing & Midwifery Personnel 4.9 30.1 26.2 18.0 8.7 12.1 2844 Medical Assistants 2.8 24.2 35.2 14.5 9.5 13.8 718 Community health workers 3.8 20.6 33.0 14.6 6.3 21.8 3883 Allied Health 5.9 28.9 29.6 13.9 6.6 15.2 409 Other health workers 2.8 19.0 28.5 13.6 11.1 25.0 579 Health Support Workers 5.4 23.2 27.0 9.8 8.0 26.6 1821 Unknown 0.4 4.3 5.9 2.3 4.5 82.5 555 TOTAL 4.1 23.4 28.6 13.9 7.5 22.5 11142
Only limited self-report data is available regarding non-nationals indicating a mix of Chinese, African, Indian and Sri Lankan nationals working as physicians in PNG. Further anecdotal evidence indicates a significant number of nurses in PNG are non-nationals, primarily from Australia, the US and the Middle East and are mainly spouses of expatriates working in country. A number of technical and assistant positions remain to be filled. Workforce Retention and Incentives Data not reported/unavailable Professional Registration and Legislation The PNG Medical Board (for medical officers, dentists and prescribed allied health workers) and PNG Nursing Council (for the registration of nurses and nurse-aides) respectively are the only active professional licensing Boards in PNG, both of which were established under the Medical Registration Act (1980). Whilst the Act does not make provision for the Council to review Standards of Practice, it does allow for minimum standards for particular training schools and courses. In late 2007 NZAID provided some initial scoping support for a new Medical Registration Act (under the PNG Health Sector Framework). Occupational Standards have been reviewed in conjunction with curriculum reviews in a number of key cadres: medical officers (reviewed in 2001), nursing (2002), midwives
43 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries (2007), dentists (2005), pharmacists (2000), medical laboratory scientists (2004), radiographers (2004), Health Extension Officers (2007) and Community Health Workers (2001-02). These are predominantly cadres requiring under-graduate training only. By contrast, relatively fewer specialisations (requiring post-graduate training) have been reviewed with a view to developing Standards of Practice. As part of broader public sector reform, competencies in health sector management are being worked on by the NDoH in collaboration with the Department of Finance. Planning PNG has an endorsed National Health Sector Plan to 2010, and a Strategic Plan for HRH produced in 1999/2000. It was reported that a priority activity for 2009 is the review of workforce projections. The Health Sector Improvement Program will support these planning initiatives. Current Donor Support HRH-related donor initiatives include: . National AusAID (ADS and ARDA) and NZAID scholarships (for undergraduates). . WHO Fellows – Upgrading professional skills of medical officers and clinicians in current biennium . Health Sector Improvement Program (WB, AusAID, NZAID, UNICEF, WHO). . Medical School Support Project (AusAID) - providing institutional support to the School of Medicine and Health Sciences, UPNG. Education, Training and Development Activities PNG provides a wide range of training for its health workers, and is largely self-sufficient. Specialist training is the only cadre requiring overseas education, mostly in Australia or New Zealand teaching hospitals. There has been considerable effort in reviewing the local curricula of many of the undergraduate programs in the last five years. Only a few curricula continue to be delivered in a „standard traditional mode‟ (mainly post-graduate courses), the majority are Problem-Based (50%) or Competency-based (28%). Nevertheless, all training courses from Diploma upwards are now coordinated by the Commission for Higher Education (CHE) in PNG. The only cadres at Certificate level are Community Health Workers. For more detailed information about education, training and development activities refer to Section 2 of the report. Sources of Data Workforce data and other HRH information was provided by the Human Resource Management Branch of the PNG National Department of Health through key informant interview. Health system data was obtained via WHO WPRO CHIPs (PNG) accessed at http://www.wpro.who.int/countries/2008/png/national_health_priorities.htm on 10th March 2009
44 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Republic of the Marshall Islands
After almost four decades under US administration as the easternmost part of the UN Trust Territory of the Pacific Islands, the Marshall Islands attained independence in 1986 under a Compact of Free Association. Compensation claims continue as a result of US nuclear testing on some of the atolls between 1947 and 1962. The Marshall Islands hosts the US Army Kwajalein Atoll (USAKA) Reagan Missile Test Site, a key installation in the US missile defense network. The Republic of the Marshall Islands (RMI) comprises five single islands, part of numerous atolls in the North Pacific Ocean, about half way between Hawaii and Australia and is home to an estimated 64 000 people. US Government assistance is the mainstay of this tiny island economy. The Marshall Islands received more than $1 billion in aid from the US from 1986-2002. Agricultural production, primarily subsistence, is concentrated on small farms; the most important commercial crops are coconuts and breadfruit. The tourist industry, now a small source of foreign exchange employing less than 10% of the labor force, remains the best hope for future added income. The islands have few natural resources, and imports far exceed exports. Under the terms of the Amended Compact of Free Association (2004), the US will provide millions of dollars per year to RMI through 2023, at which time a Trust Fund made up of US and RMI contributions will begin perpetual annual payouts. Government downsizing, drought, a drop in construction, the decline in tourism, and less income from the renewal of fishing vessel licenses have held GDP growth to an average of 1% over the past decade. High population growth and crowded conditions in urban areas have caused the re-emergence and/or rise of certain communicable diseases, such as tuberculosis and leprosy. In addition, a rise in levels of adult obesity, non-communicable disease, teenage pregnancy, suicide, alcoholism and tobacco use is apparent. The Government focuses on training Marshallese health professionals, strengthening community health care programmes, upgrading the quality of health care services, and improving the dissemination of health care information to its citizens. Other health-related issues include the need to reduce population growth, urban population density and malnutrition, and strengthen the capacity of the health sector. Workforce Data Workforce occupational data by gender or age-group was not made available prior to this map being produced. Nor were vacancy rates available. Consequently, the following table is sourced from the WHO WPRO Country Health Information Profile for the Marshall Islands for 2008.
45 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1 Health Workforce Occupation totals for 2008
Occupation Total Number Physicians (incl. epidemiologist) 31 Nurses and Midwives (incl. Women‟s Health Nurse Practitioner) 177 Dentists and technicians 11 Pharmacists and technicians 10 Environmental and public health workers (health promotion) 10 Laboratory Technicians 35 Other health workers (incl. respiratory health, psychologists, social workers and 33 biomedical engineers) Community health workers 0 Administrative and support staff 219 TOTAL 526
Workforce Retention and Incentives No incentive program exists. The contact reported the MoH has a difficult time retaining staff, especially nurses. There is a proposal to upgrade the pay of nurses and doctors; this is awaiting feedback from the Public Service Commission. Professional Registration and Legislation There is a Nurses Registration Board in the Marshall Islands, established under the Nursing Practice Act (1995). Continuing Professional Education (CPE) is endorsed and accredited through the Board; examinations, annual licensing and CPE are the core roles of the Board. The Ministry of Health makes appointments to the Board. There is a draft Bill before the Chamber of Parliament (Nitejela) with policies and procedures prescribed for a Medical Board. This legislation will also include allied health professions (pharmacy. laboratory and x-ray technicians). Standards exist for all health workforce occupation and are used for job advertisements and staff performance evaluation. Every 3 years a performance evaluation of all staff is undertaken. The Nursing Board has a role in reviewing the relevant standards for its members. Planning There is a current Marshall Islands Fifteen Year Health Strategic Plan 2001-2015. There is a HRH Plan for 2008 and one of its goals is to strengthen the intra-agency HRH Working Group (which includes the Ministries of Education, Finance and Health). The HRH Working Group has just come into in existence. The Budget Committee meets annually – all ministries meet with Finance. There are frequent donor-led discussions involving the Ministry of Health, analyzing the Health Strategic Plan to support donor planning. Current Donor Support The informant reported on the following donor HRH-activities: . WHO/CDC Training - Fellows training in undergraduate medicine at FSMed, 3 annually at the most. . Taiwan (RoC) Assistance – Taiwan is training medical staff and two nursing staff in clinical training programs
46 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries . JICA – Supports clinical training; 3 staff are being trained for 3 months, although the informant could not confirm their specialties. . Taiwan - Also assists with training upper level managers. . Education, Training and Development Activities . The RMI informant listed the following as local health worker training initiatives: . Health Assistants – There is a course in existence, and a new curriculum is being drafted currently. Health Assistants mainly work on the outer islands, not at the hospital. The 12 month course is offered by the Ministry of Health, they are trained on the job and train in the spare rooms in the hospital. The trainees receive a Health Assistant Certificate (to enable them to work in the Marshalls) which also provides some recognition towards further nurse training . Dental Outreach Worker – This position is trained by the Dental Doctor on the job, at the community level, with a focus on oral health prevention . Nurse Assistants – This course is also 12 months of on the job training. Training is done in the hospital in which they are based . College of the Marshall Islands Nursing School - Nursing Degree and post-basic training in midwifery are the core activity of this training program Sources of Data Descriptive data was collected via a telephone interview with a key informant from the Ministry of Health. Workforce totals and other RMI health information was sourced from the WPRO Country Health Information Profile for RMI for 2008, accessed at http://www.wpro.who.int/countries/2008/msi/
47 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Samoa
Samoa's population of 217,000 is concentrated on two main islands, with a majority living in small, coastal villages. Samoan‟s enjoy a relatively high standard of living and limited wealth disparity, reflecting the Samoan commitment to community and social institutions. Samoa has a small open economy dependent upon agriculture, tourism, small-scale manufacturing and fisheries. Samoa's macroeconomic performance is vulnerable to external factors including commodity pricing, crop disease and weather related shocks. GDP per capita remains low at US$1,800 (2002). Samoa is heavily dependent on overseas development assistance and increasingly reliant on remittances as a source of foreign exchange, currently accounting for around 14 per cent and 20 per cent of GDP respectively. Since the mid 1990s, Samoa has achieved good economic growth relative to other Pacific Island countries. A sound and stable political environment and the Samoan government's priorities of strengthening economic management, governance and public sector reform are important contributing factors. Samoa‟s health system has undergone significant reform since 1996, recently resulting in the separation of the functions of governance and service delivery within the Ministry of Health into two new bodies - a governance and regulatory body and the newly established National Health Service (NHS) which takes responsibility for service delivery. The reform agenda has also reoriented the sector towards a population-health approach, bringing services closer to home, strengthening primary health care services and improving health services for the most vulnerable groups. Greater emphasis is also being placed on health promotion, protection and prevention services. More specialised care not available in Samoa is provided to some patients through overseas treatment, either through programs funded by the Samoan and NZ Governments or at personal expense. Workforce Data The development of a new Samoan MoH HRH database has just commenced, with the support of the World Bank SWAp. Towards the end of 2008 the HRH Database Design Specification was produced, following the development of HRH indicators, agreed fields and the commencement of data of collection. However development of the full database and its testing is not yet underway, so the data reported here is an estimate only. A fully tested operational HR database is expected to be available in 2 to 3 years. Ministry of Health, National Health Service, private sector and NGO health workforce are included. Neither gender or age specific data is available at this stage.
48 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1 Distribution of health workforce by occupation
Occupation Number Male Female Total Physicians - - 85 Nursing Personnel - - 298 Midwifery Personnel - - 50 Dentists - - 17 Dental technicians/assistants - - 46 Pharmacists - - 16 Pharmaceutical technicians/assistants - - 43 Laboratory scientists - - 1 Laboratory technicians/assistants - - 44 Radiographers - - 20 Environmental Health Workers - - 23 Public Health Workers - - 4 Community health workers - - 0 Medical Assistants - - 0 Personal Care Workers - - 0 Other health workers (incl. social workers, speech therapists. Nutritionists, - - 56 biomedical technicians, physiotherapists and acupuncturists) Health management workers (incl. administration, support workers, - - 436 drivers and cleaners. These cadres included for the first time) TOTAL - - 1139
In relation to non-nationals, there are Chinese, Indian and Bangladeshi nationals working as physicians in Samoa, mainly in specialist roles and they usually fill positions for which there are no skilled national available. There were 220 workforce vacancies reported as of June 2008, representing one-fifth of the total workforce, including a surgeon, enrolled nurses, midwives, a registrar, a laboratory scientist, medical laboratory technicians, pharmaceutical assistants, support workers (public), dental therapists, environmental health officers, health managers (public), administrators, dental officers, senior dental therapists, principal radiographer, senior radiographer, consultant specialists, nurse specialist (haemodialysis), pharmacist and senior physiotherapist. Workforce Retention and Incentives Nursing, medical and some allied health professionals are the only cadres in the Samoan public service to receive overnight shift allowance and on-call allowances. They are also given housing if posted to one of the three district hospitals. The amount of in-service training is recognised as relatively high compared to professional staff of other agencies or departments. Professional Registration and Legislation Medical officers, dentists, pharmacist‟s nurses and midwives are all registered under councils established by the Samoa, Medical Practitioners Act 2007, Dental Practitioners Act 2007, Nursing and Midwifery Act 2007 and Pharmacy Act 2007 as listed below. These councils are independent bodies, although the Board membership includes the CEO of the Ministry of Health, and all members are appointed by Cabinet. The Registrar for Healthcare Professionals, recruited in 2008, reports to the CEO of the MoH and the Minister of Health directly and the position falls under Healthcare Professionals Registration and Standards Act (2007). A new Allied Health Council, legislated under
49 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries the Healthcare Professionals Registration and Standards Act (2007) is about to be formed and will incorporate registration for laboratory scientists, physiotherapists, environmental health officers and several other cadres. Samoa‟s Traditional Birth Attendants (TBA) are one of the few traditional healers who will in the future be granted registration via this Allied Health Council. Registration is in the process of being developed, whereby following completion of a MoH Safe Birthing Course, TBAs would be allowed to practice in the district hospitals at the request of the birthing mother. The Healthcare Professionals Registration and Standards Act (2007) enables the Medical, Nursing and Midwifery, Pharmacy and Dental Council to approve competency-based standards for each profession and an annual review of all professional standards. The four above-mentioned Councils have produced all standards as required, and once the new Allied Health Council is properly formed, standards for all cadres included within that Council will be produced. Table 2 below describes Occupational Standards for each occupational group. Table 2. Occupational Standards
Occupation Standard(s) Physicians Medical Professional Standards Nursing Personnel National Standards for Nursing and Midwifery Practice 2007 Midwifery Personnel National Standards for Nursing and Midwifery Practice 2007 Dentists Dental Professional & Services Standards 2008 Dental technicians/assistants Allied Health Care Professional Standards (under development) Pharmacists Pharmacists Professional & Services Standards Pharmaceutical technicians/assistants Allied Health Care Professional Standards Laboratory scientists Allied Health Care Professional Standards Laboratory technicians/assistants Allied Health Care Professional Standards Radiographers allied Health Care Professional Standards Environmental Health Workers. Ministry of Health Services Standards 2008 Public Health Workers Ministry of Health Services Standards 2008 Community health workers National Standards for Nursing and Midwifery Practice 2007 Medical Assistants Not Applicable Personal Care Workers Not Applicable Other health workers Ministry of Health Services Standards 2008 Health management workers Ministry of Health Services Standards 2008 Planning Samoa has an endorsed National HRH Policy and Action Plan 2008-2012 (Ministry of Health) and all occupational workforce plans are developed as part of this Action Plan. This Policy is linked to the Health Sector Plan 2008-2018 - Work Program and Strategies for planning purposes. The HRH Plan adapts the WHO WPRO HRH Regional Framework to Samoan context. The HRH Plan is underpinned by a Reference Group whose role it is to operationalise the Action Plan, the first action being to develop a HRH Database for Samoa inclusive of public, private and NGO health workforce. The Government operates a Performance-based Budget which is reviewed by publicly funded organisations every 6 months. This review process involves the Ministries of Health and Finance and the Public Service Commission and discussions include new establishment, staff appraisals and salary budgets. The Samoa Health SWAp commenced in October 2008 and now the SWAp Steering Committee meetings bring the Ministry of Health, Ministry of Finance and donor partners together formally several times a year. The MoH also has close links with the National University of Samoa (Faculty for Nursing and Health Science) with regard to health workforce needs and annual intakes of trainees.
50 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Current Donor Support HRH-related donor activities include: . AusAID and NZAID scholarships - for undergraduate places and post-graduate places. This is an ongoing program . WHO Fellows – These fellowships enable upgrading the professional skills of approximately 20 medical officers and clinicians in current biennium . JICA – Several 6 month courses for Environmental or Public Health trainees (in Japan) . EU Water and Sanitation Program – Component 5 includes training in Environmental Health . SPC and UNICEF/UNFPA Reproductive and MCH Program – Clinical training is offered . Health Sector-Wide Approach Program – until 2013 – The Training Plan for 2008-2009 includes upgrading skills of medical officers, nurses, health administrators, and health managerial levels. The SWAp includes a component for Training and Capacity Building Education, Training and Development Local training of the workforce occurs primarily at the Faculty of Nursing and Health Science, at the National University of Samoa and also at the University of the South Pacific (Alafua Campus, Samoa). Enrolled Nurses/Nurse Aides receive 1-2 years of training, Registered Nurses complete a 3 year Bachelor of Nursing, and Nurse Midwives complete a Bachelor of Nursing plus post-graduate training. A total of 30 nurses graduated in 2008. Dental therapists also train within this Faculty and a Bachelor of Health Science is on track to be taught by the Faculty. Midwives can also complete an undergraduate Bachelor program. Community Health Workers and Traditional Birth Attendants are trained locally. The Oceania University of Medicine- Samoa (OUMS) recently commenced operations and has produced 1 local MBBS graduate and several US and Australian graduates. This is a small private university, with funding from the USA. Sources of Data Workforce data was retrieved from the Ministry of Health - Samoa Health Sector HRH Interim Database 2008. Data regarding planning, legislation and professional registration was collected via key informant interview and email questionnaire. Demographic, economic and health system data was sourced from the DFAT Country Information websites [9 March 2009] and the WHO/WPRO Country Health system profile [accessed on 19 March 2009 available at http://www.wpro.who.int/countries/2008/sma/national_health_priorities.htm].
51 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Solomon Islands
The Solomon Islands are a scattered archipelago of mountainous islands and coral atolls east of Papua New Guinea. More than 80 per cent of the Solomon Islands‟ estimated 595 000 people rely on subsistence agriculture and fishing. The islands are rich in undeveloped mineral resources including lead, zinc, nickel gold and bauxite. Since 1998 ethnic violence, government misconduct and crime have undermined stability and civil society. In June 2003 an Australian-led multinational force, the Regional Assistance Mission to the Solomon Islands (RAMSI), arrived to restore peace, disarm ethnic militias and improve civil governance. The Solomon Islands continue to face significant development challenges. High annual population growth rates of around 2.4 per cent and migration to urban areas continue to place pressure on infrastructure and increase the demand for water, sanitation, housing, education and health services. Adult literacy is around 76.6 per cent and access to primary and secondary education is limited compared with other Pacific countries. Net primary school enrolment is 80 per cent. The country also has one of the highest malaria rates in the world. Deforestation, soil erosion and the deterioration of surrounding coral reefs are serious issues. Workforce Data Table 1.a reports available data on the distribution of the health workforce by occupation and gender. Age-specific data is not available. Table 1a Distribution of health workforce by occupation and gender
Occupation Number Male Female Total Physicians 87 2 89 Nursing Personnel - - 620 Midwifery Personnel - - 74 Dentists 29 23 52 Dental technicians/assistants - - - Pharmacists 40 13 53 Pharmaceuticals technicians/assistants - - - Laboratory scientists - - - Laboratory technicians/assistants - - - Radiographers - - - Environmental Health Workers - - - Public Health Workers - - - Community Health Workers - - - Medical Assistants - - - Personal Care Workers - - - Other health workers - - - Health Management Workers - - - TOTAL 888
Table 1.b describes vacancy rates as at March 2009. A number of professional health staff positions (doctors, nurses and dentists) are not filled, along with a sizeable group in the support and allied health cadres (most notably laboratory technicians and public health workers).
52 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1.b Number of vacancies by occupation
Occupation Number of Vacancies Physicians 2 Nursing Personnel 11 Midwifery Personnel - Dentists 7 Dental technicians/assistants 0 Pharmacists 6 Pharmaceuticals technicians/assistants 2 Laboratory scientists 0 Laboratory technicians/assistants 7 Radiographers 1 Environmental Health Workers 0 Public Health Workers 10 Community Health Workers 2 Medical Assistants - Personal Care Workers 3 Other health workers 9 Health Management Workers -
Workforce Retention and Incentives Data not reported/unavailable Professional Registration and Legislation Physicians and dentists in the Solomon Islands are registered by the country‟s Medical and Dental Board, established under the Medical and Dental Practitioners Act (1990). Nursing and midwifery practitioners are covered by the Solomon Islands Nursing Council, in turn regulated by the Nursing Council (Amendment) Act (1997). Information on workforce standards or code of practice is unavailable. Table 2 below lists Registration Boards by occupational group. Table 2 Registration Board by occupational group
Occupation Registration Board Physicians Medical and Dental Board Nursing and Midwifery Personnel Solomon Islands Nursing Council Pharmaceuticals Personnel Nil Dentistry Personnel Medical and Dental Board Laboratory Health Workers Nil Environment and Public Health Workers Nil Other health workers Nil Community and traditional Health Workers Nil Health Management and support Workers Nil
Planning The following HRH plans are used by the Ministry of Health:
53 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries . Ministry of Health National Health Strategic Plan (2006-2010): Strategic Area 8: Health Systems Strengthening – Capacity Building . Conditions of Service for Members of Solomon Islands Nurses‟ Association, 2005: Section 2 – Training for Nurses Current Donor Support Donor support includes: . WHO (2009) Training of National Coordinator, Non Communicable Diseases at the Fiji School of Medicine, Diploma in Public Health . AusAID Training of Nurses, Diploma in Public Health, Fiji School of Medicine . Solomon Islands Health Sector Support Program (SWAp) - In 2009 the SWAp is contributing to the Training of Health Promotion Officer on IEC graphic design, New Zealand . Education, Training and Development Activities . Several cadres of health workers, at various levels, are trained locally in the Solomon Islands: . Nursing pre-service – A Certificate in Nurse Aide Training is provided by the Ministry of Health – Nurse Aides assist Registered Nurses to deliver clinical nursing care and Primary Health Care activities. Provided by the Ministry of Health and Medical Services – Nursing division . Diploma in Nursing – Registered Nurses. Training for Registered Nurses involved in nursing service delivery, Public Health and Primary Care. This training is provided by Solomon Islands College of Higher Education (SICHE), School of Nursing . Certificate in Community Based Rehabilitation (CBR) – CBR Aides Training for CBR Aides – care for people living with disability, offering basic physiotherapy and occupational therapy. Provided by Solomon Islands College of Higher Education, School of Nursing . Certificate in Pharmacy – Pharmacy Aides. Training for Pharmacy aides – assists Pharmacists and Pharmacy officers. Provided by Pharmacy Services Division, Ministry of Health . In-service - Diploma in Nursing. Training for Registered Nurses – To bridge Certificate Nurses to Diploma level. Provided by the Ministry of Health and Medical Services – Nursing division. . Midwifery In-service - Advanced Diploma in Nursing – Midwifery. Training for Registered Nurses to become midwives. Provided jointly by SICHE and MoH through the Reproductive Health Division Sources of Data Workforce data was collected via key informant interview and survey data from Solomon Islands Ministry of Health and Medical Services Nursing Division. Demographic and economic data for Solomon Islands was retrieved from the DFAT Country Information websites [March 20 2009]. Health and systems information was sourced from WPRO CHIPS for Solomon Islands, 2008 accessed at http://www.wpro.who.int/countries/2008/sol/national_health_priorities.htm
54 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Tokelau
Tokelau is a territory of New Zealand, about 480 kilometres north of Samoa, which is only accessible by sea. It consists of three small atolls, surrounding large lagoons, with a land area of 12 square kilometres. Tokelau‟s population of around 1500 is of Polynesian origin, and are predominantly Christian. The village on each atoll is governed by its own Council of Elders. Tokelau‟s Health Department is based in the Tokelau National Office in Apia (Samoa). Many New Zealand laws are enforceable in Tokelau, however there is movement towards a system of free-association with New Zealand. Currently the Council for the Ongoing Government of Tokelau can legislate in its own right. This government is the country‟s executive council which reports to national parliament, known as the General Fono. Tokelau has both national and village level health workforces. The National Office in Apia houses the Director of Health, who deals with implementation, monitoring and evaluation, budgets and administration of donor assistance. Doctors and hospitals are under nuku (village) control and have their own HR Officers. Each of the atolls has its own health service. Tokelau‟s small size, isolation and lack of resources greatly restrain economic development and confine agriculture to subsistence level (particularly tropical fruits and small livestock). The government relies heavily on aid from New Zealand to maintain public services with annual aid being substantially greater than GDP (which, in 1993, was estimated at $US1000 per capita). Limited natural resources and overcrowding are contributing to emigration to New Zealand, and remittances from family members there are an important source of revenue. The Tokelau International Trust Fund (TITF) was established in 2000, by the Governments of New Zealand and Tokelau. The purposes of the TITF are to provide the Government of Tokelau an additional source of revenue for recurrent expenditures and to contribute to the country‟s long-term financial viability. The overall health status of Tokelauans is reasonably good, but changes have been observed in the last few years. There has been an increase in non-communicable diseases, with cerebrovascular disease the leading cause of death. Obesity is common and is attributed to diet and physical inactivity, with prevalence rates of 70% for men and 83% for women between the ages of 30 and 39. Workforce Data All the data presented in this section is current as of March 17, 2009. Overall health care worker numbers are small, and just over a quarter are non-Tokelauan. The health workforce is also predominantly female, except among physicians, who are all male.
55 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1a Distribution of the health workforce and non-nationals by occupation and gender
Occupation Number male female total non-nationals Physicians 3 0 3 0 Nursing Personnel 0 11 11 3 Midwifery Personnel 0 8 8 2 Dentists 1 0 1 0 Dental technicians/assistants - - - - Pharmacists - - - - Pharmaceutical technicians/assistants - - - - Laboratory scientists - - - - Laboratory technicians/assistants - - - - Radiographers - - - - Environmental Health Workers - - - - Public Health Workers - - - - Community health workers - - - - Medical Assistants - - - - Personal Care Workers - - - - Other health workers 3 0 3 0 Health management workers 4 2 6 2 TOTAL 11 21 32 7
As can be seen in Table 1.b, Tokelau‟s health care workers are mostly in the middle years of their careers, with the majority aged 30-49 years. Table 1.b Distribution of health workforce by occupation and age group
Occupation Number Age group (yrs) 0-29 30-49 50+ not spec Total Physicians 0 1 2 - 3 Nursing Personnel 1 8 2 - 11 Midwifery Personnel 0 6 2 - 8 Dentists - 1 0 - 1 Dental technicians/assistants - - - - - Pharmacists - - - - - Pharmaceutical technicians/assistants - - - - - Laboratory scientists - - - - - Laboratory technicians/assistants - - - - - Radiographers - - - - - Environmental Health Workers - - - - - Public Health Workers - - - - - Community health workers - - - - - Medical Assistants - - - - - Personal Care Workers - - - - - Other health workers 0 3 0 - 3 Health management workers 0 4 2 - 6
56 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 2. Number of vacancies by occupational group
Occupation Number of vacancies Physicians 1 Nursing Personnel 1 Midwifery Personnel 0 Dentists 0 Dental technicians/assistants 0 Pharmacists 1 Pharmaceutical technicians/assistants 0 Laboratory scientists 0 Laboratory technicians/assistants 1 Radiographers 1 Environmental Health Workers 1 Public Health Workers - Community health workers 0 Medical Assistants 0 Personal Care Workers 0 Other health workers - Health management workers 0
Workforce Retention and Incentives At present there are no specific retention strategies, although medical officers based on the atolls are encouraged to attend WHO regional workshops (as opposed to the National Office - Health Management staff based in Apia). This works both as a way of re-connecting often isolated medical officers with their peers and networks, and usually provides both a form of leave and professional development. The Directorate is also implementing a new policy of requiring all village doctors to do annual in-service attachments in Samoa, to ensure the quality and consistency of service. No strategies exist to provide incentives for trainees/secondary school graduates to enter the health workforce. Professional Registration and Legislation There is no local Tokelauan professional registration system, however Tokelauan nurses who work for the National Health Office, are required to be registered with the Samoan Nurses‟ Association. There have been discussions with the Samoan Nurses‟ Association to allow Tokelauan nurses to become registered, however recently the Samoans have advised Tokelau to implement its own independent structures. Medical officers are required (by NZ law) to be licensed. Most new MB BS graduates do their internships at the Apia National Hospital in Samoa, and are therefore registered with the Medical Registration Council of Samoa. There is a requirement that all health care workers are licensed. There are no current Standards of Practice, however the National Nurse Adviser is currently developing code of practice for nursing. Planning The HRH section of the Health Strategic Plan (2008-2009) aims to ensure on-going health workforce capacity-building and up-skilling of staff. There are presently no projections or forward plans for human resources in health, as most health worker training appears to be demand-driven by villages themselves. Tokelau‟s national public service was presented with the country‟s Human Resource Plan
57 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries in November 2008 at a meeting of the General Fono. In February 2009 all agencies met again to discuss budgetary needs. Current Donor Support WHO is the main external donor for pre-service training, aside from the health directorate itself. The Directorate has a training budget which pays for in-service attachments and workshops. Current and/or recent donor activities mentioned in the interview include: . WHO Fellowships There is presently one Fellow, an MB BS student studying in Fiji. WHO support is also facilitating the upgrading of health management skills in the Tokelau National Office in Apia. . NZAID Their focus is on pre-service training through Tokelau‟s Directorate of Education. NZAID has supported the Directorate‟s initiatives in recruitment and skilling of trainees from the three atolls. Education, Training and Development Activities Tokelau‟s entire health workforce has been trained outside of the country. The main regional institutions utilized are Fiji School of Medicine, Fiji School of Nursing, the National University of Samoa and universities in New Zealand. Specifically: . Fiji School of Nursing: offers a Diploma in Nursing/Post Basic Midwifery, and a Nurse Practitioner Programme. . Fiji School of Medicine: trainees can take MB BS, public health, dentistry, dietetics, pharmacy and lab technician programmes. . National University of Samoa: offers undergraduate studies, degree courses and postgraduate studies in Nursing and Health Sciences. „Traditional practitioners‟ on Tokelau are not really regarded as „healers‟, therefore there has been no attempt to incorporate them into the mainstream health workforce. A number of issues in the training of Tokelauan health workforce arose during the interview. Last year the government called for applicants for training for positions as midwives, nurse-practitioners (two) and nurses (three), a public health officer, pharmacist and laboratory technician in order to increase the size of its workforce; it received no applicants. Some nurse trainees studying in Fiji have not been able to reach required Fijian standards. The lack of standards in educational achievement on Tokelau is an issue for regional institutions when Tokelauan applicants enrol to study. Similarly the relatively low numbers of Tokelauan students who complete their secondary education through to Year 13 means there is an insufficient pool of students from which to draw on the future members of the country‟s health workforce. Sources of Data All descriptive data was obtained during a phone interview with the Health Manager in the Ministry of Health for Tokelau‟s National Office (based in Apia) on March 12, 2009. Workforce data was supplied in an email by the Health Manager on March 18, 2009. General information on Tokelau from the Council for the ongoing Government of Tokelau. Website is http://www.tokelau.org.nz/, last accessed March 18, 2009.
58 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Tonga
Tonga is an archipelago in the South Pacific Ocean with a population of around 121 000 (July 2008 estimate). The country is composed of 170 limestone islands (36 of them inhabited), but most people live on the main island of Tongatapu. The larger islands are fertile and support vegetable and other crops for local consumption and export. However, Tonga‟s small, open economy is vulnerable to fluctuations in world commodity prices and susceptible to natural disasters. The public sector and remittances play a dominant role in the economy. Tongans enjoy a relatively high quality of life – the adult literacy rate is about 99%, and estimated GDP per capita in 2008 was US$2690 – with a strong sense of community and national identity. However, it faces significant social challenges, including high levels of emigration among its well-educated workforce coupled with dependency on their remittances, a narrow base of economic activity, a small private sector and a lack of employment and development opportunities for young people. Environmentally, too, Tonga must contend with numerous issues, including land clearing and overfishing. Tonga‟s constitutional monarchy is the last remaining indigenous monarchy in the Pacific. The government is embarking on an ambitious program of economic and public sector reform in parallel with political reform. The reforms aim to improve the accountability and responsiveness of the country‟s public institutions, improve fiscal policies, develop a more effective and equitable revenue system, promote private sector growth and create a more efficient and streamlined public service, and will include increased investments in health and education. The current healthcare services system is based around four hospitals in Tonga: the tertiary Vaiola Hospital in Nuku‟alofa, with 191 beds; and three district hospitals. However, transportation between islands remains difficult and acute referrals to the tertiary hospital are uncommon, making centralisation of services problematic. The four hospitals also serve the populations on their respective islands with primary health care and they all run busy outpatient and emergency departments. Patients requiring specialist care that is not available in Tonga can be referred to New Zealand. The Tongan burden of disease has also undergone a period of epidemiological transition increasing life expectancy and falling fertility rates, childhood mortality rates and maternal mortality. The proportion of deaths caused by infectious diseases fell from 32% in the 1950s to 6% in the 1990s. The steep rise in non- communicable disease (NCD), although underreported is now the most important current health problem. Obesity, diabetes and cardiovascular diseases have increased to levels of epidemic proportion and prevalence rates now surpass those of most industrialized countries. Tonga developed a multi-sectoral national strategy to prevent and control NCD in 2003. Tonga spends more on healthcare than most other Pacific countries (about 8 percent of GDP), and has made significant progress in improving the health status of its population over the last two decades. The government sought assistance from the World Bank to help address the growing challenge that Tonga faces from the increase in prevalence of noncommunicable conditions – especially diabetes and cardiovascular disease. The Bank is helping the government to improve the quality of health care on the most heavily populated island of Tongatapu. The project is also providing guidance on public expenditure management issues – such as health financing mechanisms and information systems – which support the government‟s efforts on cost containment and the consideration of options for revenue-raising.
59 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Workforce Data
Table 1a Distribution of health workforce occupation by gender, number of vacancies and non- nationals Occupation Number male female total non-nationals vacancies Physicians 38 24 62 3 8 Nursing Personnel 38 319 357 - 37 Midwifery Personnel - 21 21 - 4 Dentists 8 3 11 - 2 Dental technicians/assistants 4 22 26 - 8 Pharmacists 1 3 4 - 0 Pharmaceutical technicians/assistants 1 10 11 - 7 Laboratory scientists 4 3 7 - 1 Laboratory technicians/assistants 11 10 21 - 7 Radiographers 6 1 7 - 5 Environmental Health Workers 21 4 25 - 2 Public Health Workers 5 7 12 - 6 Community health workers 0 0 0 - 0 Medical Assistants 12 10 22 - 6 Personal Care Workers 0 0 0 - 0 Other health workers 73 70 143 - 18 Health management workers 8 42 50 - 7 TOTAL 230 549 779 3 118
Table 1.b Distribution of health workforce by occupation and age group
Occupation Number Age group (yrs) 0-29 30-49 50+ not spec Total Physicians 10 39 13 - 62 Nursing Personnel 187 162 8 - 357 Midwifery Personnel 0 17 4 - 21 Dentists 0 9 2 - 11 Dental technicians/assistants 2 23 1 - 26 Pharmacists 0 3 1 - 4 Pharmaceutical technicians/assistants 2 21 0 - 23 Laboratory scientists 0 5 2 - 7 Laboratory technicians/assistants 14 7 0 - 21 Radiographers 1 6 0 - 7 Environmental Health Workers 5 17 3 - 25 Public Health Workers 2 9 1 - 12 Community health workers 0 0 0 - 0 Medical Assistants 1 20 1 - 22 Personal Care Workers 0 0 0 - 0 Other health workers 4 128 11 - 143 Health management workers 10 37 3 50
60 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 2. Occupational Standards and Competencies Occupation Name of Standard Competency 18 months internship programme for new graduates. Physicians Code of practice and standard are currently reviewed by the Medical and Dental Practice Board. 2001 Standard set by WP/SEAR, currently under review in Nursing and Midwifery Personnel collaboration with the Nurse Board. 2001 Work in progress towards completing a code of practice. One year internship programme for new graduates. Planning Dentists & Dental technicians/assistants underway to develop new standards to cover dental therapists and dental technicians. 2001 Pharmacists & Pharmaceutical Code of practice been developed and in the process of regulation. technicians/assistants Quality control system in place. 2001 Laboratory scientists & Laboratory Competency set by quality control system. technicians/assistants Use standard personal qualification 2001 Radiographers Standardized based on qualification 2001
Environmental Health Workers Nil
Public Health Workers Nil
Community health workers Nil Code of practice set by the Medical and Dental Practice Board. Medical Assistants 2001 Personal Care Workers Nil
Other health workers Nil
Health management workers Nil
Table 3. Professional Registration and Legislation
Occupation Registration Board Governance Issues Physicians Medical and Dental Board – Need for the Board to be independent. chaired by the Medical Any complaint against the Board‟s Superintendent. decision is to be referred to the Medical Practitioner Review Council chaired by the Director of Health or appeal to the Minister for Health. Appointment of members of the Board vested in the Minister for health. Regular reporting of the Boards activities are submitted to the Minister for Health. Standard procedures applicable to most health occupations. Nursing & Midwifery Personnel Nurses Board Pharmaceuticals Personnel Pharmacy Board Dentistry Personnel Medical and Dental Board Laboratory Health Workers None Environment & Public Hlth None Other health workers None Community Health Workers Health Officers are registered under Medical and Dental Practice Board Management & support staff None
61 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries
Workers not covered by legislated „scope of practice‟ include: Laboratory, traditional health workers, and health management and support workers. Environment and Public Health workers are covered by the Public Health Act.
Workforce retention and incentives Specific incentives are offered to Physicians, these include: . 20% duty allowance incorporated to their basic salary . Overtime rate – 1.5 week day and x2 for weekends and public holidays. . Career path developed for all Doctors . Post graduate training opportunities available . Provide ongoing refresher course . Study leave with pay package available . Master Degree graduate must work in the Ministry for 4 years then he/she is immediately awarded a Specialist position. Incentives for Nurses include: . 20% duty allowance incorporated to their basic salary . Overtime rate (as above) . Career path developed for nurses . Study leave with pay package available . Opportunities for further study readily available . Diploma of Nursing graduates is bonded for 3 years after training. Planning The Ministry of Health works in four programme areas: (1) policy formulation and administration; (2) preventive health services; (3) curative health services; and (4) dental health services. The Ministry is currently working on establishing a Human Resource Plan. In this context studies have been undertaken for using tools such as WISN (Workforce Indicator for Staffing Needs). The application of this tool was trialled with the Nursing Division with the intention to apply this approach to the rest of the health workforce. Findings from this process indicated that this tool (WISN) was not appropriate for Tonga based on incomparability of workloads, resources etc. The Ministry is exploring other suitable methodology. This is one area where the Ministry requires the support and assistance of the Pacific Human Resource for Health Alliance to develop a National Human Resource Profile and Plan for Tonga. The Ministry of Health, undertakes regular consultation meetings between the Ministry of Finance and the Public Service Commission regarding staffing resources and financial planning. Annual consultations with development partners including WHO, UNFPA, UNICEF, AusAID, NZAID, JICA, ADB and Taiwan –People‟s Republic of China is undertaken to coordinate support for priority areas of health sector development, specific health programmes and services, and HRH training and continuing education of health professionals.
62 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries The Ministry of Health intends to invest substantially in the area of health information to strengthen both the collection information and the analysis and dissemination of health statistics for decision- making, partly with resources made available through a World Bank loan. Current Donor Support Australia is the largest aid donor to Tonga and is contributing to improved governance and accountability, stronger economic growth and better service delivery. The Asian Development Bank (ADB) supports Tonga‟s continued economic and social development and achievement of the Millennium Development Goals. The World Bank supports the Health Sector Support Project focussed on improving the performance of its health sector by supporting selected reforms. The project is comprised of four components. The first component, strengthening health care financing will support the review, development and implementation of policies which define the funding and overall allocation of resources to health services. The second component, improving health information management, will include three sub- components: (i) strengthening the information culture, (ii) developing and implementing a Hospital Information System at Vaiola Hospital, and (iii) information management for Non-Communicable Diseases (NCD) prevention and control. The third component, improving the quality of Vaiola Hospital, will improve the administrative, technical and functional efficiency of Vaiola Hospital by investing in infrastructure redevelopment and management strengthening. This component will focus on three areas: redevelopment of Vaiola Hospital, improving hospital management and developing a health care waste management system. The fourth component concerns project management and coordination and the operation of the Project Management Unit (PMU). NZAID Patients requiring specialist care that is not available in Tonga can be referred to New Zealand under two treatment schemes, one funded by the Government of Tonga and one by the Government of New Zealand. The decision to refer is made on a case-by-case basis by the Medical Transfer Board. Specialist treatment teams in such areas as eye surgery, plastic surgery, corrective orthopaedic surgery and rheumatic heart disease visit Tonga regularly. The following is a list of WHO Fellowships for the period 2009-2011: . 1 Nurse: 12 months Bachelor of Nursing training in Fiji . 2 Nurse practitioner: 13 months training in Fiji . 1 Radiographer: 24 months training in Fiji . 1 Anaesthetist: 12 months training in Papua New Guinea . 1 Ophthalmologist: 12 months training in Fiji . 1 Physician: 12 months training in Fiji . 1 Health planner: 1 month attachment to New Zealand . 1 Accountant: 24 months Bachelor training in Fiji (distance education) . 2 Administrators: 12 months certificate training in Fiji (distance education) . 1 Surgeon: 24 months training in Fiji . 1 Nutritionist: 18 months training in Fiji . 6 Dental therapists: 24 months local training . 6 Medical recorders: 6 months training – Australia (Distance education)
63 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries . Other donors active supporting the Ministry of Health include: UNFPA, UNICEF, JICA, Taiwan, People‟s Republic of China Education, Training and Development Activities Doctors normally train in Australia, Fiji or New Zealand, often on bilateral scholarships or WHO fellowships. Three-year health officer training courses are organized by the Ministry of Health when required. Nurses train at the Queen Salote School of Nursing in Tonga. On average, 30 nurses graduate each year from the basic nursing training programme. A decision has been made to increase the intake several-fold in order to make up for the continuous loss of nurses to Australia, New Zealand and the United States of America. The Nursing School also runs a postgraduate certificate training programme in collaboration with the nursing department at the Auckland University of Technology, New Zealand. The Ministry of Health provides a range of local training programmes for health workers in both the main Hospital and outer Island Hospitals, and community clinics. Such initiatives are tailored to support the continuing education and development of Tonga‟s health workforce with a specific focus on Dental therapists/Technicians, Radiologists, Pharmacists, Laboratory Technicians, Health Inspectors, and Nursing and midwifery. Further information on education, training and development activities can be found in Section 2. The Ministry of Health recognises the need to develop appropriate policies and strategies to enforce bonding for returning Government sponsored scholars. Additionally, the Ministry of Health is keen to explore opportunities for Pacific Island countries to work towards cross crediting curriculum (health related) within the South Pacific region. Sources of Data Data obtained from the Ministry of Health, Tonga. Demographic and economic data obtained from DFAT and AusAID country profiles. Tonga health system and disease burden information is sourced from WPRO CHIPS 2008 for Tonga, accessed at http://www.wpro.who.int/countries/2008/ton/health_situation.htm
64 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Tuvalu
Tuvalu is a geographically remote chain of nine islands located to the north of Fiji. Its population of around 12300 (July 2009 estimate) is largely dependent on subsistence fishing and agriculture (primarily the production of copra and coconuts) that provides about 70% of employment opportunities. The government and state-owned enterprises provides most of the continuous paid employment, with 10% of Tuvalu‟s population working for the government. Tuvalu‟s people are mostly Polynesian and overwhelmingly Christian. The country‟s government is a parliamentary democracy, under a constitutional monarchy headed by Queen Elizabeth II (having gained its independence from the United Kingdom in 1978). Tuvalu has performed moderately well on economic and social indicators compared with many of its Pacific neighbours. Its real Gross Domestic Product (GDP) per capita has grown at an average annual rate of 2% between 1995 and 2005, although mainly in the public sector (the 2002 estimate for per capita GDP was $US1600). The rule of law is upheld, access to basic services is generally good and serious poverty is not a major problem. Tuvalu has made progress on many of the Millennium Development Goal targets, including universal access to primary education. Despite this relatively good performance, however, Tuvalu faces significant development challenges. The country has no known mineral resources and few exports and is almost entirely dependent upon imported food and fuel. In an effort to ensure financial stability and sustainability, the government is pursuing public sector reforms, including privatization of some government functions and personnel cuts. Growing income disparities, continued availability of sufficient fresh water and vulnerability to climatic change are among leading concerns for the nation. Maintaining the health workforce and financing the health system are two of the key priorities for the Tuvalu government. With one hospital, on Funafuti and a network of clinics on the other islands, the small workforce is geared towards managing the communicable disease burden (particularly tuberculosis, filariasis and skin infections related to the limited water supply), monitoring and addressing the non-communicable diseases and referring patients for tertiary care by visiting specialists when required. Workforce Data Workforce category totals are available and shown below (Table 1). No data disaggregated by gender or age-group is available at this stage. Vacancy rates in the health service are small; perhaps the most notable is the shortage of two doctors which, from a current total population of seven, is significant. The MoH Secretary reported that in absolute terms, Tuvalu has sufficient doctors, specialists, nurses and paramedical staff to meet its population‟s health needs, but the existing workforce does not permit any buffer for personnel going (or currently) on training, staff on annual leave or those who resign from the service.
65 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1 Distribution of health workforce occupation by gender, number of vacancies and non- nationals
Occupation Number Male Female Total Non-Nationals Vacancies Physicians 3 4 7 3 2 Nursing Personnel 54 0 Midwifery Personnel 6 0 Dentists 2 0 Dental technicians/assistants 2 0 Pharmacists 1 0 Pharmaceutical technicians/assistants 1 0 Laboratory scientists 0 1 Laboratory technicians/assistants 1 0 Radiographers 0 1 Environmental Health Workers 11 0 Public Health Workers - Roles overlap with 1 0 EHW, above Community health workers 0 0 Medical Assistants 0 0 Personal Care Workers 0 0 Other health workers 9 0 Health management workers 4 0 Total 99 4
Workforce Retention and Incentives There is currently a lack of incentives, in terms of salary, to encourage retention among local Medical Officers. This may be one of the factors exacerbating the health „brain drain‟ Tuvalu is currently experiencing. Lessons learned from other countries and good practice which may be introduced in the future include the development of workforce retention strategies, increased salary packages, Government housing support, salary increments on completion of training, leave travel entitlements and annual performance-based increments. Professional Registration and Legislation No data reported / unavailable. Planning Tuvalu‟s Ministry of Health has identified a need to develop both a Health Master Plan and a Workforce Master Plan, and requested technical assistance to this end. A draft Health Workforce Strategy for Tuvalu 2005-2008 was produced in 2004. Current Donor Support Tuvalu is seeking finances for more long-term specialist training for Medical Officers and other medical personnel, and to support the procurement of medical equipment. The current HRH initiatives are: . The AusAID Pacific Islands Project, managed by the Royal Australasian College of Surgeons, who send specialist surgical teams to Tuvalu whilst also building local capacity. Australia sends two teams per year: an ear, nose and throat team and an eye team.
66 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries . Taiwan (Republic of China: (RoC)) also sends two surgical teams per year. These have previously included a number of specialists but an agreement has been reached whereby Tuvalu can request the specialities it requires on the team. Teams are selected depending on hospital data. A doctor is sent out first from the hospital to the outer islands to check for patients to bring in for examination by the visiting teams. Education, Training and Development Activities Because of its small population, Tuvalu has no health personnel training institutions of its own and is therefore totally dependent on scholarships for training health workers offshore, mainly in Fiji, but also wherever support can be obtained. There are a number of initiatives in medical training for Tuvalu: . Twenty-one MBBS undergraduate students are currently overseas (5 at the Fiji School of Medicine, 4 in Taiwan, 10 in Cuba and 2 at the Otago School of Medicine (NZ)). . Another twenty applications for the Cuban scheme are currently being processed. Those covered by such schemes sign a bond to return to Tuvalu and work for three years. . Two doctors are being sent overseas for specialist training (obstetrics/gynaecology and anaesthetics). . Cuba has agreed to send five specialists; three are already in-country and two are being recruited. There is an identified lack of specialist training in the region for nurses and paramedical staff. NZAID pays for a Nurse Educator/Training Officer to carry out continuing education and ensure appropriate skill levels in nursing staff. Tuvalu also intends to make further use of the Pacific Open Learning Health Network in the future. Nursing staff numbers are relatively stable, and the outer islands have a very effective model of care (Registered Nurse/Midwife, plus Registered Nurse, plus Sanitation Officer) which could be severely strained by the expected influx of doctors currently being trained overseas, some with inappropriate skills for a small island country. In all medical cadres, the most pressing need is for training relevant to Pacific needs – specifically, those of Tuvalu. Further information on education, training and development activities can be found in Section 2. Sources of Data Workforce data was collected via key informant interview. Demographic and economic data for Tuvalu was retrieved from the DFAT Country Information websites (March 23 2009). Health data and systems information was sourced from WPRO CHIPS for Tuvalu, 2008 accessed at http://www.wpro.who.int/countries/2008/tuv/health_situation.htm.
67 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Vanuatu
Vanuatu is an archipelago consisting of 83 islands (several of which have active volcanoes), located in the southern Pacific Ocean. Its population of about 230 000 (July 2008 estimate) is largely rural, with more than 75 percent of the population engaged in agriculture. 98.5% of the population are ethnically Ni-Vanuatu, but linguistically diverse: more than 100 languages are spoken (the principal ones being Bislama (Pidgin), English and French).Vanuatu has enjoyed relative political stability since 2004. Its fiscal position has improved through financial reforms, more transparent and accountable budget processes, and improved public sector practices. Although growth in real GDP reached 6.8% a year in 2005 and an estimated 5.5% in 2006, sustaining long-term growth will be a challenge for Vanuatu given its young and growing population. Vanuatu‟s economy is based primarily on small-scale agriculture, fishing, offshore financial services and tourism (with more than 167 000 visitors in 2007) are other mainstays of the economy. In mid-2002 the government stepped up efforts to boost tourism through improved air connections and resort development, and secondly agriculture, especially livestock farming. Poverty levels in Vanuatu are amongst the highest in the Pacific and improving the delivery of basic services remains a priority, particularly in rural areas. Most of the population does not have access to a reliable supply of potable water and deforestation is a major environmental issue. Around 20% of the islands‟ population does not have access to health services; almost 25% of children under five are underweight and infant mortality, while reducing, remains a significant issue. Malaria remains the primary public health concern in Vanuatu; however a number of other communicable diseases are of concern - tuberculosis, sexually transmitted infections, pneumonia and diarrhoeal diseases. With a relatively large and growing population spread over 80 islands the health service delivery challenges faced by the Ministry of Health are significant. The six public hospitals and one private hospital, 32 health centers and aid posts in every village provide a decentralized system of health services across this dispersed population.
Workforce Data Table 1 Health Workforce Occupation totals for 2007
Occupation Number of staff Physicians 26 Nurses and Midwives 344 Dentists and technicians 0 Others for hospital services 228 Others for community health services 113 Environmental and public health workers 10 Administrative and support staff (portfolio management, exec & corporate services) 56 TOTAL 777
Workforce data by gender or age-group was not received from the Ministry of Health by the time this resource map was produced. Consequently, Table 1 (above) shows the latest publicly available Vanuatu workforce data totals, for 2007.
68 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Workforce Retention and Incentives A bonding agreement covers all public servants (including medical officers) who go to train overseas; the amount of time they will be bonded varies in proportion to how long they spend away. When away on such training, doctors are paid their full salary for the first year, in addition to any allowances paid by the donor. In subsequent years their salary is proportionately decreased but they are still paid any donor allowances. Professional Registration and Legislation Vanuatu‟s Health Practitioners Board and Vanuatu Nursing Council register medical and allied health staff, and nursing and midwifery staff respectively; this registration is a legal requirement for permanent employment in the government health system (within which most health workers operate). All Ministry of Health employees are covered by the Public Sector Staff Manual, which outlines such matters as the terms and conditions of employment and disciplinary procedures for all public servants. The Vanuatu Nursing College Act allows for the establishment of the College, which has its own legally-binding standards and Code of Practice. Nurses are given a copy of the Nursing Manual, which lists these standards. Where there is no standard that covers particular staff, the Ministry refers to the Employment Act, which pertains to all public and private employment in Vanuatu. Scope of practice for health workers comes under the various Codes of Practice; otherwise our informant was unsure and suggested that this might be covered by the Public Service Staff Manual. The regulation of traditional practitioners has been discussed in Ministry of Health meetings and at the National Health Conference, but no decision has been taken as yet. There is an acknowledgement that these workers need to be recognized and regulated. Planning The Ministry of Health‟s „Workforce Development Plan 2004-13‟ includes both medium- and long- term human resources for health plans, and a training plan. The Plan identifies and addresses different categories of health workers requiring training (doctors, nurses, allied health workers, etc); the Ministry is presently trying to implement it but has not yet fully done so. Last year the National Heath Conference looked at the Plan and conducted a provisional revision. Out of this, a Thematic Group on HRH surveyed all of Vanuatu‟s health facilities. At present the Ministry is compiling the conference report, which will include this data. At present the Ministry of Health has a Human Resources for Health unit with two sections: Personnel, and Training and Development. The latter has advertised for an In-service Training Manager, hopefully to be hired soon, who will oversee the implementation of the Plan. Current Donor Support The Vanuatu government provides assistance for health care worker training, but the Ministry of Health cannot cover all these costs. A Donor Co-ordination Unit in the Ministry manages relationships with donors. Some on-going donor-assisted projects in HRH include: . French assistance for Francophone MoH officers to train in France, and undertake work attachments . NZAID funding for short-term, overseas attachments for allied health workers . Management training for administrators and supervisors in the Ministry of Health, overseen by the Public Service Commission Training Unit
69 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries . WHO-funded short-term training and assistance for Medical Officers to secure work attachments and attend continuing professional education workshops . AusAID funding, directed through the Global Fund (for instance, an IT Officer is going to Brisbane shortly to do 18 months‟ training) is also training health care workers in the provinces . AusAID Regional Development scholarships for long-term training (for example, the education of doctors at the Fiji School of Medicine) Education, Training and Development Activities Registered Nurses train at the Vanuatu College of Nursing Education, which also trains Nurse Practitioners and midwives; the Ministry is looking to them to train Nurse Aides in the future as well. This is the only nurse training provider to which the Ministry of Health has access. Nursing education is for three years and graduates hold a Diploma which is only valid in Vanuatu. Vanuatu‟s doctors train at the Fiji School of Medicine or in Papua New Guinea. Allied health workers also train overseas (for example, at the University of the South Pacific). One nurse is sent each year to the Fiji School of Nursing l to obtain a Bachelor of Nursing. There is a Village Health Worker training program, in conjunction with Save the Children Australia, to train local, rural health care workers. Sources of Data Data regarding planning, legislation and professional registration was collected via telephone interview with a key informant from the Ministry of Health. Demographic and economic data was sourced from the DFAT Country Information websites [March 23, 2009]. Data on the health situation and systems was sourced from WPRO CHIPS Profile for Vanuatu 2008, accessed at http://www.wpro.who.int/countries/2008/van/
70 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries
Results
Section 2: In-Country and Regional Education Institutions
71 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries In-country and external education institutions assisting HRH development
This section presents information on education and training in the designated countries. Given the low response rate and lack of detailed information received from the majority of the countries to the set of questions on education and training, a comprehensive analysis of documents was undertaken to collate existing data on HRH education, training and development in the Pacific Island countries. Four key documents provided the main source of information: . Human Resources for Health in Pacific Island Countries – A Situational Analysis, University of Western Sydney 2007. . Situational analysis of mental health needs and resources in Pacific Island Countries, University of Auckland NZ, 2005. . HRH Training in Pacific Island Countries-PNG, Samoa, and Fiji. Asia-Pacific Action Alliance on Human Resource for Health, 2008. . Expanding the Professional Healthcare Education Resources in Pacific Countries, Hezel Associates, 2001. These profiles detail the available information on education, training and development, and identified factors affecting HRH training, education, development and ongoing professional capacity building. These in turn served as the basis for a gap analysis/needs assessment in each country around those same areas. It begins with an overview and then provides a summary of observations on HRH Education, Training and Development. The programmes considered here are those run on a recurring basis as opposed to one-off courses. These are mostly associated with health more generally. Table 1 consolidates these data identifying the relevant programmes in each country in terms of nursing, medicine, other health, or generic programmes. The type and nature of programmes and who provides them are indicated where possible. The commentary following Table 1 provides additional detail regarding these programmes and providers as well as other relevant information for each country.
72 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1: Country Profile: Health Workforce Development: Education, Training and Development
Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies Cook Cook Islands School of Nursing –Diploma. Cooks Islands Gvt Graduates in Gvt funding National funds Islands Also, offers a Nurse Practitioner (9 months) 2008 WHO & NZAID course with on-the job training Dental programme (1 year) Fiji School Medicine WHO Fellowships: Midwifery training (2) ; Graduates. Health professionals. MBBS; 1 Bachelor of Pharmacy; 1 Masters in Medicine; 1 Internships
Federated In country-Chuuk DHS - Health Career Govt traineeships, Improved States of Opportunity Program and Certificate in Public donors, WHO or organizational Micronesia Health – Planning stage NGO, individuals capacity. Out of country – CMI, UoG, Palau, US, FSM, FSN: Allied health workers (lab radiology, dental) In-service training WHO Fellowships: Training in ICD Coding; Graduates. Up Health professionals. Clinical attachment in Fiji; Attachment course skilling health on BFHI. Other programmes include: Medical professionals. lab (1); Bachelor Pharmacy (1); Environmental Health (1); Bachelor of Science in Nursing; Midwifery (1); MBBS (2).
Fiji Fiji School of Medicine: Fiji Gvt, Graduates In May 2009 the FSMed is Medical Training WHO, AusAID undertaking a regional Offer a 6 year Problem based Learning (PBL) consultation All Heads of curriculum. The exit (final) exam is at the end Departments from FSMed of year 5. Year 6 is taken up with the will travel to various completion of the skills book which has to be countries in the region to completed before graduation. There is then a consult with stakeholder one year compulsory (pre-registration) Ministries and Government internship. A recent proposal to extend the as to how FSMed programs
73 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies internship to 3 years was not successful. Fijian are meeting regional needs students are funded by AusAID, NZAID, WHO and a small number by country funding. Specialist Training is provided by a Masters of Medicine (MMed) Degree. The MMed is offered in the specialities of Internal Medicine, Paediatrics, Surgery, Obstetrics and Gynaecology and Anaesthetics and is the qualification for registration as a specialist in these specialties. The annual intake into each of these MMed streams is 5 candidates Allied Health Training FSMed also provides training in the following allied health disciplines: Diagnostic Radiography – 3 year degree Physiotherapy – currently 3 year Diploma which is about to be upgraded to a full Degree Program Medical Laboratory Science – 4 year degree Pharmacy – 4 year degree Each program has an intake of about 20 students each year. Of those 5 places are reserved for students from regional countries. It was also acknowledged that in some countries in the region that informal training of Allied Health practitioners took place “on the job” in hospitals in home countries without any formal qualifications being obtained Public Health related training provided by FSMed: Environmental Health – 3 year degree program. Nutrition and Dietetics – 3 year degree program. Public Health – with a focus on Public Health practice, Health Promotion. A Graduate Diploma, Bachelors and Masters of Public Health degrees are offered
74 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies A full range of dental training programs are offered: Dental Hygienist – 2 year Certificate. Diploma Dental Technology – 3 year Diploma of Dental Therapy – 3 years. Bachelor of Dental Surgery – 5 year degree Fiji School of Nursing: Post-Basic training in Midwifery, Public Health and Management. Government Training Centre run by Public Service Commission- MOH staff (administration) On-the-job training of hospital staff Out-of-country training: US, Australia & NZ WHO Fellowship programmes: Up-skilling Nursing Tutors; Physiotherapists, Health Inspectors; Health service management; Public Accounts and ICD Coders. Masters in Health Service Management, NSW, Aust (Dist Learning); Masters in Clinical Nursing Practices BSN Programme MPH.
Kiribati Out-of-country institutions: FSM, Australia, NZ, Graduates Enlistment of and PNG: Most allied health science pre-service donors to meet training. Medicine, Pharmacy, Nursing and cost of in-country some allied workers. and out-of- WHO Fellowship programme: Masters in country training Surgery; Bachelor in Environmental Health (1); activities. Postgraduate Dip Surgery (1).
Kiribati School of Nursing Improved In-service training & development: Refresher, organizational update and/or specific knowledge/skills to capacity. enhance staff performance
75 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies Republic Out of country Fiji School of Medicine Graduates of WHO Fellowship programme: Short term Marshall (clinical attachment) – Nurse Anaesthetist Up skilling of Islands training in PNG; Training in nutrition; Health health Education & counselling attachment in Fiji. professionals, and Other fellowship support includes Dip.Med.Lab; graduates. Dental Tech; Bachelor of Dentistry; Midwifery (1).
University of Auckland developed a distance Improved learning post-graduate programme for medical organizational practitioners capacity Affiliated with UoG and University of Hawaii- PREL
Nauru Fiji School of Nursing: Nursing Basic ARDS, AusAID 3 Graduates in Donor funded Donor funded. Gvt of Nauru 2008 Fiji School of Nursing: Midwifery course, Post AusAID 4 Graduates in AusAID AusAID. Basic Nurse Education 2009 Fiji School of Medicine – Basic Public Health WHO/NZAID Courses via POHLN University of the South Pacific: Management, AusAID Development (Distance learning). Also, Preliminary & Foundation Science (to enable students achieve FSM entry requirement) Kiribati School of Nursing. Basic Nurse training
Niue Otago University Master Degree-Australia/NZ NZAID, Niue Gvt Graduates NZAID NZAID University FSN- Basic Nursing Training, Midwifery-6- month course Manukau Polytechnic (NZ) Foundation Nursing
76 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies Advanced Certificate
Palau Out-of-country 3-year programme (e.g. Guam or Graduates USA) for bachelor degree level qualifications In-country: 12-18 month courses for: Health Assistants, Practical Nurses Out-of-country 2-3 year courses: Dental Therapy Health Promotion Medical Imaging Prosthetics-orthotics Out-of-country 3-4 year courses: Medical laboratory science, Nursing, Pharmacy, Physiotherapy, Social work: Community/public health nursing, Geriatric nursing, Intensive care nursing, Midwifery/Child health, Nurse practitioner, Nursing service management Out-of-country 5-year course: Medicine: Operating Theatre/Anaesthetic nursing, Psychiatric nursing Internal medicine, Surgery, Paediatrics, Anaesthesiology, General/family/community medicine. WHO Fellowship programmes: Quality Graduates. Assurance; Training for Nurse Supervisor/Manager; Licensed practical & Nursing Training; Midwifery (2); MBBS (1).
Samoa School of Nursing at the National University of Graduates Gvt Samoa Samoa: Nursing, and Health Leadership & Management Post-graduate Cert Department of Health: Both in-country and out- of country, organised by the Dept of Health, WHO and other agencies: Assistant
77 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies Environmental Officer (1 year training), Dental Nurse (3 yrs) Pharmacy Assistant (1 year), and Laboratory Technician New private Oceania School of Medicine – Private based in Apia – Offers MBBS and B Med funded/self curriculum for Aus, and USA candidates. Mode funded of delivery – online learning Discussions have been initiated with the Ministry of Health; University Without Walls in Sydney, FSM, and Australian Medical Schools to develop Internet based training for health care professionals WHO Fellowship programmes: MBBS (2) Graduates. Bachelor of dental surgery (1); Bachelor Pharmacy (2); Dip in Dietetics & PH Nutrition (1); Postgraduate Dip in Eye care (1); Bachelor in Dental Surgery (3).
Solomon Solomon Islands College of Higher Education: Graduates Gvt Funded Islands Nursing Strengthened HRH capacity. WHO Fellowship programmes: TB Course for Nurses (Hanoi); MBBS (1); Masters Anaesthesia (1); Masters in Medicine (1); Bachelor Environmental Health (1); Postgraduate Public health (1); Postgraduate Dip Medicine (1); Diploma in Health Promotion. Internal training of providers in comprehensive STI management in the various provinces.
Tonga Ministry of health-Queen Salote School of Gvt Funded WHO; 38 nurses Government of Gvt and donor Ministry of Health Corporate Nursing, and Tonga Health training Centre. UNFPA, Auckland graduated in Tonga. funded support Plan. Basic Nursing, Midwifery, and public health. University of 2008, and the Funded WHO; Technology, The 2009 intake in and NZAID.
78 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies WHO Fellowship programmes; MBBS Open Polytechnic this 3-year course (1);Environmental Health (1); Masters Surgery of NZ. was 33. (1); Bachelor medical imaging (1); Post Grad Dip Obs & Gynae. Officer, Midwifery, Health Inspector, Assistant Pharmacist, Laboratory Technician, Radiographer, Dental Therapist and Chair side Assistant Out-of-country: Medicine, Surgery, Obstetrics and Gynaecology, Other clinical specialties, Dentistry, Nursing, Pharmacy, Laboratory Science, Medical Imaging, Physiotherapy Training Unit of the Prime Minister‟s office: In service training (MOH) Tuvalu In-country continuing training programme for all NZAID pays for a Improved staff annually, plus other ongoing activities and Nurse organizational programmes Educator/Training capacity Officer to carry out continuing education and ensure appropriate skill levels in nursing staff Scholarship programme for training in the Graduates region, especially Fiji and Kiribati Twenty-one MBBS undergraduate students are currently overseas (5 at the Fiji School of Medicine, 4 in Taiwan, 10 in Cuba and 2 at the Otago School of Medicine (NZ). Another twenty applications for the Cuban scheme are currently being processed. Those covered by such schemes sign a bond to return to Tuvalu and work for three years WHO Fellowship programmes; Clinical
79 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies Attachment in Obs & Gynae; Clinical attachment for 1 nurse on ICU in Fiji; Midwifery (2); Post Graduate Dip Anaesthesia (1). Cuba has agreed to send five specialists; three are already in-country and two are being recruited Tuvalu intends to make further use of the Pacific Open Learning Health Network in the future There is an identified lack of specialist training in the region for nurses and paramedical staff
Tokelau Fiji School of Nursing - Diploma in Nursing WHO, Govt, Graduates. Govt. WHO, /Post Basic Midwifery / Nurse Practitioner Catholic Church. Donors (NZAID) Programme Fiji School of Medicine - MBBS Programme / Public Health programme / Dentistry / Dieticians / Pharmacist / LAB Technician National University of Samoa - Undergraduate studies in Nursing and Health Science / Degree courses in Nursing and Health Science / Post Graduate Studies in Nursing and Health Sciences
Vanuatu Vanuatu Centre for Nurse Education (VCNE) Graduates Vanuatu Rural Development and Training Centres Assn (NGO) broad curriculum some health related works with local nurses and health workers Institute National de Technologie de Vanua AusAID, NZAID, Improved (INTV) – originally a French training course France, WHO capacity centre focusing on vocational education. It has linkages to other training organizations including the Open Learning Institute in
80 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies Queensland, Australia, and the Fiji Institute of Technology: Nursing and Health Workers WHO Fellowship programmes: MBBS (2).
Papua University of Papua New Guinea, School of Graduates New Medicine and Health Sciences, Taurama Guinea Campus, Port Moresby: MBBS Programme Bachelor in Pharmacy Bachelor in Medical Laboratory Sciences Bachelor in Oral & Dental Surgery Bachelor in Medical Imaging Diploma in Anaesthetics Diploma in Community Health Masters in Public Health Bachelor in Clinical Nursing, Midwifery & Paediatrics Bachelor in Nursing; Administration & Education Bachelor in Nursing Acute Care Bachelor in Nursing Mental Health Divine Word University, Faculty of Health Sciences, Madang. Health Extension Officer Environmental Health Officer Physiotherapy Eye Care Health Management Lutheran School of Nursing, Affiliated with DWU Registered General Nurse Midwife University of Goroka, Eastern Highlands Province Diploma in Health Teaching
81 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Name of provider & type of HRH activity Funding & Sustainability Country Outputs Student funding Identified Need being provided partners Strategies Diploma in Health Education Degree in Maternal and Child Health Highlands Regional College of Nursing, affiliated with University of Goroka General Nurse Pacific Adventist University, Central Province, Degree in General Nursing Degree in maternal and Child Health Various Church-run Hospitals/Health Services . Certificate in Community Health Work (on site at 12 church-run hospitals Lae School of Nursing, affiliated with Lae UniTech Registered General Nurse St Mary‟s School of Nursing, Vunapope, East new Britain Province Registered General Nurse Nazarene College of Nursing, affiliated with Christian Nursing Colleges of Nazarence Universities Registered General Nurse St Barnabas School of Nursing, Alotau, affiliated with DWU Registered General Nurse
82 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Summary Small Pacific Island Countries share a relative lack of resources because of their size. Geographically, they are isolated from the “developed” countries and, to a large extent, from each other. These two criteria form the basis for many of the challenges that can impact on education, training and development within the Pacific region. Because of their limited ability to provide a variety of accredited institutions for HRH training, this has implications for the demand for training offered. The second criterion – the dispersion and relative isolation of small island states - has encouraged a focus on distance education as a means for providing training. Two of the challenges posed by this focus, however, are selecting as appropriate mode of delivery and ensuring „organisational capacity‟ and resources are adequate Doctors and specialists in Fiji, PNG and the Pacific are well trained and already provide a broad range of services. Their abilities are limited only by lack of resources and supporting infrastructure. However, the remoteness of much of the population and the large number of patients mean that, in practice, their skills are only accessible to a small proportion of the population. WHO has a biennium budget for the Pacific which also supports Fellowship programmes including short term clinical attachments, Midwifery training and Bachelor of Medicine and Bachelor of Surgery (MBBS) training. . Most education and training programmes are reliant on external donors support . Pre-vocational education programmes identified as a priority in some countries (prepare health students for tertiary study i.e. Nauru) . Preferred mode of delivery – face to face . Internet-based capability is limited in some countries . Countries expressed desire for training of staff not to occur in Australia or NZ as participants often do not return and potential benefits are lost . In PNG, Education Curriculum has been subjected to regular review and updating . Common gap across countries - inadequate / lack of continuing education of health professionals . Need for regional mechanism for quality control, standard setting and accreditation/credentialing . A national and regional stock take is needed to reliably identify where the „gaps‟ are for building capacity of education and training institutions, and continuous professional learning and development of health professionals
83 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries
Results Section 3: External Partners Providing Assistance in HRH
84 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries External partners providing HRH assistance
Funding, human resources and technical expertise have been contributed by multiple development partners; international organizations and regional agencies. The following table provides a limited overview of HRH activities supported by international donors. It is based on responses from a questionnaire designed and administered as part of the PHRHA mapping exercise. Table 1 on the following pages identifies the types of Human Resources for Health activities undertaken and or supported by Regional Institutions, Donor Organisations, and Specialised UN agencies (i.e. WHO).
85 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Table 1: External partners providing HRH assistance
Donor & Country Activity Description Schedule Budget Partners Focus/Regional NZAID Pacific Paramedical Training Centre The PPTC provides technical training and development 2007-2011 NZD1million (PPTC) assistance to clinical laboratories and blood transfusion services of the Pacific region. Mostly runs training courses in Wellington but retains flexibility to run in- country courses, short-term attachments to NZ medical labs and offers on-line courses through POLHN. Also has a quality management component (Regional External Quality Assurance Programme) Fred Hollows Foundation New Aims to strengthen Pacific eye health training institutes Zealand – Blindness Prevention and workforce support Programme
WHO – Strengthening Workforce Strengthen the quality of nursing services and nursing 2009 – 2013 TBC (NZAID Capacity education in Pacific Island Countries. Funding specifically and AusAID) supports WHO through their POHLN programme to strengthen capacity of PICTs to produce and deliver online continuing education for health professionals with particular emphasis on nursing Pacific Medical Treatment Scheme Combined scheme where MTS provides for referral of 2008-2011 NZD4.5millio (MTS) and Visiting Medical patients for specialised medical care to New Zealand and, n Specialists Scheme (VMS) where appropriate to Fiji. VMS provides for specialist teams to visit Pacific Island countries, and also provides for capacity building (on-the-job training) Currently being redesigned to coordinate with AusAID‟s VMS scheme and increase the focus on capacity building (under title Strengthening Specialised Clinical Services in the Pacific Initiative). Development Partnership Counties-Manukau District Health Board is the partner 2005-2009 Tonga, Tuvalu, Arrangement between Niue and DHB to Niue Foou Hospital, providing services that NZD2,080,00 Samoa, Kiribati, Counties- Manukau District Health cannot be delivered at Niue Foou Hospital, as well as a 0 (for bilateral Vanuatu, Fiji. Board programme of visiting specialists. These specialists deliver programmes a range of secondary services, as well as provide public and
86 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional health and human resource capacity building coordination)
Samoa Rheumatic Fever Rheumatic Fever staff development 2008-2009 Samoa Improving Midwifery Training in Improve the capacity of training institutions and midwifery April 2009 – PNG Papua New Guinea educators to deliver a new midwifery curriculum in PNG March 2010
New Zealand Development These scholarships enable individuals from developing Ongoing NZD20,000 Scholarships - Open Category countries to undertake development related studies at tertiary education institutions in New Zealand. This category provides opportunities for individuals involved with driving development, and who work in the private sector, civil society organisations, tertiary institutions and other public institutions not eligible for the Public Category Short Term Training Awards NZAID's Short Term Training Awards (STTA) enable Ongoing Not finalised individuals from developing countries to undertake training of up to one year duration for the purpose of vocational up-skilling and as a quick response to meeting the high priority human resource needs of their country.
New Zealand Regional Development These scholarships allow for study at In 2008, 291 Scholarships Pacific tertiary institutions. The NZRDS students study NZRDS mainly at USP Suva, but also at USP campuses in Apia students were and Port Vila. Also, a number study at the Fiji School of funded at Medicine, Fiji Institute of Technology, Fiji School of NZ$7,471,484 Nursing, and a small number of NZRDS students study at (not all health- tertiary institutions in PNG related).
NZAID and the World Health Organization are to work $NZ4.5million Regional together on a three-year, $4.5 million regional programme. The aim is to strengthen nursing services in the Pacific as well as expanding continuing education opportunities for both nurses and other health professionals.
87 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional Nurses make up more than 50 percent of the national health workforce in most Pacific countries and play a key role in keeping people healthy through disease prevention activities, and by caring for mothers and babies. Implemented by the World Health Organization, the projects will help to address the critical shortage of skilled healthcare workers in the region, which presents a serious threat to people‟s health. The joint initiative supports the objectives of NZAID‟s health policy in the region and those of the World Health Organization‟s Regional Strategy on Human Resources for Health. Pacific Disability Forum NZAID has provided support to the Pacific Disability Ongoing Regional; Forum (PDF) since 2006/07. The PDF is a regional non- government organisation that is made up of national organisations focusing on disability, including Disabled Persons Organisations. The PDF provides support to member organisations to advocate for the rights of persons with disabilities and also represents the unique situation of people with disabilities in the Pacific both within the region and internationally. AusAID AusAID (Harmonised with NZAID). This project focuses on strengthening the management and Samoa Contractor is JTA International Pty operational capacity of the Ministry of Health. Activities Ltd are designed to improve the quality of hospital clinical services, improve the quality and increase the reach of rural health services, and reduce the incidence of non- communicable diseases, particularly diabetes Tackling NCDs in the Pacific This program, being jointly implemented by SPC and 2007-2011 AUD20 Regional WHO, includes financial and technical assistance to 22 million Pacific Island countries and territories, including Samoa, to help them: develop and revise NCD strategies in alignment with national health plans; facilitate and upscale the implementation of these strategies, including provision of direct grants to help countries implement priority NCD
88 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional activities; develop sustainable funding mechanisms to deliver NCD programs; strengthen health systems and capacity to prevent and control NCDs; and strengthen monitoring, evaluation and surveillance of NCDs in order to improve planning and decision making AUSAID Pacific Islands HIV and STI The Pacific Islands HIV and STI Response Fund will 2009-2013 AUD30 Regional Response Fund provide additional financial resources and technical million assistance to national governments, civil society agencies and regional organisations, including in Samoa, for the implementation of the Pacific Regional HIV and STI Strategy 2009 -2013. The Fund will enhance the focus on prevention activities at a community level, expand the availability of testing and treatment for HIV and other sexually transmitted infections (STIs) and will complement additional Global Funding to help in scaling up the response Pacific Health Systems Strengthening Support to Fiji School of Medicine 2008-2010 AUD8.95 Regional This initiative will: million Improve the management capacity, curriculum development and infrastructure of the Fiji School of Medicine to enable the school to train higher numbers of doctors and other health workers from Pacific Island countries. Develop an improved, demand-led coordination mechanism for the provision of specialist surgical and training services in the Pacific region Pacific Human Resources for Health Enable WHO to help Pacific Island countries, address Ongoing AusAID Regional Alliance constraints in the health care workforce by providing funded. assistance to develop medium-term health workforce plans and appropriate regional standards for health care worker training and accreditation through the Pacific Human Resources for Health Alliance; and Develop an improved, demand-led coordination mechanism for the provision of specialist surgical and training services in the Pacific
89 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional region
Kiribati-Australia Nurses Initiative Implementing Agency: Griffith University 2007 - 2013 $AUD6 Kiribati (Kani) The initiative will enable I-Kiribati youth to attain million Australian nursing qualifications and industry experience. In Australia, I-Kiribati nurse educators attain further education and skills development to Australian standards to strengthen Kiribati nursing education outcomes and health care services. The Pacific Regional Reproductive The program will strengthen the organisational 2007-2011 AUD$1.millio Cook Islands, Fiji, Health Programme effectiveness of its Member Associations (Cook Islands, n Papua New Guinea, Fiji, Papua New Guinea, Samoa, Solomon Islands, Tonga, Samoa, Solomon Tuvalu and Vanuatu) in the Pacific and improve access to, Islands, Tonga, and the quality of, the sexual and reproductive health Tuvalu and services they provide. The program will focus on building Vanuatu. Member Association capacity in governance and management, advocacy and program delivery. International Planned Parenthood Foundation is implementing the program in cooperation with regional partners and donors working in sexual and reproductive health Partnerships in Vulnerability This initiative aims to extend the development program of Kiribati Reduction regional organisations and other donors such as UNICEF, World Bank and Asia Development Bank. Working through partnerships provides better co-ordination and reduces the administrative burden on Kiribati officials dealing with multiple donors and activities Australian Government Department Library Capacity Building – Tonga, Samoa, and Kiribati, 2007-2011 AUD$1.85 Regional of health & Ageing: Pacific Senior Development of an Online Information Database and million
Health Officials Network Development of Health Workforce planning tool (Workforce Indicators for Staffing Needs (WISN)-Tonga
90 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional Pacific Islands Project (P.I.P) AusAID Pacific Islands Project (P.I.P), managed by the Cook Islands, Fiji, Royal Australasian College of Surgeons. The Pacific Kiribati, Federated Islands Project provides specialist surgical and medical States of services to 11 Pacific Island Countries, and Micronesia, delivers capacity building activities for health Marshall Islands, professionals in the region. The Project organises short Nauru, Samoa, term visits by multi-disciplinary medical teams in the Solomon Islands, following specialties: Tonga, Tuvalu and ENT Vanuatu, Urology Radiology Psychiatry Neurosurgery Ophthalmology Paediatric surgery Orthopaedic surgery Plastic & Reconstructive surgery Cardiac surgery (including Open Heart surgery) The Project is developing the medical knowledge and skills of Pacific Island health workers, enabling them to deliver a range of primary, secondary and tertiary health services to their populations. This is achieved through the delivery of specialist training workshops and supporting local medical personnel to accompany and work with the visiting specialist teams. JICA Capacity building –Nursing Supervisors. This initiative Regional aims to support practical initiatives at building management and leadership of Nursing Supervisors with a 3 year implementation to occur from 2010. Project design team due in July 2009. It will not include scholarships or support for training institutions European The Kiribati-EU Health Improvement Project is funded by 2006-2009 Euro 7.7 Kiribati Union (EU) the European Union under its 9th European Development million Fund Financing Agreement (F.A. 9288 / KI) with the Government of Kiribati. It is anticipated that the Project
91 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional will be realized within 48 months at a total estimated cost of Euro 7.7 million (or approximately AUD 12.83 million). The Project commenced in June 2006. The date of the end of the Operational Implementation Phase will be 31st December 2009 and the date of the end of the period of execution of the Financing Agreement will be 31st December 2011. Executing Agency is the Fiji School of Medicine (FSM) working in partnership with the Ministry of Health and Medical Services (MHMS), Ministry of Finance / National Authorising Office (NAO) and other stakeholders. Key Project areas include: Improvement of Management Systems: Establishment of an Outer Islands Health Management Centre; to enhance outer islands drug policy and management systems in place. Improvement of training systems: Health curriculum teachers and national Health Managers trained. Secretariat of The SPC Public Health Programme (PHP) aims to improve 2009-2013 Regional the South the overall standard of health of Pacific Island peoples. It Pacific works across numerous public health fields, particularly Community communicable and noncommunicable diseases and public (SPC) health policy. Current regional HRH programmes include: PREPP – Training on pandemic preparedness and outbreak investigation. PPHSN – Training in Communicable Disease Surveillance. Global Fund – All regional projects have a Human resource Capacity building component. Human Development Programme – training on use of Global Information systems and Biostatistics (re; MDGs). ADB ADB has approved a $1.5 million technical assistance 2005-2009 project which aims to enhance the relationship between ADB and the governments, strengthen development partner coordination, and improve ADB‟s country
92 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional portfolio performance. Under the grant, ADB country officers will initiate aid coordination in Samoa, Solomon Islands, and Tonga, as these countries have greater needs over the next three years than other ADB developing member countries in the region Cuba-Pacific Cuba's medical aid to Pacific countries has been two- Kiribati, Solomon Relations pronged, consisting in sending doctors to Oceania, and in Islands, Nauru, providing scholarships for Pacific students to study Vanuatu, Tuvalu, medicine in Cuba at Cuba's expense. Tonga, PNG, There are currently sixteen doctors providing specialised medical care in Kiribati, with sixteen more scheduled to join them. Cubans have also offered training to I-Kiribati doctors. Cuban doctors have reportedly provided a dramatic improvement to the field of medical care in Kiribati, reducing the child mortality rate in that country by 80%. In response, the Solomon Islands began recruiting Cuban doctors in July 2007, while Papua New Guinea and Fiji considered following suit. As of September 2008, fifteen Cuban doctors were serving in Kiribati, sixty-four Pacific students were studying medicine in Cuba, and Cuban authorities were offering "up to 400 scholarships to young people of that region". Among those sixty-four students were twenty-five Solomon Islanders, twenty I-Kiribati, two Nauruans and seventeen ni-Vanuatu. Cuba was due to send doctors to the Solomon Islands, Vanuatu, Tuvalu, Nauru and Papua New Guinea, and may also provide training for Fiji doctors. WHO The Pacific Open Learning Health The Pacific Open Learning Health Net (POLHN) Ongoing Funded by Regional Net (POLHN) initiative, launched in 2001, is aimed at meeting the WPRO. continuing education needs of health professionals in Pacific Island countries, while remaining in their jobs and overcome costly overseas training. Learning centres equipped with computers and internet connections in ten
93 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Donor & Country Activity Description Schedule Budget Partners Focus/Regional Pacific countries enable health personnel, such as nurses, doctors, allied health workers and, health managers to access or search for electronic health information or undertake online learning courses. Specific health courses designed to meet training needs of health personnel are developed and delivered through POLHN. 28 health courses on a variety of subjects, such as blood safety, HIV/AIDS, health informatics, communications and counselling have been conducted through the learning centres, benefiting more than 600 health professionals in the past four years. Fellowship programmes WHO has a biennium budget for the Pacific which also Ongoing Fiji, Vanuatu, supports Fellowship programmes including short term Tuvalu, Tonga, clinical attachments, Midwifery training and Bachelor of Tokelau, Solomon Medicine and Bachelor of Surgery (MBBS) training. Islands, Samoa, Palau, Federated States of Micronesia, Republic of Marshall Islands, Kiribati, Cook Islands. Engagement Other donor agencies and partners contributing to building of other HRH capacity include: UK (DFID), France, Japan, partners USAID, China, Taiwan (Republic of China), Canada, and UN agencies
94 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Summary Most countries have developed external or strategic partnerships with Australia and New Zealand. AusAID provides support to Fiji School of Medicine to improve the management capacity, curriculum development and infrastructure of the school and to help the FSMed develop an improved, demand-led coordination mechanism for the provision of specialist surgical and training services in the Pacific region. NZAID funds a range of initiatives that are in line with the priorities articulated by key partners in the Pacific. This includes human resources for health (strengthening workforce capacity). While the provision of primary health is the focus of NZAID‟s support, the agency also contributes to secondary and tertiary health care through the provision of specialist medical treatment either in New Zealand (Medical Treatment Scheme) or in-country (Visiting Medical Treatment Scheme). The Pacific Regional Health programme funds coordination costs, with treatment costs coming out of the relevant bilateral. The NZAID Programme will continue to be guided by Pacific priorities identified through the Pacific Plan. JICA provides support for capacity building of Nursing Supervisors. Cuba's medical aid to Pacific countries has been two-pronged, consisting in sending doctors to Oceania, and in providing scholarships for Pacific students to study medicine in Cuba at Cuba's expense. SPC through its donor funds provides technical support as well as national and regional training programmes in HRH capacity development for Pacific Island Countries and Territories. 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. ADB has expanded its role in the Pacific in recent years, and its regional office in Vanuatu. At a recent DAC meeting, donors agreed that ADB would provide the background country-based analysis for UNDP-sponsored aid groups. To enhance the effectiveness of external aid to PICs, it is essential that the activities of various donors are well coordinated and aligned with national health system priorities including those of HRH development. It is crucial that governments take a leadership role in this. The primary value of this approach is that it will build on the Pacific Plan, which provides a demand-driven framework for implementation of key Millennium Development Goals.
95 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Discussion
The HRH resource mapping was intended to generate baseline data on current HRH situation in the PICs as well as information on education and training institutions involved in HRH development and on external partners providing HRH-related support. In line with the Terms of Reference of the contract the data was not analyzed and as a result this discussion section is focused more on the key findings which emerged from the mapping process rather than from the data itself. The findings are as follows: . Variations in the availability of workforce data . Lack of disaggregated workforce data . Varied HRH data repositories . Limited continuing education, training and development . Limited coordination among external partners engaged in HRH support Variations in the availability of workforce data There were marked variations in the availability of workforce data across the 15 countries studied as evident from the country maps. Countries like PNG and Cook Islands had detailed workforce data including numbers of health personnel disaggregated by gender and age. Data on education and training institutions were also readily available in PNG. By contrast, the majority of the countries had limited workforce data readily accessible. Data on recruitment and retention including incentive schemes designed to retain personnel were unavailable in many countries. It is important to note, nonetheless, that this study was conducted within a limited time frame and the questionnaire was administered largely over the phone and via email communications as oppose to being conducted in greater detail in-country. The inability to provide responses to some of the questions may relate more to the limited time the respondents had to collate these data rather than the data not being available. That leads to the next key finding - the varied HRH data repositories in most Pacific Island countries. Varied HRH data repositories It was evident from the mapping process that many of the countries studied have varied HRH data repositories. The Ministries of Health had information on the number of personnel (nurses, doctors, dentist, etc.) currently working in the government health sector but knew very little about the education and training institutions and the annual turnover of health personnel of these institutions. Such information was largely held at the Ministries of Education and the various medical and nursing training institutions. Information on current vacancies was also limited in all the countries. In general, there was lack of any effective system of workforce data collation and management across the region. In countries like PNG, the health system is partially decentralized and as a result some amount of workforce data are held at decentralized levels with little knowledge at the central MOH. Smaller countries may not have the need for a complex HR information management system but an effective monitoring and collation of data systems. Lack of disaggregated workforce data There were significant gaps with regards to disaggregated data. Only five (Tonga, PNG, Cook Islands, Nauru and Niue) of the 15 countries studied had disaggregated workforce data by gender, age or nationality. Such disaggregated information is essential for effective workforce planning including planning for education and training. There is anecdotal evidence that increasing numbers of expatriate
96 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries health workers are employed in the Pacific. For example, recent reports indicate that Cuban and Chinese health workers have been employed in several countries in the Pacific. Ascertaining health worker nationality will enable the Health Ministers in the Pacific to set effective licensing and registration regulations for Health Workers, to manage both the international partner relationships, as well as planning the internal training needs of the country. Limited continuing education and training resources Limited continuing education, training and development of health professionals emerged as a key issue in the Pacific. There were wide variations across Pacific Island countries in terms of the existence and appropriateness of health worker education and training, as well as their type, frequency, coverage and quality. The lesser-resourced Pacific Island countries (e.g. FSM, Kiribati, Tuvalu, Republic of the Marshall Islands, Nauru) are at a significant disadvantage in terms of HRH training, education and ongoing professional development, due to both their geographical location and access to regional training and education Institutions. Limited coordination among external partners engaged in HRH support Development partners, both international donors and regional agencies, play an active role in the health sector of Pacific Island countries. Key organisations/agencies including AusAID, NZAID and WHO provide significant support for the health sector in the Pacific, generally, and HRH capacity development in particular. Findings of the studies synthesised indicate that coordination among the various organisations is inadequate, leading to potential duplication of projects. To enhance the impact and effectiveness of donor support to the PICs, it is essential that the support is well coordinated and aligned to meet the goals and objectives of national HRH programmes /strategies of each country, with government taking the lead.
97 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Conclusion and Recommendations
Most Pacific Island Countries have attempted to enhance their national health information systems, often with the support of partner agencies (i.e. SPC, WHO). However, findings of this mapping exercise demonstrate that significant deficiencies in the collection, analysis, management and application of HRH data persist in many PICs. Additionally, there appears to be no systematic way of linking HRH information to policy-making at the national level. The main factors underpinning these deficiencies as evident in the study include: . Weak organizational support for data collection systems . Lack of standardization and coherence in attempts to improve health information systems . Decentralised/autonomous/fragmented systems in some countries . Limited capacity for data management and use of workforce data to guide policy making at the national level . Lack of coordination among external partners supporting HRH development Although not directly evident from the study, other factors such as inadequate collaboration between the Ministry of Health and other Ministries such as Education, Finance and the Public Services Commission appear to also constrain HRH data collection and management in the Pacific Recommendations On the basis of the above findings the following recommendations are suggested: RECOMMENDATION 1: That support be provided to countries to develop a standard and coherent system of health workforce information gathering. This should include a system of disaggregating workforce data by gender, age and nationality RECOMMENDATION 2: That countries be supported to develop one centralised HRH data repository that brings together data on all aspects of HRH including data on education and training resources as well as donor support for HRH development. RECOMMENDATION 3: That greater attention be paid to providing continuing education and training services/resources that contribute to the goals of building capacity and capability in HRH in the region. It is crucial that external donors support this engage adequately with Pacific Island Health Ministries in order to identify accurately their education and training needs. RECOMMENDATION 4: That donor support to be better coordinated as well as aligned to meet the goals and objectives of national HRH programmes/strategies, with government taking the leadership role. The primary value of this approach, builds on the efforts of The Pacific Plan, which provides a contextual framework for implementation of the key health Millennium Development Goals. As previously explained, the survey was not designed or intended to be a „Gap Analysis‟, the findings and recommendations presented in this report should be considered as indicators of institutional capacities for development and management of data collection, which are vital for the analysis of systems instrumental for HRH capacity building.
98 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries References
AAAH. (2008). HRH Training in Pacific Island Countries-PNG, Samoa, and Fiji: Asia-Pacific Action Alliance on Human Resource for Health. Aitken, I. (2002). Papua New Guinea Training Institution Review Boston: Management Sciences for Health. Aitken, I., Bhattarai, H. R., Kolehmainen-Aitken, R-L., Newbrander, W., O'Neil, M., Pollock, J. (2002a). Papua New Guinea Human Resource Development Strategy: Realigning and enriching skills of a workforce that cannot be enlarged Draft for Review. Boston: Management Sciences for Health. Aitken, I., Bhattarai, H. R., Kolehmainen-Aitken, R-L., Newbrander, W., O'Neil, M., Pollock, J. (2002b). Papua New Guinea Human Resources for Health Policy Issues Review Paper. Boston: Management Sciences for Health. Beckett CL. Taking the family to East Timor. Med J Aust 2004; 181: 603-604. Cuban-Pacific relations. Retrieved from: Source: http://en.wikipedia.org/wiki/Cuban-Pacific_relations Connell, J. (2006). The Health Workforce of Niue. Stability or Change? Dever, G., Finau, S., Kuartei, S., Durand, A. M., Rykken, D., Yano, V., et al. (2005). The Palau AHEC-- academizing the public health work plan: capacity development and innovation in Micronesia. Pacific Health Dialog, 12(1), 110-117. Diallo, K., Zurn, P., Gupta, N., & Dal Poz, M. (2003). Monitoring and evaluation of human resources for health: an international perspective. Human Resources for Health, 1(1), 3. Hezel Associates. (2001). Expanding the Professional Healthcare Education Resources in Pacific Countries. Kolehmainen-Aitken, R.-L., Shipp, P. (1990: ). Indicators of staffing need‟: assessing health staffing and equity in Papua New Guinea Health Policy and Planning, 5(2), 167-176. Kruske, S. (2006). Papua New Guinea Midwifery Education Review Final Report. Ministry of Health Fiji. (1997). Fiji National Health Workforce Plan 1997-2012. Ministry of Health Fiji. (2007). Nursing Workforce Review Report from the Short Term Advisers. Nodora, R. (2008). Country HRH Country Profiles - Optimum Data Requirement for Human Resources for Health Plan. Paper presented at the PHRH Alliance Meeting. Pollock, J., O‟Neil, M. (2001). Papua New Guinea Health Workforce Management Review. Boston: Management Sciences for Health. University of Auckland. (2005). Situational analysis of mental health needs and resources in Pacific Island Countries. University of Western Sydney (2007). Human Resources for Health in Pacific Island Countries - A Situational Analysis. WHO. (2004a). A guide to rapid assessment of human resources for health. Geneva: World Health Organisation. WHO. (2004b). Guidelines for Human Resources for Health Policy and Plan Development at Country Level (Draft): World Health Organization. WHO. (2006). Working Together for Health Geneva: World Health Organisation. WHO. (2008a). Current HR National Data Sets Retrieved 2 February, 2009, from http://www.emro.who.int/hrh- obs/Tools.htm WHO. (2008b). Establishing National Health Workforce Observatories: Challenges and Opportunities: World Health Organization. WHO UTS. (2008). WHO Human Resources for Health Minimum Data Set - for Nursing/Midwifery. Geneva: World Health Organisation. WHO WPRO. (1991). Report on the Conference on the Development of a Health Workforce Plan for the Pacific Islands Manilla: World Health Organisation, Western Pacific Regional Office. WHO WPRO. (2005). Regional Strategy on Human Resources for Health 2006–2015. Geneva: World Health Organisation.
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Appendices
100 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Appendix 1: Terms of Reference
1. Prepare and implement a detailed work plan including travel to up to 3 Pacific island countries and timelines to undertake data collection of HRH resources of Pacific island countries as identified in the proposal document including: a. country HRH baseline information; b. in-country and external education institutions currently assisting with HRH development in country; c. other stakeholders who may be providing assistance in the area of HRH in country. 2. Submit a comprehensive report outlining the consultation process and report components as outlined in the proposal document; and achievement of 1a to 1c above; as well as a financial statement.
101 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Appendix 2: Survey Questionnaire Instrument
DATE of INTERVIEW...... INTERVIEWEE......
The HRH Hub@UNSW is undertaking a short exercise to determine key HRH resource gaps amongst countries in the Pacific. As the PHRHA Focal Contact you are being asked to complete this questionnaire, to the best of your ability, in order to contribute to this map of HRH resources. The UNSW Project Officer will be phoning you shortly to go through these questions and answers with you. If you will be absent over the next 2 weeks please let the HRH Hub@UNSW know (our contact details are above) and arrange for someone else in your area to be responsible for this questionnaire. We thank you for your support in this. For a number of these questions the following categories of health worker titles are used. These definitions are very similar to the WHO definitions used in its Health Workforce tables. Please refer to these descriptions when you are completing this questionnaire.
Occupational Definitions
Occupation categories (source: WHO Global Atlas of Health Workforce) 1. Physicians - All medical doctors, includes both generalists and specialists. 2. Nursing Personnel - Includes professional nurses, auxiliary nurses, enrolled nurses and other personnel, such as dental nurses and primary care nurses. In some countries, also includes nurse-midwives. 3. Midwifery Personnel - Includes professional midwives, auxiliary midwives and enrolled midwives. (Note that for some countries, nurses with midwifery training are counted under nursing personnel.) 4. Dentists - Includes dentists. 5. Dental technicians/assistants - Includes dental assistants, dental technicians and related occupations. 6. Pharmacists - Includes pharmacists. 7. Pharmaceutical technicians/assistants - pharmaceutical assistants, pharmaceutical technicians and related occupations. 8. Laboratory scientists - Includes laboratory scientists. 9. Laboratory technicians/assistants - Includes laboratory assistants, laboratory technicians and related occupations. 10. Radiographers - Includes radiographers and related occupations. 11. Environment health workers - Includes environmental health officers, environmental health technicians, sanitarians, hygienists. 12. Public Health Officers - All public health officers, district health officers, public health inspectors, food inspectors, malaria inspectors and related occupations. 13. Community health workers- Includes community health officers, community health-education workers, community health aides, family health workers, lady health visitors, health extension package workers, community midwives and related occupations. 14. Medical assistants - Includes medical assistants, clinical officers and related occupations. 15. Personal care workers - Includes institution-based personal care workers, home-based personal care workers, health care assistants and other categories of care attendants in health services. 16. Other health workers - Includes dieticians and nutritionists, occupational therapists, operators of medical and dentistry equipment, optometrists and opticians, physiotherapists, podiatrists, psychologists, respiratory therapists, speech pathologists, medical trainees and interns. 17. Health Management workers - Includes other categories of health systems personnel, such as managers of health and personal-care services, health economists, health statisticians, health policy lawyers, medical records and health information technicians.
Question 1: Please find below the baseline tables of the health workforce numbers. We would appreciate it if you could complete the following two tables - Table 1.a Describes gender and nationality of occupations and Table 1.b describes the age groups of these occupations. Table 1.a also asks for the number of non-nationals employed, that is, those that are not citizens of your country. Please complete this column to the best of your ability. If you already have separate data tables of health workforce numbers you may just add these tables as
102 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries attachments and send these directly back to the HRH Hub@ UNSW when you complete this questionnaire
Table 1a - Health Workforce Numbers by Gender and Nationality. occupation number number total number number of non- male female Nationals 1. Physicians 2. Nursing Personnel 3. Midwifery Personnel 4. Dentists 5. Dental technicians/assistants 6. Pharmacists 7. Pharmaceutical technicians/assistants 8. Laboratory scientists 9. Laboratory technicians/assistants 10. Radiographers 11. Environmental Health Workers . 12. Public Health Workers 13. Community health workers 14. Medical Assistants 15. Personal Care Workers 16. Other health workers 17. Health management workers SOURCE: (List year of data collection...... )
Table 1.b Health Workforce Numbers by Age Group
Occupation Age 0-29 Age 30-49 Age Age not Total years years 50+years specified 1. Physicians 2. Nursing Personnel 3. Midwifery Personnel 4. Dentists 5. Dental technicians/assistants 6. Pharmacists 7. Pharmaceutical technicians/assistants 8. Laboratory scientists 9. Laboratory technicians/assistants 10. Radiographers 11. Environmental Health Workers 12. Public Health Workers 13. Community health workers 14. Medical Assistants 15. Personal Care Workers 16. Other health workers 17. Health management workers SOURCE: (List year of data collection...... )
103 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries Question 2: Can you please list the number of current vacancies in each occupation nationally? Table 2 - Occupational Vacancy Rate
Occupation Number of vacancies date 1. Physicians 2. Nursing Personnel 3. Midwifery Personnel 4. Dentists 5. Dental technicians/assistants 6. Pharmacists 7. Pharmaceutical technicians/assistants 8. Laboratory scientists 9. Laboratory technicians/assistants 10. Radiographers 11. Environmental Health Workers 12. Public Health Workers 13. Community health workers 14. Medical Assistants 15. Personal Care Workers 16. Other health workers 17. Health management workers
Question 3: Has your country produced either an endorsed Human Resource Plan for the Health Sector or is there a chapter/section within a broader Health Sector Strategic Plan? Please include the titles of the document, who produced it and dates of these reports. Question 4: What health workforce standards are in existence in your country? These can include registered standards, competencies or codes of practices for a variety of occupations, listed below.
TABLE 4 - Occupational Standards and Competencies Occupation Name Of Standard/Competency Date 1. Physicians 2. Nursing Personnel 3. Midwifery Personnel 4. Dentists 5. Dental technicians/assistants 6. Pharmacists 7. Pharmaceutical technicians/assistants 8. Laboratory scientists 9. Laboratory technicians/assistants 10. Radiographers 11. Environment health workers 12. Public Health Workers 13. Community health workers 14. Medical assistants 15. Personal care workers 16. Other health workers 17. Health Management workers
Question 5: Does the Ministry of Health have a donor assistance program (either current or planned) for the development of health care workers? Please list any donor projects, grants or loans that include fellowships, scholarships, e-learning, in-country training/education and broader HRH support and list the category of health worker and the name of the donor or supporting partner. Three different examples are listed below: AusAID Nurse Training Project (2005-2010) - Upgrading the skills of nurse practitioners and registered nurse
104 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries educators at 3 nursing schools. WHO Fellowships (2008) - 1 respiratory physician (2 year training in Melbourne), 2 laboratory technicians (6months on-the-job training in Suva) ADB Support for updated Health Workforce Plan (2005-2010) - rewriting country’s health workforce plan
Question 6: Can you please list below the locally trained health workers specific to your country; for example - nurse, midwife, nurse practitioners, Community Health Workers. Please list their title, who provides the training (list all the different training providers) and their broad scope of practice. Question 7: Are any health professionals in your country governed or registered by their own Board or a generic registration board? From the following list please write YES (or tick) those governed by a Registration Board. In a few words please describe the governance of the Registration Board, for example, “prescribed in specific Medical Board legislation since 1998” OR “is more like a Medical Association”.
Table 7 - Registration/Licensure to Practice by Occupation occupation Registration Board description of governance issues (to be completed by interviewer) 1. Physicians 2. Nursing and Midwifery Personnel 3. Pharmaceutical Personnel 4. Dentistry Personnel 5. Laboratory Health Workers 6. Environment and public health workers 7. Other Health Workers 8. Community and traditional health workers 9. Health management and support workers
Question 7 a: Is there national legislation outlining scope of practice for health workers? If so, please list those cadres NOT covered by legislated „scope of practice‟ Question 8: Are health professionals employed by your country‟s government given any specific incentives or working conditions that apply ONLY to those in the health sector (eg. extra training leave for doctors or a period of bonding that requires them to work in rural locations for a period after graduation? Please describe any that you are aware of and which category of health worker they apply to. Question 9: Are you able to list any official meetings between the Department of Health and the departments of Finance, Treasury, Planning and/or Administration or your country‟s Public Service Commission/Department of Personnel, specifically in relation to the health workforce, its numbers, budget or training needs? (For example: Yearly budget meeting between Minister or Secretary of Health/Public Service/Department of Personnel and Minister for Finance regarding workforce needs and budget availability in following year budget). Question 10: The following table (Table 10) describes some of the courses available to trainees in the health workforce in your country. Please complete the following table to the best of your ability. Please try to include as many of the key basic and post-basic educational programs and activities (especially basic training, not in- service training courses) as you can think of. Don‟t worry if you do not have all details for these courses. During your telephone interview we will try to fill in gaps in data and may also use other information reports to do so. If there are other major HRH educational activities currently being undertaken please include these also (for example curriculum development for new health workers or major curriculum review for medical doctors). An example is provided to help you understand types of data required. Table 10 - Pacific Island Countries Educational Institutions - Courses and other Initiatives in the Health Sector (NOTE: The explanatory notes for each column are found at the end of this table).
105 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries a. Name of b. Type of c. d. Funding and e. f. g. Sustain- h. Institution HRH Purpose partners outputs Student ability Identified activity funding Need (including method of delivery) Example Midwifery Midwifer USAID, WHO FSoN own donor Govt. of only: course - Post y and and graduates country funded OWN Basic Nurse post- Government of from support support till COUNTR Fiji School Education basic Fiji OWN 2013 Y of Nursing (allows nurse COUNT Workforc distance training RY in e Plan education, for 2008 via computer trainees laboratory from Fiji POLHN) and several
other PICs to work in their country of origin
Explanatory Notes for Table 10 above Column a. Name of institution - Name of institution. Column b. Type of HRH activity/program or course (including method of delivery) - State if an ongoing course or program or one-off activity (such as development of new curriculum). How is course delivered face- to-face on campus or distance learning or other form of delivery? Column c. Purpose - Purpose of the program, eg. to provide registered nurses in-country Column d. Funding and partners - State who is providing core funding for the program and any other contributors, particularly support from donors, other universities or partners (for example, MoH or MoE budget with 5 year funding by AusAID, ongoing technical support from an Australian university) Column e. Outputs - State the yearly intake per course and most recent graduate numbers (or other useful output if not a yearly course). For example, 42 nurses graduated in 2008, and the 2008 intake in this 3 year course was 60. Column f. Student Funding - How are most students funded? By government traineeships, donors, WHO or NGO funding? Please list the main sources of student funding Column g. Sustainability - Describe any issues relating to this program‟s sustainability. (For example, are all graduates employed in-country, are many choosing to work overseas or not the private sector? Column h. Identified Need - Where is the need for this educational activity identified? In the national Health Sector Plan or your country‟s national development plan or in a Donor Plan? Any other additional notes regarding educational activities This is the end of this questionnaire. We very much appreciate the time and effort you have made to complete this. The survey will be used by WHO Suva and the PHRHA to support HRH development efforts in the next few years. If you have any technical issues regarding this questionnaire or the data collected please contact Ms Jacqui Davison (Email: HYPERLINK "mailto:[email protected]" [email protected] or Phone: +61 2 9385 8464). THANK YOU AGAIN!
106 | P a g e M a p p i n g H uman Resources for Health P r o f i l e s f r o m 1 5 Pacific Island Countries