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SECTION 6. POLICY IMPLICATIONS The migration of health workers is part of a larger exodus (sometimes temporary, sometimes permanent) of skilled and unskilled workers in search of employment. the important role migration plays in the production of remittance flows and the way in which the ‘transnational corporation of kin’ has become a structural feature of many Pacific Island economies. At the micro level, migrating overseas to secure relatively wellpaid employment has become a purposeful strategy practiced within many families as a means of supplementing household income. At the macro level, economies like Tonga’s have become heavily reliant on the flow of remittances from those who have migrated and are now regarded as remittance economies. In short, the migration of health workers is part of a larger exodus (sometimes temporary, sometimes permanent) of skilled and unskilled workers in search of employment. Having come to play a vital economic role for individuals, households and families, as well as national economies, it is unlikely that international migration will diminish in the near future. That many participants did not identify emigration as a problem, instead focussing on labour market conditions (workforce conditions and salaries, workforce planning and workloads, unfilled positions, inadequate funding, worker shortages and so on), is also consistent with the observation that health worker migration is often a response to difficulties in establishing and maintaining principles of fairness and equity for those working within health systems (Buchan 2008) and to social and economic difficulties encountered outside health systems (OECD 2010). It follows that collaborative efforts by government and stakeholders focussed on recognising the skills of health workers and deploying them efficiently within health systems would go some way towards reducing the negative effects of migration. The perceptions and understandings of participants indicate an acceptance of skilled health worker migration and a strong desire to manage staff shortages, recruitment and retention problems by developing sound policy and appropriate education and training structures either locally or within the Pacific region. They also indicated the need to develop and maintain partnerships which would support the fulfilment of needs and priorities. There are three groups of stakeholders for whom policy implications arise; national governments, regional training institutions, and donors, agencies and international organisations. National governments National governments have a role to play in developing evidence-informed policies which have the potential to influence the numbers and distribution of HRH within the health system. The crucial issue for national governments is to be proactive in the areas of health workforce planning and production, recruitment and retention, career progression and establishing acceptable terms and conditions of employment. For instance, when posting health workers to rural and remote areas, and to avoid them leaving the service as a consequence, key questions need to be appropriately addressed: • Have appropriate incentives been designed by government to help overcome the perceived disadvantages attached to a non-urban posting? • Have mechanisms been developed which take into account the financial and physical security of the health worker and their families? • Has adequate housing and access to continuing education been provided? These are just some areas where compensatory measures could be developed and implemented by national governments to help offset some of the disincentives associated with working in non-urban areas and to strengthen health workforce retention overall. Policies and initiatives such as these which actively promote and encourage a return to rural areas have the potential not only to impact positively on the distribution of health workers, but to help address equity issues. Disparities between urban and non-urban populations could be reduced as rural populations, traditionally disadvantaged by poorly resourced health services and more recently by internal migration of health workers, have increased access to health care services. 14 HRH issues and challenges in 13 Pacific Islands countries: 2011 Doyle et al.
Developing bridging courses and outreach programs in schools may go some way towards increasing the skill level of high school graduates and increase their likelihood of gaining entrance to tertiary health professions education. This is not to suggest a ‘one-size-fits-all’ approach to addressing the challenges of staff shortages, deployment, recruitment and retention. Indeed, building equity and developing human capital within health systems require localised solutions which take local conditions and contexts into account. Nevertheless, national governments have a role (albeit one restricted by limited financial resources, small populations, and economies dependent on overseas aid and remittances) to play in pursuing policies which have the potential to promote and advance HRH. A recent review of HRH migration from six PICs (Samoa, Cook Islands, Fiji, Solomon Islands, Vanuatu and PNG) (Roberts et al. 2011) revealed that none of these countries conduct exit interviews of staff leaving service, nor do they assess the impact of skills migration on services. Accordingly, it is recommended that national governments develop costed workforce plans in conjunction with their Ministries of Finance that include financial incentives for rural placement, career progression options, opportunities for continuing professional development and a system of exit interviews to ascertain the reasons for people leaving public sector service and their home country for alternative careers. Regional educational institutions The area of pre-vocational education warrants greater attention in many of the smaller PICs, where access to education is often offshore. A number of countries have expressed concern over the small numbers of young people entering health sector training; a situation believed to be largely due to too few high school graduates meeting the standard of science and maths required for entry into training programs 17 . Developing bridging courses and outreach 17 It is also worth noting that some education systems within Pacific Island countries, like their health system counterparts, are now beginning to experience growing rates of international teacher migration and staff shortages (Voigt-Graf et al. 2007; Iredale et al. 2009). programs in schools may go some way towards increasing the skill level of high school graduates and increase their likelihood of gaining entrance to tertiary health professions education. In addition, the numbers of medical graduates from the Fiji School of Medicine, traditionally the region’s medical graduate supplier, although recently increased, have not been sufficient to contain the emergence of new medical schools within the region, nor to deter PICs from entering into training agreements with Cuba. Managing the return of Cuban trained medical graduates and the integration of graduates of new medical schools into national health systems presents issues of establishing regional standards and internships, and requires planning for funding and resourcing. Accordingly, it is recommended that health professions educational institutions work with national governments to propose and prepare for regional examinations and internship programs that can accommodate graduates from a range of training institutions, including those recruited from Asian countries, many of whom are already working within PIC health systems. Donor, agencies and international aid organisations With relatively small and in some cases declining health expenditures, it is difficult to see how health workforce recruitment can be adequately increased without significant increases in financing. As Connell (2010) notes, success primarily depends on international agencies and aid donors realising that achieving Millennium Development Goals (MDGs) requires an efficient and productive health workforce. In this sense, health needs to be regarded as a ‘special case’ (p.19) deserving of adequate funding from aid organisations. Furthermore, given the very real limits on the numbers and types of measures Pacific Island governments can initiate to alleviate workforce, policy, education, training and migration challenges, support from the international community is required. There are opportunities for donors to provide technical and/ or financial assistance in a number of areas. HRH data inadequacies across the region have been well documented. Mobility and attrition rates, although fundamental elements required in devising appropriate retention strategies and workforce planning, are largely matters of guesswork. Technical and financial assistance in developing practical methods of recording the internal mobility of skilled health workers (ie movements to and from public to private health sector, rural to urban areas, and movement out of the health sector altogether) and the emigration and return migration of skilled health workers, would provide a sound evidence base HRH issues and challenges in 13 Pacific Islands countries: 2011 Doyle et al. 15
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 and 14: SECTION 4. NEEDS AND PRIORITIES Hav
Page 15: Most discussions of the precise imp
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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