Critical to the performance of health systems

Dr Chen Ken*
On 17 February 2006, Fiji’s Ministry of Health received a report of three children admitted to hospital with suspected measles.

The development caused concern. Fiji had been measles free since 1998. In 2005, it had decided together with other countries in the Pacific to try and eliminate the disease from the region. 

To do that, more than 95% of children had to be vaccinated. But, unknown to the ministry and the World Health Organisation (WHO), the coverage rates had slipped to below 80%. Part of the problem was that Fiji had lost skilled health workers to countries such Australia and the United States.

On top of that, there had been a considerable amount of internal migration for various reasons. New settlements had popped up in places such as the Sigatoka Valley in the interior of the main island of Viti Levu.

However, clinics in those areas often did not receive additional staff to deal with the increase in population. Some children in those areas had fallen through the cracks and had not been vaccinated. Eventually, the number of measles cases rose above 130—a huge outbreak for a country such as Fiji.

The response was impressive. With assistance from WHO, UNICEF, and aid organisations such as AusAID and JICA, an intensive vaccination campaign was organised and vaccination coverage rates returned to more than 95%.

However, this took an extraordinary mobilisation of healthcare workers, many of whom had to put other work on hold for three months. This unsettling episode reminded everyone that diseases are waiting just around the corner and will take advantage of any lapses in public health programmes.

The strength of the health workforce is critical to the performance of the health system. Deficiencies in human resources for health directly impact the health of the community.

The importance of this issue has been recognised by WHO, which has made human resources for health a priority for the next decade.

Substantial effort has been invested in workforce planning to strengthen human resources for health in the Pacific region and globally.

Nevertheless, significant barriers remain, including political, social and economic factors, limited funds for health care delivery and the training and ongoing professional development of the health workforce.

Significant challenge: Perhaps the most significant challenge facing health services is the rising prevalence of chronic non-communicable diseases (NCDs), including cardiovascular diseases and cancer, which have become the leading cause of death in most Pacific Islands countries.

Recent surveys found that the prevalence of overweight and obesity among adults aged 25 to 64 years is as high as 93.5% in Tokelau and American Samoa; 93.3% in Nauru; 88.5% in Cook Islands; 85.1% in Samoa; 80.1% in Marshall Islands; and 62.8% in Fiji.

American Samoa has the second highest prevalence of diabetes in the world, with 47.3% of adults aged 25 to 64 years old affected. Tokelau and Marshall Islands are not far behind, with 43.6% and 41.0% respectively among 25 to 64-year old adults.

Addressing these issues require well trained and motivated staff committed to reaching out to communities they serve. Notwithstanding the rise in chronic conditions, communicable diseases (infectious and parasitic diseases), maternal/peri-natal conditions and nutritional disorders still comprise the second largest group of conditions causing death in the Pacific Islands countries.

While health systems must evolve to cope with the rise in chronic conditions, they must also ensure the continued provision of primary health care services for those with acute conditions, as well as chronic communicable diseases, including HIV/AIDS.

“I have been waiting for four hours and have not yet been seen by a nurse or a doctor,” says a patient in the waiting room of Lautoka Hospital. Unfortunately, this is not an isolated case in our region. One of the main other challenges specific to the Pacific islands countries (PICs) is the provision of accessible and quality care to remote and vulnerable populations, as well as the provision of specialist health services to a geographically disparate population.

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

WHO estimates a global shortage of doctors, nurses, midwives, pharmacists, dentists and support workers of around 4 million.

The lesser-resourced Pacific Islands are at a disadvantage in competing with wealthier countries in terms of training, recruiting and retaining the skilled health workforces they need.

Major challenges include: shortage of staff and uneven distribution of the health workforce due to geographical factors, the aging of the health workforce, gender issues which affect workforce participation, insufficient production of health workers, which is also related to insufficient investment in training institutions, loss of staff due to dissatisfaction with working conditions and environment, and inappropriate recognition and remuneration for health workers.

In view of these major challenges, the Pacific health leaders have called for a more intensive and focused approach to the development of human resources for health. Since the 1995 Yanuca Island Declaration, subsequent meetings of the Pacific Ministers of Health have made a commitment to address human resources for health issues. The 2001 Madang Commitment and the 2007 Vanuatu meeting recognised the importance of mid-level practitioners in providing basic primary health care services for rural, remote and sparsely populated Pacific islands communities.

Skilled personnel: The 2005 Samoa Commitment recognised the loss of skilled health personnel (SHP) through migration in the Pacific islands, where there is already a general shortage of workers, has serious implications for the health of Pacific people.

The meeting recommended the establishment of a regional mechanism to facilitate the sharing of skilled health personnel, expertise and training resources, including twinning arrangements among Pacific islands countries.

The health ministers have since committed themselves and their governments to take strategic measures to strengthen their national health workforce capacities and address the varied health workforce issues and challenges their countries face.

The key actions the ministers have agreed to undertake include: collation and use of reliable human resources for health data, evidence and information to inform policy, planning and decision-making; strengthen effective health workforce planning and management, including managing the migration of skilled health personnel; retention of health workers and improved performance through better remunerations and use of incentives; and scaling up the education and training of health workers to meet health workforce shortages.

The training of multi-skilled health workers capable of providing a range of services in critical areas such as pharmacy, radiography and laboratory services is also being explored.

With this mandate, WHO convened a meeting of Pacific countries and development partners to consider ways to support the development of human resources for health.

The informal consultation led to a recommendation to establish a Pacific Human Resource for Health Alliance (PHRHA) that will promote effective partnerships and coordinated approaches for strengthening the health workforce capacity to improve Pacific health in an equitable and sustainable manner.

The priorities for the alliance include advocacy for intensified efforts and investment in the development and management of human resources for health, harmonising the contributions of development partners and donors to ensure well targeted, effective and efficient use of resources and, most importantly, better cooperation and sharing of ideas and resources among Pacific countries. WHO will serve as an interim secretariat to this forum to facilitate its establishment and commencement of work.

Underpinning the creation of the PHRHA is a widely held belief among members that they need to help each other do better. The alliance would need to be carefully scoped and coordinated so that national and regional priorities in HRH are addressed adequately. This would require a long-term strategic perspective and precludes the establishment of PHRHA as an ad hoc body or mechanism.

The success of the PHRHA will be determined by its ability to engage Pacific countries in a cooperative effort to promote human resources for health, mobilise and harmonise the support of development partners and to focus leaders’ attention and readiness to invest in human resources. All these are essential for promoting and sustaining health and well-being in the Pacific.

Innovative approaches to human resources for health Faced with surveys that shocked public health officials by revealing women in countries such as Samoa and Vanuatu had some of the highest rates of sexually transmitted diseases in the world, WHO Vanuatu Country Liaison Officer Dr Corinne Capuano decided to tackle the problem at the grassroots level by addressing the lack of basic reproductive and sexual health knowledge among staff in national health facilities. Together with the Ministry of Health and the Vanuatu Family Health Association, a non-governmental organisation, a low-cost pilot project called On-the-spot Refresher Training was developed. With WHO as the main funding agency, experienced midwife Helen Walter began visiting all 28 Vanuatu health centres throughout the country on 17 April 2002, training local midwives in reproductive health and sexually transmitted infection management, and teaching basics such as performing a clinical examination using a speculum and doing a pap smear.  Four years later, when the programme ended, all midwives in the country had been trained, 9521 women screened and 531 treated. “It was so nice to have the visit of such an experienced midwife as Mrs Helen in my little Baiap Health Centre. She provided an excellent refresher training and I learnt a lot. I also now have a better idea of all my responsibilities,” said a trained midwife in West Ambae. Future training of midwives in the region using this highly successful front-line approach will include dispensary staff and an expanded programme on Immunisation refresher course.

*Dr Chen Ken is the WHO Representative in the South Pacific.