TENTH PACIFIC HEALTH MINISTERS MEETING PIC10/10

17 June 2013

Apia, Samoa

2–4 July 2013 ORIGINAL: ENGLISH

HEALTH WORKFORCE DEVELOPMENT IN THE PACIFIC

Several Pacific island countries and areas (PICs) have health worker-to-population ratios below the World

Health Organization (WHO) recommended minimum threshold of 2.3 per 1000 population. Many face external

labour market forces that make it difficult to balance health workforce demand, supply and affordability with existing

and emerging population health needs. The imminent return of large numbers of foreign-trained medical graduates

(FTMGs) will place further demands on workforce planning and health budgets in at least five PICs. The Human

Resources for Health Action Framework for the Western Pacific Region (2011–2015) provides clear guidance on the

issues that must be addressed by each Member State in the context of its own labour market.

Many Member States, with support from external partners, are currently undertaking a detailed program of

analytical work to update national human resources for health (HRH) profiles, review evidence-based policy options

and develop or update national HRH plans. Subregional approaches have been a particularly effective way for

countries to share and discuss their strategies for the integration of FTMGs. The formation of multisectoral task

forces to address the integration of new medical graduates, for example in Kiribati, Tuvalu and Solomon Islands and

the development of specialized clinical workforce plans through the Strengthening Specialised Clinical Services in

the Pacific (SSCSiP) programme are having a catalytic effect on broader HRH planning and decision-making.

Strengthening the capacity of medical internship programmes throughout the Pacific will be a key strategy in

integrating FTMGs. It will also be an important step towards developing competency-based regional standards for

entry-level medical practitioners, complementing similar work undertaken for registered nurses in the Pacific. The

rapid uptake of Pacific Open Learning Health Net (POLHN) courses underlines the fact that distance learning and

flexible learning are important mechanisms for initial training, continuing professional development (CPD) and

career advancement.

Coherent, informed national plans are needed to ensure both the availability of quality care and the retention

and deployment of skilled and appropriate staff where needed, particularly in rural and remote settings. A

comprehensive programme of action in line with the post-2015 development agenda should be considered. A

reinvigorated Pacific Human Resources for Health Alliance (PHRHA) technical working group is proposed as a

forum to ensure alignment of the activities of technical partners within the PIC context and as a mechanism to

maintain collaborative and coordinated interaction with and among countries—key principles in promoting change

and ensuring that investments are strategically targeted.

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1. BACKGROUND

Health workers are an essential part of every health care delivery system. The health

workforce influences everything from the access to and quality of health services to the costs

of delivering health care. The health workforce usually represents the largest and most

expensive component of a health system.

There is a positive correlation between health worker-to-population ratios and infant,

child and maternal survival rates. WHO regards a health worker-to-population density of 2.3

doctors, nurses and midwives per 1000 population as the minimum needed to provide 80%

coverage of basic essential services, for example skilled birth attendance and childhood

immunization. Countries below this threshold, including several Pacific islands countries and

areas (PICs), are considered to have a critical health worker shortage (see Figure 1).

Figure 1: Pacific Health Workforce Density

(Doctors, Nurses, Midwives per 1000 population)

Source: Updates data from WHO Country Health Information Profiles (CHIPs 2011) and Country Human

Resources for Health (HRH) Profiles, 2012–2013, where available.

Pacific ministries of health (MOH) have identified a number of Human Resources for

Health (HRH) priority issues affecting countries in the region, including:

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1) shortages of specific personnel and skill sets, and recruitment, retention and an

ageing workforce;

2) lack of effective HRH policies, management and information systems, and

planning capacity;

3) access to education and training opportunities to meet current shortages and

continuing professional development (CPD) requirements;

4) public sector working conditions, institutional capacity and financial constraints to

improve; and

5) the implications of increasing mobility of health personnel, both internally and

internationally.

Other priority issues include inequitable distribution; health worker performance; the

unique requirements of small populations scattered throughout remote, rural and outer island

settings and over wide geographical distances; and the relative lack of development of other

health system components.

The WHO Human Resources for Health Action Framework for the Western Pacific

Region (2011–2015), which is summarized in Annex 1, outlines the key policy, management,

education, financing, leadership and partnership functions that need to be addressed in each

country, as well as the specific labour market context in each country, in order to build an

effective and sustainable workforce.

Many countries are about to experience a major shift in health workforce composition

as a result of increasing numbers of medical students graduating from institutions within and

outside the region. In addition to the long-established schools of medical education in the

Pacific—the Fiji School of Medicine (FSMed), now part of Fiji National University (FNU),

and the University of Papua New Guinea (UPNG), two new institutions of undergraduate

medical education have been established within the last 10 years: the Oceania University of

Medicine (OUM) in Samoa and the Dr Umanand Prasad School of Medicine (UPSM), a

private institution affiliated with the University of Fiji in Lautoka.

Since 2007, candidates from PICs have also been studying medicine in Cuba at

Escuela Latino-Americana de Medicina (Latin American Medical School, or ELAM) and in

other countries outside the Pacific, including China, Georgia, Morocco and the Russian

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Federation. Concurrently, FNU has increased its intake and UPSM has continued to accept

significant numbers of new enrolments.

Table 1 summarizes current PIC engagement with the three medical education

institutions with the largest number of enrolments in the region, compared with current health

workforce densities. Figure 2 shows the expected year of entry into the medical workforce for

each stream of graduates from FNU, ELAM, UPSM and OUM. These numbers will more

than double the non-specialist medical workforce in six countries (those above the heavier

line in Table 1) between 2013 and 2018.

Table 1: Health worker density in selected Pacific Island countries (most recent

estimates), and current numbers of medical students training at the three largest

institutions serving the Pacific

Country

Doctors per

10 000

population

Nurses and

midwives

per 10 000

population

Current number of medical

undergraduates

Medical

students per

10 000

population FSMed ELAM UPSM

Kiribati 3.8 37.1 12 31 – 4.17

Nauru 7.1 70.7 2 7 – 9.75

Solomon

Is

2.2 20.5 38 98 11 2.85

Tuvalu 10.9 58.2 6 19 – 26.15

Vanuatu 1.2 17.0 12 25 – 1.58

Fiji 4.3 22.4 301 7 176 5.78

Palau 13.8 57.1 – 6 – 3.01

Tonga 5.6 38.8 31 6 – 3.63

Total: 402 199 187

Sources: WHO (2012), Secretariat of the Pacific Community (2011), SSCSiP (2012) and

HRH Knowledge Hub (S Lin and G Roberts, University of New South Wales; personal communication, 2013)

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Figure 2: Expected numbers entering internships across the Pacific, by year

Current FNU, ELAM, UPSM and OUM medical undergraduates

Flag indicates year of entry of first cohort of Cuban graduates into medical workforce;

OUM data for students from PICs only, and only to 2015

In general, this increase in medical training has not been aligned with national HRH

plans and any objective training or workforce need projections.

While the surge in the number of doctors will clearly enable some countries to fill

vacant medical officer positions in support of national primary care strategies and community

demand, others do not have sufficient staff vacancies to absorb all of the returning graduates.

Other risks include a surge in direct and indirect costs, the potential displacement of

established cadres of medical assistants and nurse practitioners, and the capacity of countries

to provide supervision and mentoring for a medical workforce that is increasingly comprised

of relatively junior doctors.

2. ACHIEVEMENTS AND PROGRESS

Country-level initiatives

Several PICs have implemented, or are implementing, measures to strengthen their

national health workforce capacities across the main areas of the HRH Action Framework.

However, results and outcomes have so far been variable.

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Fiji, Kiribati, Marshall Islands, Samoa, Solomon Islands, Tuvalu and Vanuatu have all

established national HRH task forces, either to address specific issues, such as the integration

of foreign trained medical graduates, or to support HRH more broadly.

Fifteen PICs are currently updating their country HRH profiles, using a

comprehensive WHO profiling tool, with technical assistance from the HRH knowledge Hub

at the University of New South Wales and WHO. The revised profiles will provide updated

descriptions of the current health workforce by cadre and type of health facility, gender, age,

province, urban/rural location, skills and educational attainment. The revised profiles will

also include new sections on HRH policies, including legislation on recruitment, deployment

and the role of the private sector; financing and remuneration analysis; governance; and

health workforce information systems. This updated information will support monitoring and

trend analysis of HRH, facilitate better decision-making among policy-makers and promote

information sharing and cross-country comparisons to provide a more in-depth understanding

of the dynamics of HRH in the Pacific.

The World Bank has provided analytical and technical assistance to some PICs to

inform health system performance reforms, including support for planning and management

of human resources. This includes the recently released report Papua New Guinea Health

Workforce Crisis: A Call to Action (April 2013); ongoing assistance to Solomon Islands to

explore role delineation and HRH needs at different levels of service delivery, as well as

policy and financing options for the retention of specialist doctors; and a stocktake of the

health workforce in Vanuatu in 2012.

Following vigorous discussion at the Pacific Human Resources for Health Alliance

(PHRHA) meeting in November 2012, countries agreed that better access to and

strengthening the capacity of domestic internship programs would be a crucial, practical

strategy to assist the integration of the larger-than-usual numbers of medical graduates who

will be entering the health workforce in several PICs from 2013 to 2020. Kiribati has been

the first country to implement this strategy (see the box below).

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Development of new medical internship programme serving the Central Pacific

Kiribati is the first PIC that will receive medical graduates from Escuela Latino-

Americana de Medicina (ELAM), with a group of 18 due to return from Cuban school in

August 2013.

Kiribati does not have its own internship programme. Historically, I-Kiribati medical

graduates have completed their internship in the country of graduation, usually Fiji.

However, access to internship positions in Fiji is now severely restricted due to an imminent

escalation in the domestic demand for places by graduates of the College of Medicine,

Nursing and Health Sciences at FNU, and Dr Umanand Prasad School of Medicine (see

Table 1).

In January 2013, the Kiribati Ministry of Health and Medical Services (MHMS)

convened an intensive consultation involving clinicians, key health sector decision-makers,

WHO and FNU to examine the feasibility of establishing a new internship programme. The

workshop determined that such a programme would be feasible— with some ongoing

technical and clinical supervisory support from FNU—and developed a structure and format

based on careful and detailed analysis of competencies needed by junior medical officers.

The assessment would be conducted by the completion of a detailed logbook along with

structured supervisor reports, similar to other internship programmes in the region.

A peer review of the proposed internship programme was held in Tarawa, Kiribati, in

March 2013, with the participation of health and national workforce delegates from Solomon

Islands and Tuvalu and independent experts from WHO and FNU. The meeting confirmed

the proposed design of the 18-month internship programme, including supportive HRH

strategies being put in place by the MHMS and Public Service Office in Kiribati. The review

recommended a detailed pre-assessment of intern competencies on commencement of the

programme and an exit evaluation on completion of the programme by the first group of

interns. FNU will help to develop tools for these activities.

Nauru and Tuvalu have expressed strong interest in sending their own FTMGs to join

the new Kiribati internship programme from 2014 and 2015, respectively, and in hosting

community placements on rotation from Kiribati during the candidates’ second year. Such an

effort will create an innovative and truly collaborative three-country internship programme.

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Ongoing dialogue between the Kiribati Ministry of Health and Medical Services

(MHMS) and Public Service Office has been essential to identify and safeguard positions for

the first group of incoming graduates without displacing other categories of health workers.

Good communications and engagement with the national Cabinet and the Ministry of Finance

and Economic Development have ensured that sufficient funding will be available for these

positions.

A similar process is under way in Solomon Islands, which must assess the feasibility

of assimilating more than 90 FTMGs into its health workforce between 2014 and 2019. The

process began with a workshop convened by the Solomon Islands MHMS and the FTMG

Task Force in Honiara, with representatives from WHO, FNU, Kiribati and Vanuatu.

Kiribati shared lessons learnt from developing a new, competency-based internship

programme with multisectoral engagement and support. Critical decisions and actions from

the development of that programme are summarized in the checklist attached as Annex 2.

The new Kiribati internship programme and the strengthened programme in Solomon

Islands will be based on a detailed assessment of competencies required by entry-level

medical officers. This work can inform the development of regional, competency-based

standards for internship programmes.

Regional Initiatives

Pacific Human Resources for Health Alliance

The Pacific Human Resources for Health Alliance (PHRHA) was formed in 2008 to

address a range of HRH challenges in an integrated manner, thereby contributing to the

development of Pacific health systems. Its principal source of funding support has been the

Australian Agency for International Development (AusAID).

The third meeting of the PHRHA took place in November 2012. It further

highlighted the need to focus more strongly on priority work areas, which include:

1) relevant and timely monitoring, review and trend analysis of the Pacific HRH

situation and addressing issues and challenges at regional and subregional levels;

2) maintaining and developing a platform for coordination and collaboration among

countries and partners working in HRH in managing information and resources

among PICs; and

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3) advancing health professions education and training by establishing regional

frameworks for core curricular standards, CPD and scopes of practice.

The shortage of clinical specialists and specialized services and the limited demand in

smaller PICs means that many PICs rely on visiting specialist medical teams and offshore

medical referral schemes to deliver tertiary and higher-order secondary care. The AusAID-

funded Strengthening Specialised Clinical Services in the Pacific programme (SSCSiP),

based at FNU, seeks to address challenges in the delivery of specialized care by supporting

PICs to plan for, access, host and evaluate specialized clinical services and by strengthening

health worker skills, capacity and capability to meet clinical service needs.1

Since SSCSiP’s inception in 2011, 14 PICs have been working with the programme to

improve human resources planning for specialized clinical services, and better coordination

and access to specialized clinical training. Some of their joint achievements include:

1) mapping the demographic profiles and highest postgraduate qualification of

clinicians employed by MOHs;

2) improving access to specialized clinical training, developing a web page that lists

postgraduate courses available to PIC health workers at the specialized level;

3) working closely with professional clinical organizations in the Pacific (for

example, the Pacific Society of Anaesthetists and the Pacific Islands Surgeons

Association) to enhance access to quality CPD activities;

4) securing funding for selected postgraduate clinical scholarships as a response to a

genuine shortage of scholarships for postgraduate clinical studies,; and

5) addressing the lack of qualified biomedical technicians and engineers in the

Pacific and working with training institutions to establish a Pacific Biomedical

Training Programme.2

Selected findings of the mapping exercise are included in Annex 3. Each national

profile reflected the HR capacity to deliver core and specialized clinical services and

provided a sound baseline against which to compile specialized workforce development

1 The SSCiP programme covers 14 PICs: Cook Islands, Fiji, Federated States of Micronesia, Kiribati, Marshall Islands,

Nauru, Niue, Palau, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu and Vanuatu. 2 The Pacific Health Ministers Meeting has previously identified biomedical engineering as a high priority for the Pacific; it

is envisaged that the Biomedical Training Program will commence in 2014.

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plans. In some cases, these plans are now acting as a catalyst for broader national HRH

planning.

HRH Knowledge Hub

The HRH Knowledge Hub undertakes strategic analyses of HRH issues in the Asia

Pacific region to inform the development of innovative evidence-based policy options and

solutions for strengthening HRH planning and workforce management. It has been funded by

AusAID through June 2013. The Hub has developed a series of analytic papers entitled

Evidence and Policy Options for Healthcare Education and Training in Pacific Island

Countries. Condensed versions of the analytic papers are currently in press in Pacific Health

Dialogue, and a range of policy briefs has been extracted from the analytic papers and will be

available at the Tenth Pacific Health Ministers Meeting.3

Pacific Open Learning Health Net

Following a successful pilot in 2002–2003, the Pacific Open Learning Health Net

(POLHN) was established in 2004 by WHO and ministries of health in the PICs. Initial

funding was provided by the Government of Japan (2003–2008), followed by New Zealand

(2009–2012). As Internet connectivity and bandwidth have improved in the Pacific, the

number of POLHN learning centres, courses and students has also increased (see Figure 3),

providing much improved access to continuing education through distance learning and

flexible learning. The network currently operates through 37 learning centres in 12 countries.

3 The Hub analytic papers and policy briefs address the following topic areas: a) Commissioning of health

worker education and training; b) Medical education; c) Nursing and midwifery education; d) Accreditation of

healthcare professional education programmes; e) Expanded and extended health practitioner roles; f) Medical

Internship programs; and g) Regulation and licensing of healthcare professionals.

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Figure 3: Growth in POLHN capacity and enrolments, 2007–2011

Fiji, Solomon Islands and Vanuatu have achieved a dramatic expansion in coverage

and activities by establishing additional learning centres and/or increasing the student intakes.

Accredited courses are available through POLHN on behalf of FNU (diploma and Masters in

Public Health and Health Services Management), the Pacific Paramedical Training Centre

(diploma in laboratory sciences) and the Penn Foster Career School in the United States of

America (dental assistant programme piloted in American Samoa and the Marshall Islands).

The needs of ancillary support staff, for example clerical and administrative workers, have

also been addressed through POLHN by providing three levels of computer-literacy training.

POLHN now represents an increasingly important resource for CPD in the Pacific,

providing health professionals with access to both online and “hybrid” courses and with

access to telephone- and video-conferencing facilities for CPD.

Other partners are engaged in providing technical and analytic support in the Pacific,

working in areas like HRH policy and management, standards and quality of education and

training, competencies, and professional conduct and practice. They include the medical,

nursing and allied health professional associations; the Pacific Senior Health Officials

Network (PSHON); the Pacific Islands Health Officers Association (PIHOA); health training

institutions; and WHO Collaborating Centre for Nursing, Midwifery and Health

Development at the University of Technology in Sydney and WHO Collaborating Centre for

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Nursing and Midwifery Education and Research Capacity-Building at the James Cook

University Australia in Townsville.

3. CHALLENGES AND ISSUES

Ongoing country-level analytic work in support of HRH planning

All countries need accurate health workforce data to support HRH planning and

policy development. These data have not always been available. The challenge then will be

to gather, analyse and ensure that the data become “live” through the establishment constant

updating of efficient national information systems.

Similarly, there is also a need for the health workforce distribution and need

projections to be based on the priorities identified in national health strategic plans and on a

sound analysis of epidemiology, burden of disease, models of care, patterns of referral and

role delineation. While some initial work has been undertaken in Solomon Islands and

Vanuatu, other countries will need more data to provide objective evidence on which to base

updated HRH plans.

Multisectoral engagement in national HRH planning

Pacific leadership on HRH and related service delivery challenges has tended to be

concentrated within the health sector. However, in most PICs, responsibility for pre-service

training may rest with either the education or health sector and may differ for different groups

of health workers. The ministry of health may remain the employer, but overall public sector

job creation and management fall under the national labour or public service administration,

and workforce financing is ultimately determined by the finance sector or, in some countries,

directly by Cabinet.

There is currently minimal engagement from relevant sectors in the government to

increase country commitments to prioritize domestic resources and create the fiscal space to

train and retain the right number and mix of health-care professionals.

The emergence of multisectoral task forces to address the assimilation of FTMGs into

the workforce, for example in Tuvalu, and the direct engagement with the public service

sector and Cabinet, for example in Kiribati, clearly demonstrates the importance for such

participation. Such high-level, multisectoral strategic approaches need to be maintained if

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Pacific health systems are to provide sustainable services to meet present and future

population needs.

Quality assurance for new or expanded internship programs

There is a need for new and expanded internship programmes to support the

integration of new FTMGs. The demands on these programmes are significant—especially

for quality of supervision, which determines not only the overall credibility of an internship

programme but also the future career prospects of medical graduates. Sound quality-

assurance mechanisms will contribute to the evolution of regional standards as a prerequisite

for general registration and eligibility to apply for future training in clinical specialties.

The thorough preparation and analysis undertaken by the Kiribati MHMS, the Tuvalu

Ministry of Health, the Solomon Islands MHMS and partners to develop and implement a

relevant internship programme validates the importance of this step towards developing

agreed competencies for new medical graduates.

An accredited forum for consideration and approval of standards and competencies

for pre-service and in-service education and training in the health sector does not yet exist in

the Pacific.

Continuing professional development

Continuing professional development (CPD) has an important place in ensuring that

health professionals are competent and their practices are aligned with advances in medicine

and health technologies for quality care and patient safety. Some of the issues and challenges

that need to be addressed include undertaking CPD-oriented training needs assessments to

develop and implement CPD programmes; adopting policy and regulations that include

mandatory participation in CPD activities as prerequisites for renewal of licensing and

registration to practice; improving the availability of accessible, flexible and diverse CPD

options; and performance-based incentives for CPD and for career advancements.

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4. FUTURE DIRECTIONS

Country focus: enhanced quality of national HRH planning

In line with the recommendations of the November 2012 PHRHA meeting, the

establishment and/or strengthening of national HRH task forces to include multisectoral

representation will be prioritized.

The task forces are intended to provide a point of reference at the national level for

technical and analytic input on national workforce planning and systems, as well as a robust,

authoritative, national- level forum for discussions and the development of policies, strategies

and plans. They would have responsibility for developing or strengthening national HRH

plans to reflect current needs and address current and future HRH challenges affecting each

country and the Pacific region.

Intercountry collaboration at the subregional level

A heads of health meeting and directors of clinical services meeting were held in

Nadi, Fiji in May 2013 and examined a number of options related to the organization of the

Pacific regional “architecture” in the health sector.

Multi-country participation in the FTMG workshops in Tarawa, Kiribati, and Honiara,

Solomon Islands, and breakout groups with directors of clinical services in Nadi both

demonstrated the efficiency and effectiveness of subregional approaches where a number of

neighbouring countries are faced with similar challenges. Participants can work together to

find collaborative solutions to shared issues, and, as with the example of the Kiribati

internship programme, those solutions may involve an ongoing joint programming response.

Although the focus of the Tarawa and Honiara meetings was on the integration of

FTMGs, strategic discussions included the broader HRH situation in participating countries.

The meetings also proved to be an effective way of engaging with non-health sectors, such as

national workforce agencies.

Maintaining balance within the clinical workforce

In the context of current debate about the regional health architecture in the Pacific,

the meetings of heads of health and clinical directors also noted that SSCSiP is able to

provide advice on effective options and solutions at the national, subregional and regional

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levels that are appropriate for the current needs of countries. The SSCSiP Stakeholder

Reference Group, with the participation of permanent secretaries of health and clinical

directors, identified the following HR priorities for specialized clinical services in their

countries and the region:

1) support countries with their HR development plans for specialized clinical

services;

2) support PICs with the implementation of their HR plans for specialized clinical

services; and

3) strong advocacy to national scholarship offices and development partners to

allocate, or reserve, more scholarships for short- and longer-term postgraduate

clinical training.

The return of large numbers of FTMGs to several countries will also add to the

supervision requirements for an increasingly junior medical workforce and create a wide gulf

within the clinical workforce between specialist supervisors and interns. Increasing the

number of registrar-level supervisors with postgraduate diploma qualifications as soon as

possible would quickly contribute to achieving a better balance within the medical workforce.

Maintaining momentum for regional standards

More focus will be given to the improvement of quality, standards and opportunities

in the education, training and employment of health-care professionals. This should take

place within the context of the countries’ health systems and defined national health

priorities.

Some evolving initiatives in the region provide an excellent platform for further

development. For example, the South Pacific Board of Educational Assessment (SPBEA)

has already embarked on an ambitious programme to map tertiary and vocational

qualifications in the Pacific, and to develop criteria and mechanisms for cross-accreditation.

The end result would be health-care professionals that are “fit for purpose” and “fit to

practise” in a mobile, cross-border labour market. This effort would include clear definitions

of the unique standards and competencies required for doctors, midwives and nurses to

practise in the Pacific. It could be developed to meet current and future population needs

specific to the region while drawing on the international trends and evidence on health

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workforce education, licensing and CPD standards, as well as the need for compatibility with

future career choices and vocational training.

Collaboration, coordination and partnerships

Engagement of several partners in broader HRH analytic work, policy development

and planning will be further promoted. These mechanisms will also interface with a number

of other Pacific regional strategies and programmes. Consideration will be given to

promoting the most effective use of resources, reducing administrative and transactional

burdens on countries, and generating a coherent and compatible set of evidence for national

decision-making and regional policy dialogue—in keeping with the Cairns Compact on

Strengthening Development Coordination in the Pacific.

The current platform available with PHRHA could be effective, based on the initial

outcomes of collaborative activities on the integration of FTMGs. The PHRHA Technical

Working Group could be reinvigorated to undertake regular reviews of partner activities and

country progress. This will provide a useful, small group forum for technical partners to

share plans and results, examine emerging evidence, review the PIC context and overall

directions, and maintain collaborative communication with and between countries.

The current review of the Pacific Plan for Regional Integration and Cooperation

represents a timely opportunity for countries and development partners to re-examine

solutions to the region’s long-standing HRH challenges in a way that transcends national

borders and can catalyse multisectoral actions. In this way, it also can promote change,

providing additional investment that is strategically targeted to outputs, outcomes and results.

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ANNEX 1

Summary of the WHO HRH Action Framework for the Western Pacific (2011–2015)

Critical Success FactorsResults-focused planning and practices

System-linked alignment

Knowledge-based decision-making

Learning-oriented perspectives

Innovative solutions

Comprehensive and integrated approaches

BETTER

HEALTH

OUTCOMES

Improved Health

Workforce Outcomes

Critical Success Factors Country-led initiatives

Government-supported actions

Multi-sector engagement

Multi-stakeholder involvement

Donor alignment

Gender sensitivity

Equity

Effectiveness

Efficiency

Accessibility

Responsiveness

BETTER

HEALTH

SERVICES

Preparation & Planning

Situ

atio

n A

naly

sis Im

ple

me

nta

tion

Monitoring & Evaluation

Service DeliveryHealth Care Financing

Medical Products and Technologies

Health InformationGovernance

Policy

Leadership

Partnership Education

FinanceHuman

Resources

for Health

Systems

Country specific context

Including labour market

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ANNEX 2

Integration of foreign-trained medical graduates

DRAFT CHECKLIST OF PRIORITY DECISION POINTS AND ACTIONS

Key:

Red = decision points or actions specifically related to the integration of foreign-trained medical graduates FTMG into the health workforce

Black = steps related to wider HRH policy framework and enabling environment, which will broadly support FTMG integration

HRH ACTION AREA

and key outputs and outcomes

1. Leadership

Core National Task Force on FTMG Integration formed (MOH, Public Service, technical partners and donors)

TORs and secretariat functions for Core Task Force agreed

Core Task Force meeting approximately 1–2 monthly during establishment phase of internship program and until completion of evaluation of first cohort

(may be extended as needed)

Core FTMG Task Force engaging support from other key multisectoral stakeholders (Ministry of Education, Ministry of Finance and Economic

Development, Ministry of Foreign Affairs and Immigration; other development partners) as required

Once first two cohorts have entered workforce, decision made on whether Task Force to continue or to integrate its role into routine functions of

participating agencies

2. Policy Frameworks

National Health Strategic Plan in place, providing overarching context for prioritisation of HRH development within health sector

Policy decision made about whether graduates from different medical undergraduate programmes will have common or separate pathways into health

workforce and for future career options

Internship Programme endorsed as a key strategy in integration of FTMGs

National Health Workforce Plan developed – linked to public health priorities, burden of disease, models of care and referral pathways, and establishing role

delineation for different cadres of health worker at different levels of service delivery

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Annex 2

National Health Workforce Plan costed and approved

3. Human Resources Management and Information Systems

3a. Management

Lead HRH officer identified / confirmed at MOH

National HRH working group established

Begin development of HRH functions

National Health Workforce Plan guiding HRH development (including undergraduate and postgraduate medical training) over medium to longer term

National Health Workforce Plan review meeting (aligned with annual sectoral review meeting and pre-budget planning and negotiations)

3b. Information systems

Computerised national HRH information base established (incorporating all health worker categories / the whole health workforce)

4. Finance

4a. Funding for Internship Programme

Government funding identified for internship programme

Dialogue initiated with development partners / donors about any necessary supplementary funding

Fund management mechanism identified and agreed, appropriate to source(s) / streams of funding

Funds for internship programme costs disbursed in a timely and efficient manner

4b. Funding for Intern Positions

Internship positions confirmed within staff establishment in advance of arrival back in-country of each cohort of medical graduates

Cost analysis and forward projections of absorption of interns into health workforce

Internship positions funded within health budget

5. Education and Training

5a. Pathways to practice

Internship programme designed, peer reviewed and endorsed

Terms of Reference developed for programme coordination mechanism and expatriate specialists

PIC10/10

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Annex 2

Programme Coordinator(s) and expatriate specialists (as needed) recruited and mobilised

MOE keeping students studying overseas informed about preparations and arrangements for internship and entry into workforce (e.g. via periodic newsletter)

Orientation and induction programme designed and delivered

Teaching and learning programme (including medical English course, as necessary) designed and initiated

Teaching and learning programme maintained

Teaching and training activities included in terms of reference for visiting medical teams

CPD programme for medical graduates developed and endorsed, based on internship programme

5b. Assessment, Monitoring and Evaluation

Pre-assessment for first cohort of returning FTMGs conducted during orientation and induction programme

Training Committee established, active and meeting at least three-monthly; mentoring and counselling provided to interns as relevant to performance

Post-assessment conducted on completion of first cohort of returning FTMGs

Independent evaluation of internship programme

5c. Accreditation for postgraduate training

Ongoing dialogue with FNU about accreditation of internship programme

Accreditation of FTMGs to apply for postgraduate clinical training at FNU on completion of internship programme

5d. Commissioning

Recruitment of medical students aligned exclusively with National Health Workforce Plan

Postgraduate (specialty) training awards aligned exclusively with National Health Workforce Plan

5e. Infrastructure

On-call facilities for interns identified

Access to POLHN facilities confirmed for participants in internship programme; enrolment in distance education programmes as per teaching and learning

programme

In-country education and training facilities being used for delivery of education and training programme

PIC10/10

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Annex 2

5f. Licensing and Registration

Provisional medical practitioner registration category established for participants in internship programme

Eligibility for full registration on successful completion of internship programme confirmed

Policy decision made about whether a non-practising category of medical registration is needed under the national Medical Board (or equivalent)

Dialogue initiated with SPBEA after completion of Pacific Plan review regarding status of internship programme in relation to evolving regional registration

6. Partnerships

Dialogue initiated and maintained with Cuban Medical Brigade about role of in-country doctors in internship programme and teaching and learning activities

Dialogue initiated and maintained with RACS and NZMTS (with SSCSiP assistance, as necessary) about role of visiting teams in internship programme and

teaching and learning activities

Dialogue initiated and maintained between the Governments of the Pacific island countries and the International Cooperation and Development Fund

(Taiwan, China) about role of in-country doctors and visiting teams in internship programme and teaching and learning activities

Dialogue initiated and maintained with key bilateral donors about potential support for internship programme, teaching and learning activities or related

facilities (aligned with annual partnership talks on bilateral agreements)

PIC10/10

page 23

ANNEX 3

Strengthening Specialised Clinical Services in the Pacific (SSCSiP) Programme

MAPPING OF CLINICAL WORKFORCE CAPACITY IN PICs

Table 1. Number of local and expatriate clinicians in each country

Fij

i

So

lom

on

Is

Van

uat

u

Sam

oa

FS

M

Kir

ibat

i

To

ng

a

RM

I

Pal

au

Co

ok

Is

Tu

val

u

Nau

ru

To

kel

au

Niu

e

Total

Number of local clinicians

employed by the MOH 355 79 27 55 46 18 44 2 7 15 7 2 4 2 663

Number of expatriate

clinicians employed by the

MOH

38 2 8 10 18 7 0 8 8 10 2 7 0 2 120

Total number of clinicians

(Local + expatriates) 393 81 35 65 64 25 44 10 15 25 9 9 4 4 783

Number of clinicians (local

+ expatriate) per 10 000

population

4.7 1.6 1.4 3.5 6.0 2.4 4.3 1.5 6.0 17.6 8.5 9.7 28.3 30.8

Figure 1. Proportion (%) of clinicians classified as local compared with expatriate

Table 2. Highest qualification for local clinicians

Countries →

Highest clinical

qualification↓

Fij

i

So

lom

on

Is

Van

uat

u

Sam

oa

FS

M

Kir

ibat

i

To

ng

a

RM

I

Pal

au

Co

ok

Is

Tu

val

u

Nau

ru

To

kel

au

Niu

e

Total

MBBS 354 43 12 32 30 9 23 2 2 9 2 2 3 1 424

PG Diploma 65 15 11 19 11 8 10 0 1 5 3 0 1 1 150

Masters 34 20 4 2 5 1 8 0 4 1 2 0 0 0 81

Fellowship/PHD 2 1 0 2 0 0 3 0 0 0 0 0 0 0 8

Total no. of local Drs

with clinical PG

qualifications

101

36

15

23

16

9

21

0

5

6

5

0

1

1

239

% of local clinicians

with a PG qualification

28.5

45.6

55.6

41.8

34.8

50

47.7

0

71.4

40

71.4

0

25

50

36