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SECTION 5. DISCUSSION Health sector data for Pacific Island countries are often out-dated, unreliable or simply not available (Feeny & Clarke 2008); a situation which only serves to make the contributions of each country representative, based as they are on personal and first-hand experience, all the more important. Although all health sector characteristics identified do not apply to every country, they nevertheless provide a composite picture which speaks to each country on some level. Thus, we have a health sector characterised by staff shortages, recruitment and retention problems, skill gaps and imbalances, uneven distribution, and an ageing workforce; a health system characterised by insufficient financing (sometimes the result of government reforms or restructuring), out-dated (at best) workforce plans, strategies and policies, inadequate information systems, inadequate standards and competencies, regulations and legislation, and untrained and/or inexperienced leadership and coordination. To this mix can be added disjuncture between pre-service or pre-vocational education levels and those required to enter health training, small student intakes, unattractive salary levels, and few career prospects for the individual health worker. Some countries have also imposed government reforms which have resulted in reduced health expenditures, fewer health workers and deterioration in the provision of health services. Certainly, there are a number of examples of in-country responses to the sorts of problems described above. Vanuatu, for instance, has directed attention to increasing its nursing intake to 60, doubling its intake for nurse aids and increasing opportunities for postgraduate studies overseas. Health partnerships with countries outside the region have been negotiated. For example, Kiribati, Samoa, Tonga and Solomon Islands have established links and bilateral relationships of varying duration with Cuba for the training of medical staff. In regard to education and training there have also been a number of initiatives such as the Pacific Open Learning Health Net (POHLN) which offers online courses to skilled health workers in the Pacific region. In Palau the MoH developed a bridging program to assist high school graduates qualify for entry into health training. Similarly, a bridging course is currently underway in Vanuatu. Within nursing and midwifery education and training, WHO and various Ministries of Health have negotiated a number of partnerships with institutional counterparts in developed countries (for example between the Cook Islands School of Nursing, Auckland Institute of Technology and Manukau Some countries have also imposed government reforms which have resulted in reduced health expenditures, fewer health workers and deterioration in the provision of health services. Technical Institute; between the Fiji School of Nursing and James Cook University; between the National University of Samoa, Nagano University, University of Technology, Sydney, and Charles Darwin University; between the Tonga Queen Salote School of Nursing and Auckland University of Technology) in order to facilitate the sharing of resources and capacity building. The Health Assistants Training Program, a program equipping indigenous people of RMI with sufficient skills to become mid-level health assistants capable of providing health care in the absence of a doctor, was developed in response to staff shortages in the outer islands of RMI (Keni 2006). In 2007 the Australia-Pacific Technical College was established to provide vocational training at internationally recognised standards across a range of industry sectors, including health and community services (although so far the emphasis has been less on health with certificate and diploma courses focussing on children’s services and community welfare) 16 . Nevertheless, it is clear from participant responses above, that if workforce numbers are to be significantly increased and working conditions improved, then much more needs to be done to develop workforce plans and accompanying policy, create professional management systems, develop career pathways, and devise appropriate education and training programs. Importantly, developing and maintaining strong leadership in MoH which can reach out and effectively engage key stakeholders outside the health sector (for example, education and finance), obtaining political commitment, and securing financial and technical support, are all high-order priorities for fulfilling these needs. The importance of carrying out workforce planning, especially within the context of international emigration, internal mobility from rural to urban areas, and the movement of skilled health workers from the public to the private sectors, is only strengthened when one is reminded that the most recent and 16 See http://www.aptc.edu.au/courses/health/dipl_community.html. 12 HRH issues and challenges in 13 Pacific Islands countries: 2011 Doyle et al.
Most discussions of the precise impact of emigration and the nature of its relationship to HRH shortages within Pacific region countries are hampered by the lack of even the most basic data regarding numbers of emigrants, immigrants and returnees, relying instead on ‘back of the envelope’ estimates. comprehensive examination of health workforce numbers in the Pacific region was conducted more than 20 years ago (see Rotem & Dewdney 1991, referred to in Connell 2009b.) It is not surprising then that a common feature of the country presentations is the need for workforce plan development; a finding which supports the observation that even though workplans have been developed in some countries, they are unused because they have been neither costed nor funded (Nukuro 2010). Also noteworthy is the way in which the impact of migration has been viewed by participants. Given the emphasis each country has placed on staff shortages, recruitment and retention problems within their respective health sectors, it is curious that an emphasis of similar magnitude has not been placed on the issue of migration. Although it is a phenomenon thought to be deeply implicated in the development of staff shortages within countries of origin, and particularly so for small countries (Khadria 2010), participants have not given it the attention one might have expected. As noted earlier, seven countries nominated emigration as an issue or challenge, and only one (Tonga) included it among its needs and priorities. This should not be taken to mean, however, that emigration does not impact on the remaining countries. Indeed, the significance of emigration (in all its forms) for the Asia Pacific region, where health systems are often fragile, has been a consistent theme within the literature for some time. (See for instance Iredale et al. 2003, IOM 2010, WPRO 2004). Unfortunately, however, most discussions of the precise impact of emigration and the nature of its relationship to HRH shortages within Pacific region countries are hampered by the lack of even the most basic data regarding numbers of emigrants, immigrants and returnees, relying instead on ‘back of the envelope’ estimates (Connell 2009b). Nevertheless, one thing is certain - the steady loss of skilled health workers through continuing international migration, internal mobility and movement from the public to private health sector places increasing pressure on already limited resources and struggling public health sectors. This is especially so where skilled health workers from other countries who can substitute for those who have emigrated cannot be found (Forcier et al. 2004) and where the loss of only a small number of skilled health workers makes a crucial difference to efficient and effective functioning of a health system (Pak & Tukuitonga 2006). A possible clue as to why emigration has not been nominated is to be found in the comment of a participant from Fiji who noted that they produce 200 nurses per year to compensate for staff losses due to migration and retirement. Such a response clearly indicates that there is the expectation that a certain proportion of nursing graduates will migrate at some stage. Elsewhere, the General Secretary of the Fiji Nursing Association has been quoted saying that to work overseas is regarded as a ‘privilege’ because of the financial and other returns it provides to relatives at home (Lutua 2002 quoted in Connell 2007: 70). There are also examples of countries actively encouraging their citizens to work and train overseas (eg. KANI – Kiribati). The question of motivations to migrate is one which has occupied researchers exploring the global migration patterns of people from the Pacific region. (For some recent examples see Barcham et al. 2009; Gibson et al. 2010; Lee 2009, Opeskin & MacDermott 2009.) It is also a topic which is to be found in most discussions of migration patterns of skilled health workers within the Pacific region. (See for instance Brown & Connell 2006, Henderson & Tulloch 2008, Oman 2007, Rokoduru 2008, WPRO 2004.) A full exploration of this literature is well beyond the scope of this paper. What is important to the present discussion, however, is the central place economic considerations occupy (including the family responsibilities and kinship obligations to contribute to household income through remittances) in decisions to migrate. Connell’s extensive and enduring research into migration has led him to conclude that a culture of migration is in evidence within many Pacific Island cultures and that migration, far from being regarded as a problem to be removed, has come to serve a crucial economic role. Indeed, remittances have become an integral component of GDP within a number of PICs (Connell 2009a). Remittances to Tonga, for instance, the leading recipient of remittances, represent approximately 45% of GDP (Lin 2010). Such a sizable proportion reflects HRH issues and challenges in 13 Pacific Islands countries: 2011 Doyle et al. 13
Page 1 and 2: hrh issues and challenges HUMAN RES
Page 3 and 4: Contents 2 Acronyms 3 Executive sum
Page 5 and 6: EXECUTIVE SUMMARY INTRODUCTION Back
Page 7 and 8: TABLE 1: SELECTED DEMOGRAPHIC AND S
Page 9 and 10: SECTION 2. METHODOLOGY Prior to the
Page 11 and 12: SECTION 3. PERCEIVED HRH ISSUES AND
Page 13: SECTION 4. NEEDS AND PRIORITIES Hav
Page 17 and 18: Developing bridging courses and out
Page 19 and 20: REFERENCES Australian Agency for In
Page 21 and 22: APPENDIX 1 TABLE 1: SELECTED INFANT
Page 23 and 24: MMR (per 100,000 live births) UNICE
Page 25 and 26: Health Workforce Policy, Management
Page 27 and 28: Health Workforce Policy, Management
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Page 31 and 32: The Knowledge Hubs for Health Initi

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