Meeting on Migration of Skilled Health Personnel in Pacific Island Countries, Nadi, Fiji, 23-27 June 2003 : report

(WP)HRD/ICP/HRD/6.4/001 Report series number: RS/2003/GE/12(FIJ)

English only

REPORT MEETING ON MIGRATION OF SKILLED HEALTH PERSONNEL IN PACIFIC ISLAND COUNTRIES

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Nadi, Fiji 23-27 June 2003

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines August 2003

NOTE

The views expressed in this report are those of the participants in the Meeting on Migration of Skilled Health Personnel in Pacific Island Countries and do not necessarily reflect the policies of the Organization.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Meeting on Migration of Skilled Health Personnel in Pacific Island Countries, which was held in Nadi, Fiji from 23 to 27 June 2003.

SUMMARY

A Meeting on the Migration of Skilled Health Personnel in the Pacific Island Countries was held in Nadi, Fiji Islands from 23 to 27 June 2003. The meeting was attended by 32 participants from 17 countries, nine observers, and nine WHO staff. The meeting objectives were: ( 1) to discuss the findings of the two studies on migration of skilled health personnel in the Pacific Region; (2) to review current country policies for recruitment and retention of skilled health personnel; (3) to discuss policy options and their relevance to individual country situations; and

(4) to discuss and develop further subregional mechanisms and actions to address the implications of the migration of skilled health personnel. Migration of skilled health personnel is of increasing concern for the Pacific island countries, with most of them having critical shortages of workers in some fields and health disciplines. There are indications that the out-migration of health professionals has led to reduced health service efficiency, delays in delivery of acute emergency care, long waiting times for scheduled services, and closure of some services. The WHO studies on migration in the Pacific island countries show that, although the volume of migration varies among countries, the reasons and factors for migration are the same in all countries and across all cadres of health professionals. These include: poor remuneration and inflexible working conditions; lack of career advancement prospects; limited training and educational opportunities for professional development; poor working environments and Jack of supplies and equipment; social factors, such as the quest for a better life for family members, including children's education, and the presence of relatives abroad; political instability and insecurity; active recruitment and job opportunities abroad; and higher professional qualifications and experiences as a result of overseas training. Other reasons for migration, such as globalization and labour force movements, are clearly beyond the control of countries. It is, therefore, not possible to stop migration altogether. The meeting discussed the various migration studies and reviews and their findings and recommendations, shared country contexts and experiences in migration, and examined the key issues and potential policy options and strategic approaches that might be considered to reduce the volume of migration of skilled health professionals and its negative impacts on health care. Specific policy options and strategies the meeting considered were mainly in the following areas: ( 1) retention of health professionals and mitigating their need for migration where possible; (2) recruitment and return migration; and (3) training and human resource planning.

CONTENTS

1. 1.1 1.2 1.3 1.4 2. 2.1 2.2 2.3 2.4

INTRODUCTION ... .......... ... .. ................ ........................... ................. ........... .. ...... l Objcctivc3 ............................................................................ ................... 1 Opening Ceremony ................................................................. ......... ........... 1 Appointment of Chairperson, Vice-Chairperson and Rapporteur ............ .................. .2 Organization of the meeting ....................................................... ...................2 PROCEEDINGS ...................... .............................. ............................................... 3 Presentation of technical papers ........................................................ .. .... ....... 3 Country presentations ................................................................... .............. 4 International experiences ................................................................ ............ 10 Group discussions on current issues concerning migration of skilled .......... . .. ... ....... 12 health personnel CONCLUSIONS ............ ....................................... ......... ................................. .. .. 16 General .. .......... .. . .. . ........... . ............................... . .......... ..... .. ... ...... ........ 16 ANNEXES : ANNEX 1- LIST OF PARTICIPANTS, OBSERVERS, TEMPORARY .................... l9 ADVISERS, CONSULTANT AND SECRETARIAT ANNEX 2 - TIMETABLE ................................... ................................. .............. 25 ANNEX 3 - OPENING REMARKS OF THE WHO REGIONAL ............................ 27 DIRECTOR FOR THE WESTERN PACIFIC ANNEX 4 - SUMMARY REPORT ON THE FINDINGS ................. ...................... 31 AND CONCLUSIONS OF THE WHO STUDIES ON MIGRATION OF SKILLED HEALTH PERSONNEL IN THE PACIFIC ISLAND COUNTRIES ANNEX 5 - EVALUATION REPORT ................................................................. 55

3. 3.1

Key words Health personnel - congresses I Migration - congresses I Personnel turnover congresses I Pacific Islands

1.

INTRODUCTION

The mobility of trained professionals is becoming an increasingly important global issue as trained human capital moves largely from less developed nations to most developed and affluent ones, with consequent implications for economic development in the source countries. As economic performance and overall development are linked to human and financial resources, the emigration of health professionals, therefore, has implications for the health sector and beyond. International migration has grown in volume and is now an important social issue in many parts of the world. It is particularly significant in Pacific island countries, where a small number of people out-migrating may have a disproportionate effect on the country. Similar issues are also linked to migration of health personnel from remote and rural areas. In response to the growing problem of outward migration of health personnel throughout the Pacific region, and in response to a request from Ministers of Health in Pacific island countries, WHO commissioned studies in selected Pacific island countries to investigate patterns and causes of health worker migration to and from different countries. A Meeting on the Migration of Skilled Health Personnel in the Pacific Island Countries was held in Nadi, Fiji, from 23 to 27 June 2003 to enable countries to discuss the findings and conclusions of the WHO studies, review policy options, provide an opportunity for countries to exchange information and experiences and discuss possible subregional approaches to address migration of skilled health personnel. The meeting was attended by 32 participants from 17 countries, nine observers, and nine WHO staff (see Annex 1). 1.1 Objectives: (1) To discuss the findings ofthe two studies on migration of skilled health personnel in the Pacific Region. (2) To review current country policies for recruitment and retention of skilled health personnel. (3) To discuss policy options and their relevance to individual country situations.

( 4) To discuss and develop further subregional mechanisms and actions to address the implications of the migration of skilled health personnel. 1.2 Opening ceremony

Dr Chen Ken, WHO Representative in the South Pacific, delivered the keynote address on behalf of the WHO Regional Director for the Western Pacific, Dr Shigeru Omi (see Annex 3). The Regional Director noted that many countries, both developed and developing, are experiencing shortages of skilled health personnel. In countries that already have critical shortages, such as in some Pacific island countries, the loss of health professionals due to migration can have serious implications as the countries' capacities to provide adequate and good quality health services for their populations are undermined. He stressed that in many cases, migration of health professionals has led to reduced health service efficiency, delays in

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delivering acute emergency care, long waiting times for scheduled services and increased inequity in access to basic health services. The Regional Director further noted that about half of Tonga's doctors and a quarter of Solomon Islands' doctors were currently working or attending training abroad; between 5% to 10% of doctors in Samoa and of nurses in Tonga have been leaving each year for the past several years; and in Fiji, 25 doctors and 50 nurses had left within a one-year period. He stressed that, although the numbers of migrating health professionals in some Pacific island countries may be few, the impact on health services could be serious, including the closure of certain clinical or allied health services as the only one or few national health experts responsible for such services may have left the country for work abroad. As the global demand for health personnel is unlikely to diminish in the near future, the Regional Director hoped that Pacific island countries would be able to use the information and findings of the WHO migration study to develop evidence-based policies and strategies that would reduce the volume of migration and ameliorate its negative consequences on the health sector and services. The Deputy Minister ofHealth of Fiji, the Honourable Tomasi Sauqaqa, welcomed the meeting participants and stressed that human resource management was a major issue for Fiji and for the region as a whole, especially as the numbers of doctors and nurses was stabilizing or declining, following attrition and migration, while there was also a need to improve skill levels in order to match health service provision. This was of particular concern as several countries had some way to go in attaining acceptable indicators of health status. The deputy minister stressed that the ministries of health needed to have effective human resource planning and the ability to respond with flexibility to the ever-changing needs of national populations in terms of both demand and supply. He noted that, while modest increases in wages would make health personnel more conscious of their value and role, island states would never be able to compete with wages in developed countries. Noting that the recruitment of health professionals in Fiji and the Pacific sub-region was often done without the knowledge of the health ministry and that there were no existing guidelines or frameworks to follow, the deputy minister stated that Fiji had strongly supported the Commonwealth's code of practice for the international recruitment of health workers and would seek to develop national and subregional guidelines for effective implementation ofthe code in Fiji and in the Pacific region. 1.3 Appointment of Chairperson, Vice-Chairperson and Rapporteur

Dr Takeieta Kienene of Kiribati was appointed Chairperson, Mrs Shannon Toutou of Fiji as Vice-Chairperson, and Ms Denise Hutchins of New Zealand as Rapporteur for the meeting. 1.4 Organization of the meeting

Mrs Lorraine Kerse, the WHO responsible officer for the meeting, outlined the objectives and expected outcomes of the meeting and added that the meeting was also an opportunity for officers from health ministries and public service commissions to better understand the structure of migration of skilled health professionals in the region and discuss the causes of the particular situation in their own countries and the possibilities for ensuring appropriate structures of human resource development. She also outlined the proposed agenda and format of the meeting, which would include plenary presentations of papers by country representatives and meeting consultants, and working group discussions. The agenda for the meeting was subsequently adopted (see Annex 2).

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2.

PROCEEDINGS

2.1 2.1.1

Presentations of technical papers WHO studies on migration of skilled health personnel in Pacific island countries

Professor John Connell, WHO Consultant for the meeting, presented a summary of the findings and conclusions of the WHO studies on the migration of skilled health personnel in Pacific island countries. The studies, aimed at determining the patterns, extent and factors influencing the migration of skilled health personnel in the Pacific island countries and the implications of this on the health sector and services, surveyed 520 skilled health workers in eight Pacific island countries (Cook Islands, Fiji, Kiribati, Marshall Islands, Palau, Samoa, Tonga and Vanuatu) and in three destination countries (Australia, Canada and New Zealand). The summary report is attached (see Annex 4). The migration studies determined the principal reasons for the out-migration of skilled health workers to be better incomes and living standards for themselves and their families as they are poorly remunerated and face difficult working conditions such as inflexible working hours, with many extra workloads, and poor facilities. with shortages of supplies and equipment, especially in rural and remote areas. Migrants also move because of limited promotion and training opportunities, political instability and insecurity, and increased recruitment by overseas agencies. Social factors, such as the needs and expectations of the extended household members, the presence of relatives and families abroad and the educational opportunities for children are equally important factors influencing migration. It was noted from the studies that those who receive higher professional training outside the Pacific region and who possess higher and recognized professional qualifications are more likely to migrate abroad. The studies further noted that most countries lack comprehensive and reliable information and databases of health personnel, particularly regarding the distribution of the health workforce, attritions and migration flows. However, the volume of migration is greater in the Pacific island countries that have political and strong economic links with developed and affluent countries. The migration of skilled health personnel is likely to continue due to a variety of factors, including globalization, beyond the control of Pacific island countries, but there is no reason why migration should remain at relatively high levels. The impact of emigration has led to a shrinking workforce in some countries, a costly 'skill drain', loss of morale amongst the remaining workforce, unmet or poorly met health needs, concern over the cost and quality of replacements and new patterns of movement within the Pacific island region. Although the remittances have been considerable, perhaps even as great as the training costs of health professionals, little of the income remitted has been invested in maintaining or improving health service delivery. In view of the study findings and conclusions, the policy implications for countries include: the possibility of changes in employment structures such as in salaries and wages, career structures, allowances, new categories of workers, retirement age and bonding systems; in-country education and training; regulation of overseas recruitment; domestic recruitment options; twinning arrangements between various stakeholders to ensure that the impacts of migration are minimal and both the source and recipient countries benefit; and the production of more health personnel than actually needed to make up for any loss due to migration. Such policies should be evidence-based and developed and implemented as an integral part of the national human resources for health framework and plan backed by good human resource database, monitoring and evaluation system.

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The presentation stimulated discussion of the various options open to Pacific island countries to develop more effective policies to reduce the significance of migration, including the role of retirement ages, with some countries favouring a late retirement age to encourage older workers to remain in place and others seeking to reduce the retirement age to ensure there were jobs for new recruits. Bonding of trainees and the difficulties of developing and implementing effective structures and whether the critical issue is the repayment of scholarship fees or mandatory service periods if the holder defaults, were raised. The emerging subregional structure of migration, with some Pacific island countries drawing migrants from others; the desirability to more effectively regulate the movement of health professionals among countries; the role of the private sector and the extent to which movement into that sector constitutes a loss of skills; and whether there is scope for better linkages between the private and public sectors were discussed at length. Noting that globalization and global markets and economies have impacts on the Pacific island countries, including migration of health professionals, there is a need for assistance so that countries can better understand those changes. 2.1.2 A review of options for an adequate supply of nurses for the Fiji health system

Ms Monica Fang, WHO Temporary Adviser, discussed the preliminary findings of a WHO-funded survey to determine the options for achieving an adequate and more cost-effective supply of appropriately qualified nurses for the Fiji health system. The survey interviewed 320 nurses throughout Fiji, as well as key informants such as nursing managers and administrators, on a wide range of issues such as training, working conditions and remunerations, the matching of knowledge, skills and competencies with jobs and assignments, career structures and nursing policies and strategies. The survey noted that some positive measures such as salary increases, part-time work, increase retirement age and increase in training opportunities had been taken to retain nurses. However, some major issues remain. These include dissatisfaction about conditions of service and remunerations, poor career structures and limited training opportunities, duties and assignments that are inappropriate to skills and competencies, and the inadequate intake into nurse training. Managers recognize the need for an adequate national supply of nurses with appropriate qualifications, and believe that the Fiji Government should examine the possibility of training nurses for overseas markets, increasing the intake of the Fiji School ofNursing by social marketing and flexibility in nursing student intake criteria, such as extending the age limit for intake to 35 years of age and increasing the number of male students, and improving the structure of salaries and career pathways. Discussion of the outcomes of the nursing review revealed that the issues are common among countries. Some countries feel that they are unable to gain the skilled workers they need, while others are concerned about the effectiveness of those they have recruited from overseas, in terms oflanguage issues and basic knowledge, and believed that this has had a detrimental effect on national health care. Some feel that recipient countries should compensate source countries to a greater extent. A possible approach to fulfil the needs of those countries that are unable to train adequate numbers of skilled workers by themselves, perhaps because of migration opportunities or deficiencies in the high school system, is to pay for other countries to do the training for them and/or to recruit from countries that have excess numbers of nurses. 2.2 2.2.1 Country presentations American Samoa

Mr Sivia Sunia, Assistant Director, Department of Health, American Samoa, noted that the country had an adequate supply of doctors and any shortfalls, such as in some specialized fields, were easily remedied by the recruitment of experts from elsewhere as the salaries, incentives and

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working conditions were competitive and attractive. There is an over-supply of certain workers such as dentists, however, the most urgent problem is the shortage of nurses following the earlier closure of the nursing school, the very poor intake into nursing schools, the loss of interest in nursing as a career, and the easy migration to the United States of America, where better opportunities exist since American Samoans are United States citizens. Other challenges being faced include a lack of expertise in assessing and determining the appropriate number of workers requi red and estimating future requirements, and how such requirements can be accurately determined. The current practice of estimatin~ workforce neecls is h;:~sf':rl nn the m1mber of established posts determined by the Public Commission, which is deemed as inappropriate. Therefore, the Ministry of Health have requested the Public Service Commission to give priority to health workforce planning and management. Telemedicine has been introduced to facilitate diagnosis and treatment and training of health professionals, but the future impact on service and workforce needs to be ascertained. 2.2.2 Australia

Ms Katy Balmaks, Director of Health Workforce, Undergraduate Initiatives Section, Department of Health and Ageing, Australia, presented an overview of the issues that have influenced the make-up of the health workforce in Australia and the policies and strategies that have been implemented to ensure an adequate health workforce to meet the health needs of the Australian population. The key issues include an ageing health workforce; shortages in some medical disciplines; gender imbalances, such as the majority of doctors and medical students now being female; general shortages of workers in public hospitals and in other regions and remote areas; and an overall nursing shortage as a result of negative perceptions of career pathways and standing in the community. The increase in demand for health care and services and the slow increase in the health workforce signal a dramatic shortage in the future, hence a series of special policies and programmes have been developed to address the situation at both the Federal and State levels. Various national and state bodies and agencies have been established to monitor developments and provide advice and guidance where needed. Specific initiatives are being implemented to improve recruitment, deployment and retention of health workers in rural and remote areas. Ms Balmaks stressed the importance of policy-makers having access to reliable health workforce data and appropriate health workforce planning and management tools for developing evidence-based policies and strategies that ensure the right number of people, in the right place, with the right skills and training to meet the health needs of the Australian population. 2.2.3 Cook Islands

Ms Denise Rairi, ChiefExecu tive Officer, Office ofthe Minister of Health, Cook Islands, said that the political and economic links with New Zealand enabled easy migration of health professionals to New Zealand, especially after the 1996 national financial crisis. Hence, the shortage of doctors and other allied health professionals is a problem -the workforce shortages being more critical in the outer islands. It has proved very difficult to draw secondary school students into the health professions, but Career Expos and temporary work experience assignments have proved valuable tools to entice entry into the health workforce. The current workforce shortages have been met by overseas recruitment of expertise, including health professionals from other Pacific island countries, and a special recruitment fund with incentives has been established to draw skilled Cook Islanders back to serve in the health services. Ms Rairi reiterated that the small population base and the remoteness and isolation of some islands posed particular challenges, not only for the training, deployment and retention of health workers, but for the provision of health care and services. Thus twinning arrangements for

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health care provision and training with overseas health boards, hospitals and training institutions have been helpful in meeting Cook Islands' needs. 2.2.4 Fiji

Mr Kitione Mulo, Acting Director for Health Services Department, Ministry of Health and Social Welfare, Fiji, presented the health workforce situation and migration of health professionals in the country. Fiji has experienced a shmtae;e of rlor.tors ;mrl nnrsf':s fnr m:my years, as many have migrated to Australia, New Zealand and elsewhere, and doctors are moving into private practice. The main reasons for migration include better working conditions and remuneration, opportunities for training, and the political instability of the late 1980s and the 1990s. Overseas recruitment and training of nurses have contributed to high attrition rates. More than one-third of doctors are recruited from overseas to fill the gaps. Some of the measures taken to address workforce shortages include: increasing health trainee intakes, such as at the Fiji schools of medicine and nursing; increasing the numbers of part-time workers; increasing the retirement age from 55 to 60 years; and employing multiskilled workers, such as Nurse Practitioners. To encourage retention of workers, the Government has, not only improved career structures, salaries and wages and other forms of allowance, but also improved the health facilities, equipment and supplies and communications in all urban and rural and remote areas and islands such as Taveuni. Mr Mulo stressed the importance of networking with all sectors and training institutions, the need for quality health workforce planning and management, and the need to have national and regional mechanisms for recruitment of health workers, similar to the Commonwealth code of practice for the international recruitment of health workers, which Fiji supports. 2.2.5 Kiribati

Mr Tebuka Toatu, Secretary of the Education and Training Committee, Ministry of Health and Family Planning, Kiribati, gave an overview of the workforce situation in the country. The long-term shortage of health workers is mainly due to insufficient numbers being trained, the high failure rates of trainees, poor working conditions and incentives, and increasing migration. Migration has resulted from economic, social and administrative factors. Some measures taken to address workforce shortages include bonding (which has had some success in the return of overseas trainees), increasing the number of trainees, increasing salaries and allowances, and improving working conditions. The outer islands, mostly staffed by nurses, have limited resources and facilities because of the centralized structure of health care. Outreach services and twinning arrangements with overseas hospitals are other measures used to maintain an adequate level of health care, despite shortages of workers. 2.2.6 The Marshall Islands

Ms Justina R. Langidrik, Secretary of Health, the Marshall Islands, highlighted the critical shortages of national health professionals in almost all disciplines. More than two thirds of doctors are expatriates from countries such as the Philippines and other Pacific island countries, and most of the other allied health professionals are also foreigners. The workforce shortages, particularly in the case of nurses, are due mainly to external migration to the United States of America, in particular; limited trainee intakes; and loss to other government sectors that have better remuneration and working conditions. The Marshall Islands has sought to expand local recruitment, develop training facilities and improve access to technology, and is examining twinning arrangements, changes in retirement age and the establishment of a dental school. Recently, the Ministry of Health was successful in obtaining the authority and responsibility for the recruitment and employment of health workers from the Public Service Commission.

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Ms Langidrik stressed the importance of using existing subregional and regional professional groups, such as Pacific Islands Health Officers Association (PIHOA), for support with training and provision oftechnical assistance. 2.2.7 Micronesia, Federated States of

Mr Dionis Saimon, Family Health Programme Coordinator, Department of Health, Education and Social Welfare, Federated States of Micronesia, reported that almost all health workers were being trained outside the country; hence, not all of them returned home to serve in the health sector. For example, doctors are being trained in the United States of America and most of them remain to work there as Micronesia has political association with the United States. There has been some recent recruitment of overseas doctors to meet shortages. With regard to nurses, the numbers of trainees is continuing to decline; hence, present needs are barely being met. The country is considering setting up its own nursing school. The challenge for the country is that the four states are independent political entities, with each being responsible for its own affairs; thus, it is not possible to have a common approach to address national health workforce issues. It is up to each state to develop its own workforce policies and plan. Efforts to improve working conditions, remuneration and career structures have been undertaken by the states. 2.2.8 Nauru

Ms Ruby Thoma, Healthy Islands Programme Coordinator, Department of Health and Medical Services, Nauru, reaported that there were only a few national doctors and nurses in the country, all ofwhom were trained in the 1970s and were nearing retirement. Without the recruitment of foreign personnel, the few national professionals would be grossly overworked. The key issue is the general lack of interest among the population in gaining higher educational levels to enter various health training courses; thus, the country has not produced any health workers since the late 1970s. Political instability, deterioration of health services, an increase in morbidity and mortality due mainly to noncommunicable diseases, and a rapidly growing and youthful population are creating additional demands on the limited workforce. In view of these factors, the country's dependence on overseas skilled workers is likely to continue for many years to come. Ms Thoma reiterated that Nauruans themselves will have to find their own solutions to the problems, but any assistance and support from other Pacific island countries and external partners, including the sharing of human resources, would be most welcome. 2.2.9 New Zealand

Ms Helen Jean Lockyer, Principal Analyst, Workforce Sector Policy Directorate, Ministry of Health, presented the situation ofNew Zealand. The ageing and more culturally diverse population, technological advances and globalization have placed increased demands on health services. The health workforce is also ageing, and there are some specific and some generalized shortages of workers in all health disciplines and allied health services. One third of doctors are overseas-trained and half of those working in rural areas are expatriates. Retention of workers is a more major problem than recruitment, with most of the migrants leaving immediately after training or early in their careers. The main reasons for leaving include the opportunity to travel and work abroad and the quick repayment of student debts as salaries overseas are much higher. Attractive salaries and incentives have enabled New Zealand to recruit workers from abroad easily. New Zealand had instituted various health workforce policies and strategies, including appropriate initiatives for staffing rural areas, increasing the intake into all health training courses, and providing more flexibility in employment structures and work practices. There is no retirement age in New Zealand, and incentive schemes, such as permanent employment in a District Health Board, are being used rather than bonding. The Health Workforce Advisory

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Committee, an independent ministerial committee established in 2001, provides strategic advice to the Minister of Health on workforce issues. 2.2.10 Niue

Mr Bob Talagi, Manager, Niue Health Department, reported that Niue was experiencing a general problem of out-migration and population decline, including the loss of skilled health workers, mainly to New Zealand. Only one of the four doctors is from Niue, and many doctors only stay on the island for one year. Attracting workers back to the country, and training and planning of health resources are problematic. Bonding has been unsuccessful and many trainees remain in New Zealand as they are able to pay their bonds. Niue is seeking to provide multiskill training for the whole workforce and to develop appropriate twinning arrangements with training institutions and health service providers in New Zealand. 2.2.11 Palau

Ms Julie Tellei, Human Resource Development Officer, Ministry of Health, stated that the health workforce of Palau comprised a substantial proportion from overseas. Almost half of doctors are from overseas and higher salaries and incentives have ensured the country an adequate supply of workers from abroad, including Pacfic island countries. Most nurses are local, despite active recruitment of nurses from Fiji, and some ofthe better nurses have migrated to the United States of America. Recruitment of health workers from high schools remains a problem, but Palau is seeking to end its dependence on overseas workers within a decade. An absolute shortage ofworkers exists in some particular skill categories, such as pharmacy. 2.2.12 Papua New Guinea

Mr Florian Yambilafuan, Director, Human Resource Management, National Department of Health, reported that Papua New Guinea had a large but ageing health workforce, all of whom were trained within the country. There have been problems in developing an adequate number of specialized health professionals and in serving the need of remote communities, where resources are scarce, local support limited and communications difficult. Special incentives for work in rural areas have not yet solved this problem because of the rugged terrain and isolation. Some 160 nurses graduate each year, but this is less than the number leaving the workforce; hence, future shortages of nurses will worsen as the national population is growing steadily and health needs are increasing. There is some limited migration of skilled heath workers overseas. 2.2.13 Samoa

Ms Sarah Faletoese, Principal Health Planner, Ministry of Health, stated that, in Samoa, emigration was now less of an issue than it was in the early 1990s as bonding had been relatively successful, working hours made more flexible and the retirement age increased. Three or four nurses migrate to New Zealand each year. Despite the establishment of the School ofNursing in 1993, there is a need to ensure more adequate recruitment into the School. Nursing is presently not perceived as an economically viable career. There is a need for more skilled nurses as patient needs change, hence ongoing training is becoming increasingly important. The private sector is growing and contributing to health service delivery, but there is no national policy for publicprivate collaboration. Traditional practitioners also play a role in health care delivery.

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2.2.14

Solomon Islands

Dr George Malefoasi, Undersecretary for Health Care, Ministry of Health and Medical Services, Solomon Islands, reported that the country had experienced a recent political and economic crisis, resulting in a loss of morale and the emigration of several physicians. There has been a widening of the gap between demand for health care and the supply of personnel, especially as the population continues to grow rapidly. The number of nurses is perceived to be adequate, but their level of training is less so. Bonding has never been practised in Solomon islands and it may need to be implemented. Similarly there has been little attempt to develop particular policies to attract and retain staff in remote areas. Overseas doctors have been recruited, despite concerns over their appropriateness, at levels of pay significantly above those of local doctors, a situation that has led to some resentment. Improving health workforce data and planning, developing specific career structures and working conditions, and decentralization of some personnel functions from the Public Service to the Ministry ofHealth are some ofthe proposed future actions. 2.2.15 Tonga

Ms Akanesi Taufa, Senior Assistant Secretary, Establishment Division, Prime Minister's Office, stated that Tonga had experienced continued emigration of doctors, and bonding had been relatively unsuccessful because of general expectations that emigration was the norm. There are no problems in the recruitment of nurses but, since their qualifications are now recognized in New Zealand, there is steady and significant migration overseas . Emigration has placed considerable pressure on health services; hence, Tonga has sought to implement new scholarships to expand the number of health workers. Allowances and incentives enable sufficient workers to be placed and retained in outer islands. Tonga has an effective twinning arrangement with Australia for its training needs and other specialist health care. 2.2.16 Tuvalu

Dr Tekaai Nelesone, Director of Health, Ministry of Health, reported that Tuvalu had experienced a shortage of skilled health workers for several years, and there had been significant migration of the small number of nurses and doctors who had graduated in recent years, in part because their training had, necessarily, been overseas. The principal reason for migration is low incomes, especially with reference to others in the government workforce. Tuvalu has recruited workers from other countries, at considerable expense, but is now considering increasing the retirement age, enabling the employment of part-time workers, and improving working conditions and allowances. 2.2.17 Vanuatu

Ms Maturine Tary, Director of Health Planning and Administration, Ministry of Health, stated that Vanuatu was beginning to experience the start of a potential skill-loss, with the migration of a few doctors, dentists, pharmacists and other allied health professionals, such as scarce laboratory technicians. Migration is largely because of salary differentials, and migrants have mainly gone to New Caledonia and Palau. Nurses are trained locally, using a local curriculum and thus have skills appropriate to local needs. As the nurse qualifications are not recognized overseas, very few nurses, if any, would be able to migrate. Therefore, Vanuatu has an adequate number of nurses for its needs, including staffing rural and remote areas. Restructuring and downsizing of the government workforce has negatively affected health workforce morale. The Health Department is considering negotiating with the Public Service

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Commission to obtain the authority and responsibility to develop and manage the health workforce by itself. 2.3 2.3 .I International experiences Migration of health workers- A big problem?

Ms Barbara Stilwell, WHO Headquarters, provided a global context to discussions of the international migration of skilled health workers and its implications for the Pacific region. There is a considerable gap between many anecdotal accounts of the migration ofhealth workers and good data on the extent of migration, particularly on the implications of this movement for the source and destination countries. Nonetheless, the migration of skilled health workers continues to become of greater numerical significance, and its effects on unmet health care needs in source countries have increased. There has been something of a carousel or step-migration of nurses and doctors due to the globalization of health care, with various complex patterns of replacement and onward migration, with Europe and the United States of America being the ultimate destinations. The impact has been particularly great in several African states, where annual migration is substantially greater than the annual production of health workers. The reasons for migration are numerous and vary only slightly between particular countries and regions. Health care systems are often weak, especially where economies are weak, with a limited ability to support professionals and offer adequate incomes, facilities, training conditions and access to technology. In some countries, there is a rising death toll amongst health practitioners. Developed countries have vacancies in several areas, notably in rural and remote areas; hence, there is demand for, and recruitment of skilled health workers, and the probability of employment in destination countries. Extensive international migration indicates the need for ethical recruitment policies that do not substantially damage the health care systems of the source countries, and some means of reimbursement of the investments in human capital that have been made by less developed countries. This is difficult, since freedom of movement is important and cannot be stopped. While remittances from health workers may make a considerable contribution towards meeting the needs of families in sending countries, they do not directly contribute towards meeting the health needs in those countries. There is a critical shortage of data on migration in many places and contexts, and better data availability is essential for the development of ethical and evidence-based policy options. It is unlikely that improved wages and salaries in the main source countries would be adequate to reduce migration, since the gaps between rich and poor states are tending to increase, but nonpay incentives have a substantial role to play. Evidence from Africa demonstrates the considerable commitment of health personnel to provide quality health care even in the most difficult financial circumstances, but those deployed in rural and remote areas need supportive leadership, respect, and contact with the central authorities. Developed countries have a role to play in improving health outcomes in developing countries by virtue of their recruitment of their health workers and the need for a more ethical global employment context. Developed countries can encourage temporary stays of health workers, rather than long-term migration. The establishment of a GATS code of conduct (for the 'trade' in service workers) restricts migration from 'at-risk' countries, facilitates return migration and fosters bilateral agreements that benefit both the source and destination countries. Remittances have made a substantial contribution to the lives of kin and to the source countries

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themselves but may not be equal to the costs of training those who have migrated alongside the cost of unmet health needs. WHO has been assessing the impact of migration trends and policies in terms of ensuring the more effective collection of data, modelling the costs of migration (with particular reference to Ghana), and examining the specific factors that contribute to migration in particular circumstances. Such studies trace the extent to which the health sector has particular characteristics, such as the female-dominated employment structure, that make conclusions and policies specific to this sector, rather than to other sectors and areas where migration of skilled workers occurs. Policies and processes concerning migration are transitory in nature and integrated and sectorwide approaches are needed to address migration. 2.3.2 India's experiences

Professor Binod Khadria, WHO Temporary Adviser, discussed the particular case of India, where there has been extensive migration of a great range of skilled workers for many years, with reference to the implications for heath workers in the Pacific region. The global migration of skilled workers from India has intensified over the past three decades, especially to the United States of America. This has followed changes in the structure of international migration, with receiving countries favouring the inflow of skilled migrants or actively recruiting them, and some decline in the willingness of developed countries to produce the required skilled workforce of their own. A recent survey of doctors and nurses in India revealed that younger doctors especially seek to move overseas for better jobs with more training opportunities and additional experience, so that they can make faster progress through the career structure. Most seek to go to the United States of America or the United Kingdom. Nurses are even more likely to wish to go overseas, again in search of better training opportunities, and to earn higher incomes in a more attractive career structure. Although all the doctors and nurses intend to return, the massive demand for skilled health workers in the United States makes this unlikely. Some skilled health workers have returned, but tend to work in private nursing homes, or be employed outside the health sector in small businesses. Remittances to India appear to have largely failed to compensate for the skill losses. Attracting back skilled personnel requires a lot of economic incentives and better productivity and this may be difficult for most Pacific island countries as their economic base is limited. 2.3.3 Commonwealth countries

Dr Rosemarie Paul, Deputy Director/Head, Health Section, Commonwealth Secretariat, reiterated the Commonwealth governments' concerns about the migration of skilled health workers and its impact on health services, especially in small island states. The Commonwealth Secretariat has carried out a review and study of the migration situation in its Member countries as a basis for recommending policies and strategic approaches. The study outcomes and recommendations have been published (Migration of Health Workers from Commonwealth Countries -Experien ces and Recommendations for Action: Commonwealth Secretariat, March 2001) and disseminated to the Commonwealth countries, including Pacific island countries attending the meeting. Dr Paul also discussed the development of the Commonwealth Code of Practice for the International Recruitment of Health Workers. The Code emerged from concern over inadequately regulated international migration of health workers, and the negative effects this has had on various Commonwealth countries in Africa, the Caribbean and the Pacific region, as

- 12-

revealed by the Commonwealth Secretariat study on migration. The Code is designed to ensure that there is transparency, fairness and mutuality in relations between Commonwealth countries and between recruits and recruiters. Fairness requires recruiters to provide full and accurate information to potential recruits, and governments recruiting from others should consider means of reciprocation, such as training programmes for those who have been recruited and arrangements to facilitate their return. The Code is voluntary, has no legal backing and has not been signed by all Commonwealth countries. The principles of the Code are deemed to be relevant and appropriate for other countries as well those of the Commonwealth- there are no restrictions on use of the code outside Commonwealth countries. 2.4 Group discussions of current issues concerning mi gration of skilled health personnel

The most important aspects concerning the migration of skilled health personnel in the Pacific island countries and elsewhere, raised during the presentations, included: recruitment; migrant professionals; return migration; retaining the workforce; rural and remote areas; and human resources planning. Subsequently, working groups discussed these aspects further in order to achieve consensus on potential policy options and strategic approaches that could be recommended or proposed to governments for their consideration. 2.4.1 Recruitment of health workers

An extensive discussion focused on the need to develop a more flexible workforce structure that might enable part-time workers, more mature people, males and women in mid-life to play a greater role, to make use of scarce (and potential) skills and counteract migration losses. Most countries have sought to develop greater flexibility but it is evident that, in a number of contexts, there is some inertia in introducing new categories of entrants to the workforce . This is particularly so in the case of males, and there is a common feeling on the part of nurses that nursing should remain a predominantly female occupation. Nonetheless, there was a consensus that it is essential to be as flexible as possible. Discussion of retirement ages indicated that there could be no consensus in the region over what an appropriate retirement age should be. Countries which are losing skilled health workers on balance are more interested in raising the age to retain valuable workers, while those who are retaining more of their health workforce see a lower retirement age as beneficial, since that ensures vacancies for new recruits. There was consensus, even in those counties where recruitment is not perceived to be a problem, that more can be done to attract new recruits into the health professions. Several countries have some form of career day and work experience programmes and other countries believe that they could usefully introduce such initiatives. There is a need to develop information kits for social marketing of the health professions due to limited awareness and knowledge amongst school-leavers of what some jobs actually entail. It was also recognized that countries need to reduce attrition rates and that this demands more effective policies and practices to ensure job satisfaction. Some countries are concerned that a movement of workers into the private health care system represents a loss to the system as a whole.

The feasibility of developing more extensive in-country and in-region training was also discussed, in view of both the conclusion that those trained within their countries and the region are most likely to stay, and the effectiveness of training people in skills that have a direct application in their own countries. There was widespread recognition of the need to have such

- 13 -

programmes (alongside ongoing training) but doubts, especially in the smaller countries, about just how viable this might be, when their particular numbers are very small. There was widespread support for more distance education. It was generally agreed that it would be useful to examine the possibility of shared courses for more health workers in earlier years, which would increase the potential for in-country training, and enable workers to be multiskilled. There was lengthy debate over exactly how many skilled health workers should be trained, firstly, because it is evident that there are variations in how a shortage of workers is defined and recognized, and, secondly, because there are doubts over future migration rates and whether it is necessary to plan for a substantial future loss. There was some argument that training a 'surplus' is essential since it is realistic to assume that migration is likely to continue and countries may be in a position to benefit from significant remittance levels. Countries generally supported the idea that greater flexibility would also follow the training of relatively new categories of health worker, such as nurse practitioners, whose skills fall somewhere between those of nurses and doctors, and health aides, whose skills are relatively limited, but who can take the burden of routine care-giving away from nurses. Similarly it was generally agreed that, to meet the need for very particular skills, such as radiologists, scholarships should be targeted to the development of such skills. However, several countries noted just how difficult and costly it is to provide scholarships. 2.4.2 Migrant professionals

There was concern that migrant workers contracted into the Pacific island region may be inadequately qualified in a formal sense, and that their skills are sometimes difficult to apply in different language and cultural contexts. This is seen to be particularly true in remote and regional areas where migrant workers tend to be posted. Consequently, there was considerable discussion over the need for countries to be more self-reliant, but also of the need to ensure that migrants are appropriately qualified, especially since their salaries are often greater than those of local workers. It is also evident to many countries that there have been few training gains from the recruitment of overseas doctors and that the training has, at times, benefited the foreign recruit. Countries stressed the need to ensure that the qualifications of the recruits are adequately assessed and verified before recruitment, and that adequate orientation and briefing of the recruits is done before they take up positions in the country. Many countries support the notion of more effective forms of cooperation within the region so that there is less 'poaching' and more reciprocal benefits along the lines of those spelled out in the Commonwealth Code of Practice. However, that there are no evident models of this in the region and new initiatives need to be developed for more ethical and equitable cooperation. Countries recognize that several countries are in an exceptionally difficult position and are heavily dependent on the services of overseas skilled workers. There was some discussion of the possibility of the greater sharing of individuals with scarce skills within the region, but it was again noted that attempts to develop this in the past have had limited success and the contemporary prospects are poor given the possibility of referrals to developed nations elsewhere. A number of countries have developed effective twinning programmes with institutions in developed countries, and these have contributed considerably to training needs. It is evident that these could be developed further. This might be particularly so where developed countries are recruiters of skilled workers, hence such twinning arrangements may meet the spirit of the Commonwealth Code.

- 14-

Countries generally welcome the role that NGOs and churches have played in various facets of health care delivery and are conscious that there will be considerable benefits from this continuing in the future, especially if migration increases. Several countries were able to give specific instances of where particular schemes had met otherwise unmet needs and that might be models for other parts of the region. 2.4.3 Fleturn migration

Considerable discussion was attached to the possibilities of encouraging, and ensuring, the return of skilled health workers from overseas, though it is widely recognized that migration is an established and wide-ranging situation in the region; hence, realistically, only a small proportion of those who have gone overseas may be expected to return. It was particularly emphasized that countries wish those who went overseas on scholarships to return to their home countries, and that there is a role for receiving countries in ensuring that they do so. Again it was argued that this fitted in with the spirit of the Commonwealth Code of Practice. Flepresentatives debated whether it was possible, or necessary, to set up a relocation fund along the lines of that in Cook Islands, where air fares are paid for those families where a skilled worker wishes to return to the country. Most felt that it would be costly and not necessarily sufficiently effective. Flepresentatives also noted that, where there had been significant return migration it had occurred because close kin remained in the country, and because there were wider investment opportunities, etc. outside the health sector. This suggests that a wider approach is needed to secure the return of skilled workers. There was also a discussion over whether schemes like TOKTEN (The Transfer of Knowledge Through Expatriate Nationals), initiated and supported by the United Nations Development Programme (UNDP), might have some relevance and utility in the region. TOKTEN seeks to bring back overseas nationals, usually on brief contracts, to impart particular skills in a context where the returnees are familiar with the national cultural context. There is no evidence that any Pacific region state has used TOKTEN, but there is interest in whether the scheme has potential applications in the region. Country representatives discussed their various experiences with bonding of overseas scholarship holders, and recognized that it has never been easy to ensure success, especially in the wider context of migration and where data are sometimes lacking. There was a consensus that countries need more effective schemes and that they should investigate various bonding possibilities. There was also some discussion of the possibility of countries receiving compensation, in the case of non-return, in the form of return of bond payments from those countries where trainees have settled. Some countries have 'magnet hospitals' that are particularly effective in terms of good administration, professional practice models, autonomy and professional development, and these may be models for Pacific island countries. 2.4.4 Fletaining the workforce

It was widely recognized that more flexible and family-friendly employment policies are essential to maintain an effective and contented workforce. This may entail more flexible working hours and the provision of creches and childcare centres that enable workers with children to re-enter the workforce. Improved wages and salaries will boost morale and encourage stability, although many governments are currently experiencing difficulties, as there are restrictions on the size and costs of the public sector workforce. More extensive debate

- 15 -

ensued over the manner in which allowances might be given, especially for overtime, since allowances are usually particularly costly and better systems in one part of the public service would necessitate similar changes in other public sectors. Country representatives recognize that some promotion systems are perceived as being characterized by favouritism and nepotism, and that all systems should reward good workers (including those in remote places) and should be transparent, open and equitable. There Is a constant demand for regular ongoing training, and health services should seek to provide this equitably, both to ensure more effective heath care and to meet the needs of health workers. Health workers necessarily seek access to modern technology but, for financial and logistical reasons, this cannot always be easily provided. 2.4.5 Rural and remote areas

Most countries in the region are either large and/or fragmented; hence, most recognize that there are special problems in meeting the needs of populations who live in rural and remote regions. Countries also recognize that:

(1) The needs of rural and remote populations are usually less well served than those in central and urban areas. (2) In some countries, it has proved difficult to attract skilled health workers to remote areas since facilities are sometimes poor and such workers feeel ignored and forgotten there. (3) In many cases rural workers are originally from that area, hence it is necessary to ensure that potential skilled health workers are recruited from these areas. (4) It is often appropriate to provide bonuses and allowances, as well as adequate housing, for those in remote areas. (5) In some countries, similar schemes are also appropriate in large urban areas where the cost of living is particularly high. The lack of communication between workers in the periphery and those at the centre is a particular problem in many countries. Some have made strenuous efforts to ensure that there is regular radio communication and others need to investigate means of improving such schemes. It is widely recognized that this is a crucial means of keeping rural workers "in the picture" and ensuring that they are able to receive supplies and that they are not cut off from opportunities for training and promotion. Some countries feel that it is necessary to ensure a regular rotation of health workers between the centre and the periphery, but that family obligations sometimes make this difficult. Providing more effective health care in remote areas, and supporting health care workers there, usually needs to be linked to wider government rural development strategies. 2.4.6 Human resource planning

There was consensus that, in order to achieve the goal of having the right number of people, in the right place, at the right time, with the right skills, there is a need for more effective human resource planning, based on appropriate human resource core database, and that migration

- 16-

should be viewed and addressed within an overall national human resources for health context. It is apparent that, in many cases, data are being collected in quite different ways in different countries and that a greater degree of standardization would be helpful. The core human resource data required was not discussed in detail. However, there was an inconclusive discussion over what time period such plans should cover or whether there should be a rolling plan. External support for strengthening national capacity in human resources for health data, planning and management is an urgent need of most countries.

3.

CONCLUSIONS

3.1

General

Migration of skilled health personnel is of increasing concern for the Pacific island countries, with most of them experiencing critical shortages of workers in some fields and health disciplines. There are indications that the out-migration of health professionals has led to reduced health service efficiency, delays in delivery of acute emergency care, long waiting times for scheduled services, and closure of some services. The WHO studies on migration in the Pacific island countries show that, although the volume of migration varies among countries, the reasons and factors for migration are the same in all countries and across all cadres of health professionals. These include: poor remunerations and inflexible working conditions; lack of career advancement prospects; lin:tited training and educational opportunities for professional development; poor working environments and lack of supplies and equipment; social factors, such as the quest for a better life for the family members, including children's education, and the presence of relatives abroad; political instability and insecurity; active recruitment and job opportunities abroad; and higher professional qualifications and experiences as a result of overseas training. Other factors for migration, such as globalization and labour force movements, are clearly beyond the control of countries. It is not possible, therefore, to stop migration altogether. The meeting discussed the various migration studies and reviews and their findings and recommendations, shared country contexts and experiences in migration, and examined the key issues and potential policy options and strategic approaches that may be considered, particularly in the following areas: ( 1) Retention of health professionals and mitigating the need for migration where possible; (2) (3) Recruitment and return migration; Training and human resource planning.

The meeting was considered as very useful for the countries and observers and its objectives were generally achieved satisfactorily (see Annex 5). 3.2 (1)

The following are the key recommendations ofthe meeting Countries should consider more flexible and different possibilities for a range of employment/retention options and new policies and regulations for recruitment and employment that encourage flexible entry into the workforce.

- 17-

(2)

Countries should consider the development of appropriate campaigns to recruit highschoollea vers, which might include career days and work experience programmes, in collaboration with regional and international professional organizations such as the International Council ofNurses (ICN) and the World Federation Medical Education (WFME). Institutions in the Pacific region may wish to consider taking responsibility for informing countries on what courses and training programmes are available. Countries should consider supporting the role of organizations such as Pacific Island Health Officers Association (PIHOA) in their input into regional and international cooperation, and examine the possibilities for the further extension of such programmes within the Pacific region. Countries should consider greater flexibility in training categories, such as through nurse practitioners and aides, alongside greater multiskilling. Countries should seek support to develop a regional protocol for employment of skilled health personnel from within and outside the Pacific, which might link to the Commonwealth Code of Practice for International Recruitment of Health Workers, and other relevant codes of practice. Countries may consider developing national protocols for assessing competency and standards for incoming skilled health personnel to ensure safety and quality of practice. Where appropriate, this could contribute to Pacific regional guidelines and standards. Countries should examine the feasibility of developing professional networks and subregional and bilateral linkages to facilitate recruiting and twinning relationships for such purposes as sharing of scarce skills and resources. This might involve cooperation with the International Labour Organization (ILO), the Forum Secretariat or other organizations. Countries may examine the extent to which programmes such as the UNDP TOKTEN scheme and other similar schemes might be developed to encourage the return of skilled health personnel in the Pacific region on a short-term or long-term basis.

(3)

(4)

(5)

(6)

(7)

(8)

(9)

(10) Countries should consider reviewing bonding procedures and the manner in which they are designed, implemented and enforced. ( 11) Countries should consider developing more family- and worker-friendly work practices. (12) Countries should consider reviewing and developing policies, such as working conditions and entitlements, to meet the particular needs of rural and remote areas, including improving infrastructure provision (transport and communications) in the context of a sectorwide approach. Countries should consider ensuring that they have an effective system for analysing and reviewing existing and future workforce requirements and the availability of skills and competencies, which will enable the development of an ongoing human resource plan.

(13)

- 18 -

(14)

Countries are encouraged to develop and analyse core data and information on skilled health personnel, with assistance from WHO where relevant, in order to enhance capacity for policy development, planning and management.

- 19 -

ANNEXl

PROVISIONAL LIST OF PARTICIPANTS, CONSULTANT, TEMPORARY ADVISERS, OBSERVERS/REPRESENTATIVES AND SECRETARIAT

1. PARTICIPANTS

AMERICAN SAMOA

Mr Malo L. Niumata, Manager, Classifications & Data Personnel Division, Department of Human Resources, A56, P.O. Box 4838, Pago-Pago, Tutuila 96799 Tel: (684) 699-7437(H); (684) 633-4485 (W) Fax: (684) 633-1139, E-mail: maloniumata@hotmail.com Mr Sivia Fiti Sunia, Assistant Director, Department of Health Pago-Pago, Tutuila 96799, Tel: (684) 633-4606 Fax: (684) 633-5379, E-mail: publichealth8@hotmail.com

AUSTRALIA

Mrs Katy Balmaks, Director, Health Workforce, Undergraduate Initiatives Section, Department of Health and Ageing MDP 50, GPO Box 9848, Canberra, ACT 2601 Tel: (612) 6289 5132, Fax: (612) 6289 9444 E-mail: katy.balmaks@health.gov.au Ms Denise Rairi, Chief Executive Officer to the Minister of Health, Office of the Minister of Health P.O. Box 109, Rarotonga,_Tel.: (682) 20261 Fax: (682) 20262, E-mail: ceo1@health.gov.ck Ms Ngarangi Tangaroa, Overseas Training Coordinator, Department of National Human, Resource Development P.O. Box 650, Arorangi, Rarotonga, Tel: (682) 21467 Fax: (682) 21468, E-mail: nathrd@oyster.net.ck

COOK ISLANDS

FIJI

Mr Kitione Mulo, Acting Director, Health Services Department Ministry of Health and Social Welfare, Dinem House Toorak, Suva. Tel.: (679) 3-306177; Fax: (679) 3-306163 E-mail: kmulo@health.gov.:fj Mr Asaeli Tamanitoakula, Acting Director, Corporate Services Ministry of Health, Dinem House, Toorak, Suva Tel.: (679) 3-306177, Fax: (679) 3-306163 E-mail: atamanitoakula@health.gov.fj

- 20 -

Annex 1 Mrs Shannon Coalala Toutou, Senior Administrative Officer Workforce Planning and Scholarship Unit, Public Service Commission, P.O. Box 2211, Government Buildings, Suva Tel.: (679) 3316 523-524; 3316 526; Fax: (679) 3303 703 E-mail: stoutou2@psc.gov.fj KIRIBATI Dr Takeieta Kienene, Permanent Secretary for Health Ministry of Health and Family Planning, P.O. Box 268 Tarawa,_Tel.: (686) 28100; Fax: (686) 28152 E-mail: rnhfp@tskl.net.ki Mr Tebuka Toatu, Laboratory Superintendent and Secretary, Education and Training Committee Ministry ofHealth, P.O. Box 268, Nawerewere Tel.: (686) 28100; Fax: (686) 28152 E-mail: teb 1966@hotmail.com MARSHALL ISLANDS, REPUBLIC OF THE Ms Justina R. Langidrik, Secretary of Health Ministry ofHealth, P.O. Box 16, Majuro, MH 96960 Tel.: (692) 625-5660 to 5661; Fax: (692) 625 3432 E-mail: jusmohe@ntamar.com Ms Takwoj K. Lanwi, Personnel Officer Public Service Commission, P.O. Box 90, Majuro, MH 96960 Tel.: (692) 625 8298/8498; Fax: (692) 625 3382 E-mail: PSCRMI@ntamar.com MICRONESIA, FEDERATED STATES OF Mr Dionis Saimon, Family Health/Planning Program Coordinator Department of Health, Education & Social Affairs, P.O. Box PS 70, Palikir, Pohnpei FM 96941 Tel.: (691) 320-2619/2643; Fax: (691) 320-5263 E-mail: fsmunfpa@mail.fm Mrs Ruby Thoma, Coordinator, Healthy Island Programme Department of Health and Medical Services Republic ofNauru,_Central Pacific Tel.: 74 421 3702; Fax: 74 421 3100 E-mail: denugasechealth@yahoo.com Ms Denise Pamela Hutchins, General Manager Human Resource and Organisational Development Nelson Marlborough, District Health Road, Private Bag 18, Nelson. Tel.: 03 5461 733 (W), 03 5475 051 (H) Fax: 01 5461 747, E-mail: denise.hutchins@nmhs.govt.nz

NAURU

NEW ZEALAND

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Annex 1 Ms Helen Jean Lockyer, Principal Analyst Workforce Sector Policy Directorate Ministry of Health, P.O. Box 5013, Wellington Tel.: 00 64 4 4962231; Fax: 00 64 4 962210 E-mail: helen_lockyer@moh.govt.nz

NIUE

Mr Uhotau Tau Pasisi, Commissioner Niue Public Service Commission P.O. Box 125, Alofi. Tel.: (683) 4210; Fax: (683) 4211; E-mail: npscomz@mail.gov.nu Mr Bob Tunifo Talagi, Manager Niue Health Department, P.O. Box 33, Alofi Tel.: (683) 4100; Fax: (683) 4265 E-mail: malolotino@mail.gov.nu

PALAU, REPUBLIC OF

Ms Jelina Renguul, Personnel Specialist Bureau of Public Service System, Ministry ofFinance P.O. Box 6011, Koror PW 96940 Tel. : (680) 488 2415; Fax: (680) 488 1016 E-mail: training.mof@palaugov.net Ms Julita Tellei, Human Resource Development Officer Ministry of Health, P.O. Box 1087, Koror PW 96940 Tel.: (680) 488 2552/488 2553; Fax: (680) 488 1211 E-mail: Julie@palau-health.net

PAPUA NEW GUINEA

Mr Florian Yambilafuan, Director, Human Resource Management, National Department of Health P.O. Box 807, Waigani, N.C.D. Tel.: (675) 301 3671; Fax: (675) 301 3604 E-mail: fyambila@health.gov.pg Mr Ravu Verenagi, First Assistant Secretary (Industrial and Employee Relations) Department of Personnel Management P.O. Box 519, Waigani, N.C.D. Tel.: (675) 327 6336; Fax: (675) 327 6354 E-mail: Ravu_Verenagi@dpm.gov.pg

SAMOA

Ms Sarah Asi Faletoese, Principal Health Planner Ministry of Health, Private Mail Bag Motootua, Apia. Tel.: (685) 24068(W)/26836(H) Fax: (685) 23484; E-mail: saraha@health.gov.ws Ms Gabrielle V aoutumala, Principal Resourcing Analyst Public Service Commission, P.O. Box 73, Apia Tel.: (685) 22123(W)/31930/23315(H) Fax: (685) 24215; E-mail: gabrv@samoalive.com

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Annex 1

SOLOMON ISLANDS

Mr Ishmael M. A vui, Undersecretary Public Service Department, P.O. Box G.l, Honiara Tel.: 677 28617; Fax: 677 20085 E-mail: isi avui@hayoo.com Dr George W. Malefoasi, Undersecretary, Health Care Ministry of Health, P.O. Box 349, Honiara Tel.: 677 24097; 677 20830; Fax: 677 20085 E-mail: ushc@solomon.com.sb

TONGA

Mrs Patinia Patelisio, Assistant Health Project Officer Ministry of Health, P.O. Box 59, Nuku'alofa Tel.: (676) 23 200; Fax: (676) 24 291 E-mail: hpaid@kalianet.to Ms 'Akanesi Siokapesi Taufa, Senior Assistant Secretary Establishment Division, Prime Minister's Office P.O. Box 62, Nuku'alofa. Tel.: (676) 24 644 Fax: (676) 24 565; E-mail: astaufa@J?mo.gov.to

TUVALU

Ms Lagi Etoma, Member, Public Service Commission Funafuti. Tel.: (688) 20881; Fax: (688) 20648 Dr Tekaai Nelesone, Director of Health Health Division, Ministry of Health, Funafuti Tel.: (688) 20765; Fax: (688) 20750/20481 E-mail: tnelesone@hotmail.com

VANUATU

Mrs Maturine Tary, Director Health Planning and Administration Ministry ofHealth, Private Mail Bag 009, Port Vila. Tel.: (678) 22 512; Fax: (678) 26 204 E-mail: mstary@vanuatu.gov .vu Mr Bill Arthur Willie, Deputy Secretary, Public Service Commission, Private Mail Bag 9017, Port Vila. Tel.: (678) 23 299; Fax: (678) 26 381 E-mail: bwillie@vanuatu.gov.vu

2. CONSULTANT

Professor John Connell, School of Geosciences, The University of Sydney Room 475 (F09) 310 (F05), F09-Madsen, New South Wales 2006, Australia. Tel.: +61 2 9351 3244/2327; Fax: +61 2 9351 3644. E-mail: jconnell@mail.usyd.edu.au

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Annex 1 3. TEMPORARY ADVISERS

Professor Binod Khadria, Professor of Economics, Zakir Husain Centre for Educational Studies, School of Social Sciences, Jawaharlal Nehru University, New Delhi 110067, India. Tel.: 91 11 2674416; 26704417(W); 91 11 26183517;26711239(H) Fax: 91 11 26198234 (W); 91 11 26183517 (H). E-mail: bkhadria@yahoo.com Ms Monica Driu Fong, Coordinator, Pacific Health Research Council Secretariat c/o Fiji School ofMedicine, Private Mail Bag, Suva, Fiji Tel. No. (679) 331 1700; Fax No. (679) 330 5781. E-mail: m.fong@fsm.ac.fj

4. OBSERVERS/REPRESENTATIVES

Commonwealth Secretariat, United Kingdom

Dr Rosemarie Paul, Deputy Director/Head, Health Section Social Transformation Programmes Division, Marlborough House Pall Mall, London SW1 Y 5HX. Tel. No. +44 (0) 20 7747 6320 Fax No. +44 (0) 20 7747 6287/7930 1647 E-mail: R.Paul@commonwealth.int Dr Warne Baravilala, Dean, Fiji School of Medicine Private Mail Bag, Suva, Fiji. Tel.: (679) 3304 273 Fax: (679) 3305 781. E-mail: w.baravilala@fsm.ac.fj Mrs Atelina Wainiveikoso, Senior Tutor, Fiji School ofNursing Suva, Fiji. Tel.: (679) 321499; Fax: (679) 321013 Ms Rigieta Nadakuitavuki, Acting Director, Nursing Health Systems Standards, Ministry of Health Dinem House, Toorak, Suva, Fiji. Tel.: (679) 330 6277 Fax: (678) 330 6163. E-mail: madakuitavuki@health.gov.fj Mr Geoffrey Hayes, Population and Development Adviser UNFP A CST, Private Mail Bag, Suva, Fiji Fax: (679) 331 2785. E-mail: ghayes@unfpa.org.fj Dr Kesaia Seniloli, Coordinator, Population Studies Programme University ofthe South Pacific, P.O. Box 1168, Suva, Fiji Fax: (679) 3302865. E-mail: seniloli_k@usp.ac.fj

Fiji School of Medicine

Fiji School of Nursing

Ministry of Health, Fiji

United Nations Population Fund (UNFPA) University of the South Pacific

- 24-

Annex 1 5. SECRETARIAT Dr Soe Nyunt-U, Acting Director, Health Sector Development, World Health Organization Regional Office for the Western Pacific, P.O. Box 2932, United Nations Avenue 1000 Manila, Philippines. Tel. No. (632) 528 9831; Fax No. (632) 521 1036 E-mail: nyunts@wpro.who.int Dr Ezekiel Nukuro, Regional Adviser, Human Resources Development World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932 United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528 9816 Fax No. (632) 521 1036; E-mail: nukuroe@wpro.who.int Mrs Lorraine Kerse, Regional Adviser, Human Resources Development WHO Representative in the South Pacific, P.O. Box 113, Suva, Fiji Tel. No. (679) 3-304 600/631/635; Fax No. (679) 3-300 462. E-mail: Kersel@sp.wpro.who.int

Mr Ui-Guyn Shin, Technical Officer, Health Workforce Development World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932 United Nations Avenue, 1000 Manila, Philippines. Tel. No. (632) 528 9891; Fax No. (632) 521 1036. E-mail: shinu@wpro.who.int Mr Stephan Terras, Project Management Officer, c/o WHO Representative in Samoa Ioane Viliamu Building, Beach Road, Apia, Samoa. Tel. No. (685) 23 756-57; Fax No. (685) 23 765. E-mail: terrass@sma.wpro.who.int Ms Barbara Stilwell, EIP /OSD/HRH, World Health Organization, Geneva.._ Switzerland Tel: (+41( 22 791 4701; Fax: (+41) 22 791 4747. E-mail: stilwellb@who.int

MEETING ON MIGRATION OF SKILLED HEALTH PERSONNEL IN PACIFIC ISLAND COUNTRIES Nadi, Fiji 23-27 June 2003 TENTATIVET~ETABLE

WPR/ICP/HRD/6. 4/001/HRD(l)/200 3.l(b) 31 May 2003

Time

23 June 2003 (Monday) Registration 1. Opening ceremony Keynote address by the Regional Director Welcome remarks by the Minister of Health Self-introduction of participants Election of Officers Administrative announcements and group photo 2 . Adoption of the agenda 3. Overview of the meeting objectives Study on migration of skilled health professionals in Pacific Island Countries

Time

24 June 2003 (Tuesday) 6. Summary of proceedings of Day 1 (23 June 2003) 7. Country experiences in migration of skilled health personnel (American Samoa, Australia, Cook Islands and Fiji)

Time

25 June 2003 (Wednesday)

Time

26 June 2003 (Thursday) Working groups: Session 2

Time

27 June 2003 (Friday) 13. Presentation of proposed key actions at country level

0800 to 0900

0800 to 1000

c 1000 to 1230 1015 to 1230

0

Continuation: country experiences in migration of skilled health personnel (Solomon Islands, Tonga, Tuvalu, Vanuatu) 8. Migration of skilled health personnel: international experiences and lessons learned F F E E B R E A K 1015 to 1230 Plenary session: Discussion on international experiences 9. Commonwealth Secretariat's experiences and Code of Practice for International Recruitment of Health Workers H B R E A K 10. Working group sessions (assignment of topics)

0800 to 1000

0800 to 1000

0800 to 1000

Continuation: country experiences in migration of skilled health personnel (Guam, Kiribati, Commonwealth of the Northern Mariana Islands)

1015 to 1230

11. Plenary session: Working group presentation and discussion

1015 to 1200

14. Discussion and adoption of recommendations l.1l N

15. Closing ceremony

I

L 1330 to 1500

u

N

c 1330 to 1445

4. Discussion on the study of migration of skilled health personnel

1330 to 1445

Continuation: country experiences in migration of skilled health personnel (Marshall Islands, Micronesia, Nauru , New Zealand) 0

1330 to 1445

Continuation of the working group presentation and discussion

c

F F E E 1500 to 1630

B R E A K Working group (Session 1) 1500 to 1630 12. Proposed key actions at country level

1500 to 1630

5. Review of options for achieving an adequate and cost-effective supply of appropriately qualified nurses in the Fiji Health System

1500 to 1630

Continuation: country experiences in migration of skilled health personnel (Niue, Palau, Papua New Guinea, Samoa)

1900

Cocktail

- 26 -

-27-

ANNEX3

OPENING REMARKS OF DR SHIGERU OMI REGIONAL DIRECTOR WESTERN PACIFIC REGION AT THE MEETING ON MIGRATION OF SKILLED HEALTH PERSONNEL IN PACIFIC ISLAND COUNTRIES NADI, FIJI, 23 TO 27 JUNE 2003 PARTICIPANTS, LADIES AND GENTLEMEN Welcome to this important meeting. I hope you all had a good journey and we look forward to learning about your experiences and contributions at this meeting. May I convey on behalf of all of us here, our sincere appreciation to the Government of Fiji for its agreement to hold the meeting and for their warm welcome. International migration has grown in volume. It is an important global issue. Trained human capital moves largely from less-developed nations to more developed and affluent ones, with socio-economic consequences for the source and recipient nations. As health service is labour-intensive, there is a tendency for countries with shortages to resort to recruitment of trained health workers from elsewhere. In Africa, where health needs and problems are greatest, about 23 000 qualified professionals emigrate annually. The pattern affects Asia, too. In 2001, more than 15 0 000 Filipino nurses and 18 000 Zimbabwean nurses worked abroad. Many countries, both developed and developing, are experiencing shortages of skilled health personnel. In countries that already have critical shortages, such as some Pacific island countries, the loss of health professionals due to migration can have serious implications as the countries' capacities to provide adequate, good quality health services are undermined. In many cases, migration has led to reduced health service efficiency, delays in delivering acute emergency care, long waiting times for scheduled services and increased inequity in access to basic health services. There are signs that the demand for skilled and trained health personnel in developed and richer countries will increase over the next 10 to 20 years. For example, the United Kingdom currently needs 10 000 more doctors and 20 000 more nurses to support their new health plan, and a further 1 000 000 nurses will be needed over the next 10 years to meet the shortfall in the United States. How big is the problem of out-migration of skilled health professionals in Pacific island countries? About half of Tonga's doctors and a quarter of Solomon Islands' doctors currently work or are attending training abroad. Between 5% to 10% of doctors in Samoa and 5% of nurses in Tonga have been leaving each year for the past several years. In Fiji, 25 doctors and 50 nurses- 10% of the workforce -left within a one-year period. Although the numbers of migrating health professionals in some Pacific island countries may be few, the impact on health services can be serious such as the closure of certain clinical or allied health services because national health experts may have left the country to work abroad. In this regard, migration of skilled health personnel is a major concern for most, if not all, the Pacific island countries. International migration provides many health workers with opportunities to develop their careers, gain valuable experience and professional expertise, and improve living conditions for themselves and their families. Understandably, in those countries that have more health professionals than their requirements, emigration is desirable and is actively encouraged in some cases. But for the source countries where shortages have reached critically low levels, the mostly negative impacts on health services and financial resources far outweigh any gains. While remittances from migrants can contribute to national and household income and improved standards of living, little of the income remitted is invested in maintaining or improving health service delivery . .. ./

- 28 Annex 3

Furthermore, the cost implications of migration are significant for the source countries. For example, the United Nations Commission for Trade and Development estimated that each migrant African professional represents a loss of about US$148 000: South Africa lost about 37 million dollars for its 600 medical doctors who worked abroad: about 10 000 persons who left Fiji within a seven month period between May and November 2000, each one represented a loss of about Fiji $100 000 for the country (an estimated loss of about one billion Fiji dollars in total). To make up for the losses of their skilled health professionals, many countries offer attractive salaries and incentive packages for foreign experts . In most cases, the annual costs in terms of E>alarien and inoentivor> for a.n expatriate doctor is more than that of a national do~tuJ witl! tlte sal1Jt:: yualifi~.:aliuu, status and job description. Africa alone spends about US$ 4 billion a year on the salaries of about 100 000 foreign experts recruited to replace those it has lost to emigration. There are indications that the migration of skilled health professionals will continue due to a variety of factors, some of which are beyond the control of countries. Globalization has broken down barriers and boundaries among people, professions, cultures and countries, resulting in significant increases in trade, communications and movements of capital and labour. The lack of comprehensive and reliable information on migration flows and related issues led the Ministers of Health of Pacific island countries to request WHO support for studies on the migration of skilled health personnel in the Pacific sub-region. Such studies should provide information for the development of appropriate evidence-based national policies and strategies to reduce migration levels and alleviate some of its consequences. In 2000, WHO commissioned a study to investigate the patterns and factors influencing the migration of skilled health personnel in the Pacific island countries. The study, conducted in two phases over two years, involved about 400 health professionals in eight Pacific island countries, including those who had migrated to countries such as Australia and New Zealand. It is difficult to generalize or to bring coherence to such a complex topic as migration because circumstances vary from country to country and among health professional cadres. However, the study has showed some common patterns and factors influencing the migration of health personnel in the Pacific. One of the main objectives of this meeting is to examine and discuss the findings and conclusions of the study. I wish to mention a few key points here: • First, the reasons for migration across health cadres (doctors, nurses, paramedical, etc) were very consistent. The main reason included: poor remuneration; inflexible working hours with extra workload; inadequate continuing educational opportunities; limited training facilities; poor working environments with limited opportunities for career advancements; and shortages of supplies and equipment. Second, it became evident that the social factors were equally important factors influencing migration. These includes: the needs and expectations of the extended household members; discriminatory practices; low morale and job dissatisfaction; presence of relatives and families abroad; and educational opportunities for the children of health personnel. There was strong evidence that women were less likely to migrate than men. Improving salaries and working conditions alone, though important, may not be sufficient to address the migration of health personnel. Third, the volume of migration was greater in the Pacific island countries that have strong political and economic links with affluent countries. Furthermore, those who have received higher professional training outside the Region and have higher, recognized professional qualifications were more likely to migrate abroad.

•

•

...I

- 29Annex 3

Next, the recruitment of foreign personnel to replace those who had migrated was only a limited solution. Apart from being comparatively costly, the difficulties experienced by the foreign professionals in communica ting with patients and the cultural differences affected the level and quality of health care they provided. In some cases, the presence of a significant number of overseas recruits, most with better remuneration and benefits, was a source of local concern as it affected morale within the health service and contributed to further migration of national health professionals. Finally. the migration of skilleci he~ lth pe:rsonnel was likely to continue given certain faotom largely beyond the control of Pacific island countries. The fact that it is likely to continue makes it more important that countries have a clear understanding of who is moving, where, and why in order to develop appropriate policies and strategies to ameliorate the more damaging consequences. The challenge, however, is the lack of comprehensive and reliable information and database of health personnel in most of the countries, particularly on migration flows. So what are the policy options and strategies to reduce migration of skilled health personnel and address the negative consequences? I understand that this is one of the key questions for this meeting. There may not be any single, standard solution that will work for every country. It is imperative that the focus or basis of any remedial measures and strategies should include the following aspects: • • • • • Retention of health professionals. Information and human resource database. Commitments, partnerships, and collaboration. Strengthening linkages among health services and training institutions. Putting migration of skilled health personnel on bilateral, multi-lateral, regional and international agendas.

I hope each one of you will take this opportunity to share your views and experiences on these issues and to exchange your country experiences and work. In conclusion, the study on migration of skilled health professionals in Pacific island countries has confirmed that it is a growing problem. Most countries are left with shrinking and/or ageing health workforces that are inadequate to meet their populations' health needs. Furthermore, the study had also provided valuable information and some evidence on which to base policy options and possible interventions. May I take this opportunity to thank the respective governments of Pacific island countries for your collaboration in the study and all the health professionals involved in the study for your input and opinions. We are grateful to the University of Sydney, and in particular, Professor John Connell, for conducting the study on behalf of WHO. Last, but not least, to everyone here, our appreciation for your contributions and the sharing of your expenences. I wish you all a successful meeting.

-3 0-

- 31 -

ANNEX4

THF. MTGR ATION OF SKILLED HEALTH PERSONNEL IN THE PACIFIC REGION

Summary Over the past two decades there has been a widespread loss of skilled health professionals (SHPs) in most Pacific island countries (PICs), through emigration, mainly to the metropolitan states on the fringes of the region. Migration of skilled personnel has occurred in a wider context of emigration, which has resulted in the creation of a 'transnational community of kin', with extended households spread across PICs and metropolitan countries. This has been significant for the flow of remittances to most PICs where economic growth has been limited. The loss of SHPs has been at some cost toPICs and health systems, because of the high costs of training and the reduction in the effectiveness of health care. This has not always been countered by the immigration of other SHPs. To examine the situation in greater detail, a survey of over 520 migrant and non-migrant SHPs in eight PICs -Cook Islands, Fiji, Kiribati, Marshall Islands, Palau, Samoa Tonga and Vanuatu- and in three metropolitan destinations (Australia, Canada and New Zealand), examined both the reasons for migration, and the context of migration. There is extraordinary consistency in the general explanations of migration. Within and beyond the Pacific these focus on low remuneration, inflexible working hours, the lack of continuing educational opportunities, poor promotion opportunities, limited training facilities, shortages of supplies and equipment in a poor working environment, especially in rural and remote areas where health needs are least well served. In a context where mobility and emigration are often the norm and where governments have rarely sought to discourage migration for various reasons, it is likely that an increasing number of people will have relatives abroad. The presence of close kin abroad is a significant influence on migration. Political instability is a factor in Fiji. Economic factors are the principal influence on migration though social and demographic variables are of enormous significance, especially for those who remain in place.

The situation is most serious for doctors, especially young and good ones, and other skilled health workers such as dentists and radiographers because of their smaller numbers to start with, particularly in the smaller countries. The emigration rates for nurses are steadily increasing especially as overseas recruitment occurs. More PICs are now being affected by the emigration of SHPs. High levels of migration have contributed to low productivity, poor morale and frustration. Migration of Ships is not an overs pill but a definite loss, with clear negative outcomes that are both economic and health-related, limiting progress towards healthy islands and possibly even resulting in a regression in that status. Return migration is not inconsiderable but is still of limited significance.

- 32Annex4

All the factors that have stimulated recent migration of skilled people remain in place. The same factors have also influenced attrition within the health system and discouraged initial recruitment into the health services. Emigration is likely to continue, especially if external recruitment within the Pacific increases, and exacerbates the existing situation. The most serious problems of labour shortages are in the smaller countries, where skilled human resources are fewer, especially in more remote areas. Policies to reduce emigration must focus on more appropriate hiring, salary and career structures, more effective in-country training, improved working conditions and other institutional arrangements. More extensive recruitment of intakes into various health professional training courses, on the assumption that some graduates will migrate, is likely to be one valuable, if initially expensive, response. Introduction The most important resource in any country is the people. The role of human resources is central to development in many PICs and the limited availability of skilled human resources is a constraint to development. Human capital is a critical element in the economic and social development of all societies, and health is a universal basic need. In the health arena the significance of human resources is doubled. Skilled health personnel directly improve the quality of life for others, who are then able to contribute more to the wider society. Conversely the lack of availability of skilled health workers has harmful ramifications for the rest of society. Tertiary education and training are needed to provide the capacity for continued human resource development in PICs. Tertiary education and training facilities are restricted in some small PICs, yet there is a continued need to ensure that training and education are relevant to the particular situation of the countries. Training within the Pacific region has not always been able to produce adequate numbers of skilled health personnel. This situation is generally worsening. A constant source of concern in most parts of the region is the need for institutional strengthening. Firstly, this means that there should be appropriate facilities to develop adequate numbers of appropriately skilled people within the region. Secondly, it means ensuring that skilled people remain in place in their home countries, and deliver adequate services. In many PICs the inadequate delivery of services such as health, education, and transport, have been seen as a constraint to development. These issues are particularly serious in the smaller countries because of the special issue of providing training at high cost for very small numbers of people. These problems are worsened, usually most obviously in the smaller countries, where there is migration, thus attrition, of the labour force. This may be significant both within countries, with movement from peripheries due mainly to the unwillingness of skilled personnel to be located there, and between countries, through emigration. Migration of SHPs has already had a significant impact on the Pacific region, creating problems for health care and for human resource planning and development. Migration and attrition represent a costly loss of scarce and expensively trained human capital. Training of SHPs is particularly expensive because of the long duration, the costs of teaching materials and techniques, the high costs of post-graduate education and training abroad and the limited financial resources ofPICs. Recruitment of replacements is often costly and it is difficult to verify and judge whether the foreign professionals have the appropriate formal

- 33 Armex 4

qualifications, skills and experiences, languages and cultural sensitivity for work in various Pacific island country settings. There is a widespread assumption that the problem of health worker migration is worsening. Indeed there is now even some competition for SHPs between PICs. The available evidence points to an overall worsening of the situation, in terms of attrition and migration rates, during the la3t decade, accompanying the widespread dowu-siL.iug u1 sta!Jiliziug uf public service numbers. This is linked to stagnant economic growth and growing external pressures on PICs to engage in comprehensive restructuring. Nonetheless the situation was already a source of concern a decade ago: "The region faces a crisis in terms of its health workforce, not only in terms of direct care providers but at all levels of the system. It is not surprising that one of the most frequently mentioned topics is the shortage of doctor. The physician shortage is only the tip of the iceberg .. .Inefficiency in health systems is a major problem and there is a crucial need for trained administrative personnel" (Lewis 1990: 84). In some respects all the above-mentioned issues are a function of other related problems in PICs: shortages of financial resources; limited government commitment to health in some states (despite the linkage between poor health and slower economic growth); weak management capacity; and few economies of scale, which further contribute to shortages of drugs and technology alongside human resources. This is also linked to a dependence on off-island facilities such as education and training facilities and specialist hospitals, alongside rising expectations for improved delivery of services and standards of living. In some places this has Jed to an emphasis on high technology and curative care rather than on appropriate technology, preventative health care and the achievement of a balanced workforce. In some contexts there is a weakness in governance and political will at all levels and a lack of interest in the health sector as a place of employment. Underlying the problem in many PICs is simply the lack of capital to engage in restructuring. Migration in Pacific Island Countries Since the 1960s there has been a very substantial rise in the extent and significance of migration within and from the PICs, resulting in absolute population declines in some of the smallest states. International migration was initially primarily a Polynesian phenomenon. Many people from American Samoa, Cook Islands, Niue, Samoa and Tonga have moved to New Zealand (whence some have gone on to Australia) and to the United States. In the largest countries of Melanesia emigration has been relatively insignificant, though there has long been a significant migration stream, mainly of Fiji Indians, from Fiji. In terms of the migration of SHPs this is also numerically the most important stream in the region. In the last decade, there has been a very considerable movement of Micronesians from the Marshall Islands and the Federated States of Micronesia, particularly to the United States and its territories such as Guam and the Northern Marianas. Political status has been a significant influence on migration in that the nationals of the Cook Islands, Niue and Tokelau are New Zealand citizens and may move there freely, whilst the nationals of the Marshall Islands, Federated States of Micronesia and Palau are free to migrate to the United States and its territories. International movements have been paralleled by intensified migration within particular countries. This migration has been characterized by movement away from remote islands and isolated rural areas, particularly to urban areas, which has grown considerably in recent years. This has tended to increase the problems of service delivery in remote areas, a 'vicious circle' which had in turn, accounted for some of the movement away from isolated areas.

- 34Annex 4

Whilst the scale of international migration is affected by fluctuations in the international economy, migration is primarily affected by uneven development- inequalities in socioeconomic opportunities and income levels and the desire for access to education and health services. Tertiary education in the smaller countries is usually undertaken outside the home country and is a factor contributing to emigration. It is not possible to identify the extent to which either Sl-IPs a1 e a signifkant aud 1 isiug proportion of either emigrants from PICs or of immigrants to metropolitan states, since migration data are too crude or are unavailable, and there is a general unwillingness on the part of both sending and receiving countries to acknowledge the flows of skilled labour. There is however some indication that skilled workers in general, and SHPs in particular, are a higher proportion of immigrants from PICs to metropolitan states because ofthe increased focus on skilled migrants (within declining immigration numbers) in most destination countries, and the continued and increasing demand for health workers there. Each of the principal destination countries for SHPs -Australia, Canada, New Zealand and the United States- have the acquisition of permanent skilled migrants as one of the objectives of their immigration policies. New Zealand at least has actively recruited in the PICs, notably in Fiji, for SHPs. More recently there has been recruitment from even more distant countries such as the United Arab Emirates and South Africa. Throughout the Pacific it is usually the most educated who migrate first, whilst many migrants have left rural areas to take advantage of superior urban and international educational facilities. These two factors in migration tend to reinforce each other so that this bias is likely to be maintained. For some PICs the resultant loss of skilled personnel within the country and from the country, has been considerable; the Cook Islands, for example, lost more than half its vocational skilled personnel in a decade (1966-1976). This is certainly true more generally in the health sector where more costly and yet comparatively less skilled replacements have been required. The widespread education bias in migration suggests that the loss of skills is likely to continue. Young and skilled migrants are more easily and more likely to migrate following incountry political or other problems. Few studies have been undertaken of return migration in the Pacific. Although return migration occurs across a wide range of categories of personnel, the volume is always smaller than the flow outwards, notably in Polynesia. In Melanesia and Kiribati migration is usually circular, with virtually all those who have migrated returning relatively quickly. However this may be becoming more unidirectional, as has recently occurred in Tuvalu. The limited extent of return migration is partly due to the great differences in income levels between the PICs and the metropolitan countries. It is also linked to education overseas for both children and parents, which in tum is also linked to a gradual shift in the demographic balance and the presence of relatives in the destination countries. There is however potential for the return migration of the relatively skilled, in appropriate circumstances, because of the status and relatively high incomes that accrue to those with skills. Where return migrants are able to be involved in the private sector, and have close kin at 'home', return is more likely. In some contexts in the Pacific region, international migration has been viewed as a kind of 'safety-valve', reducing pressures on national governments to provide employment opportunities and welfare services especially in conditions of high rates of natural increase of population and low rates of economic growth. Thus in most countries there is little general concern over the extent of international migration of skilled health personnel or the developmental use of remittances. An illustrated observation:

" Global economic changes and the law of supply and demand for skilled health professions is affecting the retention of skilled health workers in countries that can ill afford

- 35Annex 4

losing such category of health personnel. For Fiji and other small Pacific island countries in the region sending off a relative for a job overseas is considered a great privilege because of the returns that relatives back home would get .from such moves (2002: 1)" General Secretary, Fiji Nursing Association. In many parts of the region the 'safety valve' effect, limited economic growth plus concern over individual freedom of movement, hav~:: L:UiulJiueJ lu Jesull iu sleaJy auJ domestically unimpeded out-migration. In some PICs it is usually difficult to replace skilled migrants, both because of the duration of training that is required and the very small demand for some particular skills. Similarly, because of the necessity for appropriate skilled training, it is more difficult to substitute for absent skills in the health workforce. The available evidence on international migration in the PICs demonstrates that in the short-run a number of distinct benefits accrue to individual migrants and their families and to the source country. Migration has reduced the level of open and disguised unemployment, despite the loss of skilled human resources from the formal sector. Migrant remittances have contributed to various facets of national and household development. Remittances, especially in the larger Polynesian countries of Samoa and Tonga, have raised living standards, contributed to employment and eased balance of payments problems, despite contributing to inflation. Moreover migration is embedded in strategies for extended household development, rather than simply the outcome of decisions taken by a very small number of individuals. In a sense, international migration has long had a critical and virtually uncontested role in island societies and economies, at least in Polynesia and Micronesia. The migration of skilled workers thus needs to be seen in this broad context of continuity. This general conclusion also applies to skilled migrants, and specifically SHPs, despite the widespread perception that any financial gains are outweighed by the costs of the skill drain in terms of the loss of scarce human capital. Nonetheless the compensatory gains, for both households and countries, from remittance flows (especially in Polynesia) indicate that the loss of SHPs is not without economic gains. Long term migration may however impose considerable costs. Little or none of the income remitted is being invested in the health service. Governments have not been able to or sought to control or direct the use of remittances while the rising material consumption levels following migration tend to generate increased demand for costly imported consumer goods. This demand, and other parallel demands for superior lifestyles, can usually only be met through further migration, as long as other forms of economic growth prove difficult to develop. Migration therefore imposes costs alongside benefits. Pacific Island Countries and the Health Workforce The Pacific region is an area of exceptional geographical, cultural and economic diversity, complicated by fragmentation, restricted land areas, weak infrastructures and the isolation of small islands and countries. In most countries the prospects for sustained economic development have generally been considered to be poor in comparison with other regions of the world. There are now widely perceived differences in economic welfare between the PICs and neighboring metropolitan countries, resulting in migration of people from the former to the later. In the past two years some of the difficulties attached to social and economic development have been reflected in crises in some PICs. Most, if not all, of the PICs experience low or even negative rates of economic growth.

- 36 Armex 4

·r.IC p OpUIa f IODS T a bl e 0 ne: p ac1 Population Population density (persons per sq km) 76 168 45 112 286 39 10 58 16 154 381 16 Population growth rate Urban population Total fertility rate

(%)

Life expectancy at birth

Cook Islands FSM Fij i Kiribati Marshall Islands Palau PNG Samoa Solomon Islands Tonga Tuvalu Vanuatu

18,000 118,100 824,700 90,700 51,800 19,100 4,790,800 169,200 447,900 100,200 9,900 199,800

-0.5 1.9 1.6 2.5 2.0 2.2 2.3 0.6 2.8 0.6 0.9 3.0

28 30 50 39 65 74 18 24 18 35 44 22

3.7 4.9 2.6 4.5 5.7 2.6 4.8 4.5 5.7 4.2 3.4 5.3

71.3 65.7 66.5 61.5 67.5 69.0 53.5 68.4 61.4 70.7 67.0 64.2

Source: Secretariat of the Pacific Community, 2001 Health status varies considerably within the Pacific and is least adequate in the large Melanesian countries and best in those countries politically dependent on metropolitan nations. Even between the independent countries there are considerable variations, thus life expectancies in Fiji and Tonga exceed that in Kiribati by several years (Table One). These differences are partly a function of striking differences in economic and social development, that tend to reflect the isolated and more limited social development in the Melanesian states. In recent years there has been some re-emergence of infectious diseases, including tuberculosis and yaws (in Melanesia), alongside the rapid growth ofHIV/AIDS. Population growth remains rapid in several countries, especially the Marshall Islands, Solomon Islands and Vanuatu. Elsewhere, rapid population growth has been slowed, but largely by the 'safety valve' of international migration. Longer life expectancies, ageing and growing populations and the rise of non-communi cable diseases (NCDs) has placed increased stress on health care systems in the Pacific region. The modern health care systems have tended to become more centralised, to the extent that in several countries, such as the Marshall Islands, there are particular concerns about the delivery of health care services to remote and rural areas and, as in Papua New Guinea, a clear

- 37Annex 4

recognition that rural areas are inadequately served. More generally improvements in life expectancy have slowed, and even in some cases reversed. This situation is ·linked to slow economic growth and substantial reductions in real government spending on health. Primary health care (PHC) has been widely advocated, in terms of a more equitable distribution of appropriate resources and a greater focus on environmental health. However, new directions have been hampered by weak political commitment, a dependence onl!islutit.: wutlels, sometimes influenced by the constraints of aid delivery, including the construction and maintenance of central hospitals. In several countries the small private health sector is now growing. Previously small populations, even in urban areas, lack of means to pay and competition from the public sector where most services have been virtually free, has meant that few private practitioners could be supported in the PICs. The emergence of a small private sector has followed frustrations with the public sector on the part of a small local elite. The organization of health administration is necessarily hierarchical. Such bureaucracies may seem autocratic to those in subordinate positions. The combination of hierarchy and authoritarianism in health care systems, where the opportunities for promotion may be few simply because there are few higher level positions, may be very frustrating for those at lower levels in the hierarchy. This can be a factor encouraging emigration, as opportunities for advancement are few. Pacific health care systems vary considerably. Population per hospital bed ranges from under 50 to over 300 (in Fiji and Solomon Islands), whilst the number of people per doctor ranges from under 1000 to over 15,000 in PNG (WHO 1999). In all cases where information is available, only a small proportion of health budgets are allocated to primary health care, but high proportions, as in the Marshall Islands, may fund referrals and expatriate workers rather than local care and local workers. One outcome of a centralised and hierarchical medical care system is that the planning, budgeting and human resource recruitment and allocation functions rest with central authorities. At the same time central authorities may not be in a position to assist in capacity building and the appropriate development of outlying areas - and devolution of specific functions from central to rural areas may be resisted. Everywhere in the region skilled health workers have been reluctant to move to outlying areas, especially when posted there, since there may be little support for them from the line ministry and other facilities may be exceptionally limited. Access to health care and high quality services, including SHPs, is usually least adequate in remote areas. There is often a lack of material resources such as medical supplies, equipment and facilities for health care in most PICs. The maintenance of expensive and complicated equipment is a common problem, adding to the difficulties of providing adequate health care, and adding to the frustrations of those employed to achieve this. Small island populations mean that specialisation in clinical, administrative and public health areas is not cost-effective. In some countries there is no clinical specialization at all, but in the larger countries there is some specialization such as medicine, surgery, paediatrics and obstetrics and gynaecology at the national level. There are very few, if any, trained epidemiologists or health economists. Because of small populations, self-sufficiency in medical and health resources at a level to which many aspire is simply not possible, even with reasonably high standards of living, since there is simply inadequate specialized work for some individuals. In some circumstances this may be a disincentive for those who have, or seek to have, particular specializations, to remain in the health care system in the PICs. It also means that where there are very few individuals with

-38Annex 4

particular expertise, whether medical or administrative, their loss to the health system, because of emigration or any other reason, is a greater loss to small island health care systems than within larger states. One of the implications of limited specialisation, and also the absence (perhaps because of migration) of key individuals, is that international referral and evacuation of medical cases is relatively common. In 3omo counmtrics, such as the Marshall Islands and Palau, high !t:vels uf expectation assume that people will be evacuated for diagnosis and treatment abroad. Attempts to reduce the referral rate have occurred, but referrals remain an expensive issue, whilst simultaneously emphasising the difficulties of achieving or retaining an adequate supply of health practitioners and facilities in PICs. As long as high levels of referrals continue, health systems are likely to be regarded as inferior by many of the local population. Correspondingly, as long as there is a shortage of SHPs, costly referrals are more likely to occur, even for preventable conditions. Problems exist in the organization oflocal training of health personnel in PICs. Although there are several nursing schools, training medical practitioners poses greater difficulties, though there are two institutions for doctor training in the Pacific. Overseas training has tended to be a stimulus to subsequent migration, hence greater attempts have been made to develop appropriate in-country training. Most countries have nursing schools, but low secondary education standards may prove barriers to entry or completion of the course. While this may be so, attrition rates in most nursing courses in the region are low. Training of paramedical workers such as radiographers, physiotherapists and laboratory technicians also poses difficulties since relatively few such workers are needed, hence courses can only be run intermittently, or all such workers must be trained overseas. The migration of such specialised personnel is usually a more acute problem for PICs than the loss of doctors and nurses, because their numbers are so few and replacements are very difficult. The reductions in spending on health care systems in the Pacific that became evident in the 1980s, and have subsequently continued, have had a damaging result in sustaining a skilled health labour force. This is partly because Pacific health delivery systems require high levels of skilled labour inputs to staff hospital based curative activities, operate peripheral facilities and to undertake various preventative services. They have also led to uncertainties amongst the workforce over future prospects with respect to careers or access to technology and training. Evidence of shortage of SHPs has accumulated in recent years and has become evident in the recruiting of SHPs within the region. Some countries' health care systems have thus gained at the expense of others. The pattern of high vacancy rates that now exists in Fiji and the Solomon Islands is repeated in some other Pacific island countries. Fiji has relied on donor support and direct recruitment to compensate for the loss of health workers. Other countries have resorted to other means. Kiribati and Samoa have kept many doctors in service past retirement age, and have also turned to expatriates (such as United Nations Volunteers) who account for a third of the public sector. A similar reliance on expatriates is found in and the Marshall Islands, Palau, Solomon Islands and Vanuatu. Reliance on expatriates imposes certain costs, in terms of recruitment fees and some local expenses, whilst there are opportunity costs to the donor funds that support the expatriates. Moreover there are other potential disadvantages in terms of varied medical backgrounds, different approaches and quality standards, and different cultural sensitivities, especially where they cannot speak the local language, which limits their potential input into training.

- 39Annex 4

Other countries have sought different solutions to the loss of doctors. Tonga has developed a new category of Health Officer, trained in a limited two-year course within Tonga, and who largely run rural health centres or work in hospital outpatient wards. Replacement of doctors in this way in Tonga, and also in Kiribati, has not been without controversy, because of public perceptions of limited competence. In both Fiji and Samoa there has been a policy of employing retired local medical officers on a yearly contract basis to fill vacancies. In Samoa, th~ rlClr.tor shortage has led to a growing role for nunJc3. The evidence therefore ~uggt:sls thallht: lack, and loss, of doctors has been more pronounced than that of nurses. Moreover the loss of doctors has placed greater pressure on nurses. A number of countries have instituted training mid-level practitioners such as nurse practitioners to perform most of the functions of doctors, especially in rural and remote areas. Irrespective of the value of expatriate doctors, and other health professionals, there is always considerable expense and time attached to their recruitment, including sometimes long delays, the difficulty of finding the right recruit, the cost of recruitment and so on. This puts considerable pressure on bureaucracies who are sometimes poorly equipped to cope. Migration of Skilled Health Personnel The global rise in the migration of skilled workers has been one response to the accelerated globalisation of the service sector, of which health services are part. Such professional services as health care are very much part of the new internationalization of labour, as demand for skilled health workers in developed countries has remained high. Because of relatively low wages and poor working conditions, many developing countries become the main source countries for skilled health personnel for the developed ones. Due to a variety of reasons the international migration of skilled professionals seems likely to continue and perhaps intensify. There is continued demand in most metropolitan countries for the international migration of health personnel, because jobs in the health sector are seen in many metropolitan states as too demanding and poorly paid. Wages in the health sector therefore, have fallen behind increases in the cost of living and for these and other reasons employment in the health sector is no longer perceived as favourably as hitherto. Many developed countries, including Australia, Canada, New Zealand and the United States, the main destinations of Pacific SHPs, have a shortage of SHPs, especially of nurses. This has followed high attrition rates and low recruitment. Attrition has resulted from dislike of shift work, lack of flexibility, poor work conditions and incomes and family responsibilities that have resulted in the choice of a job more suited to particular lifestyles. These are broadly the same reasons that SHPs in the Pacific have withdrawn from national health services in the PICs . In addition work burdens have increased with the ageing of developed country populations. Accelerated international migration has occurred at the same time as greater difficulties of recruitment (especially of nurses) in metropolitan countries. Low recruitment of health workers has followed declining birth rates in developed countries, hence there are fewer younger people, and more recognition of diverse employment opportunities for women, many of which offer superior wages and working conditions, and attract greater respect. Relative declines in public sector funding have enhanced that perception. International recruitment of nurses has become increasingly global. Where once it was mainly a movement from a few developing countries to a small number of rich and affluent countries, typified by the recruitment of nurses from the Philippines for the Middle East, it has now extended and become more complex. For example there are now new movements of nurses between relatively developed countries, for example from South Africa and Finland to the United

- 40Armex 4

Kingdom. In the present context it is significant that a small number of countries, including Finland and the Philippines, deliberately produce an oversupply of nurses. The international migration of nurses is both temporary and permanent, attracted by higher incomes and a range of diverse factors linked to new education and training experiences, family contacts and simply the desire to travel. As a WHO Conference noted at the end of2000, this migration, alongside problems of recruitment of domeEJtic nun; en in Govoral metropolitan countries, has left nursing and midwifery services in 'crisis'. Migration of SHPs in the Pacific region is a small part of this global flow and, with certain obvious differences, shares many characteristics with it. In the Pacific region as elsewhere, the migration of SHPs is not a new phenomenon. At least as early as 1989, a medical degree from the Fiji School of Medicine (FSM) was regarded by some as a 'passport to prosperity' and emigration of skilled workers was already well evident. However there have been few studies of any facet of the migration of SHPs. Early studies of SHP migration in the Pacific region emphasized that it is primarily related to quality of life issues that involve the particular employment context (poor working conditions, inadequate facilities, limited opportunities for research or career development), income (particular professional salary structures, costs of living) and a variety of social factors (educational opportunities for children, morale), though not necessarily in that order. A similar range of factors is usually assumed to also account for the migration of SHPs to capital cities in the region and to take up employment with regional institutions. None of these factors are surprising; they parallel similar conclusions elsewhere. The present study was designed to clarify and develop these conclusions further. The Study This report focuses on eight PICs and summarises a series of surveys of SHP movers, stayers and arrivals, which primarily focused on doctors and graduate nurses. Subsequently the study also examined the situation of other skilled health professionals in less numerous occupational groups, such as pharmacists and Dentists. Surveys were undertaken in eight countries- Cook Islands, Fiji, Kiribati, Marshall Islands, Palau, Samoa Tonga and Vanuatu- and primarily in two key destinations: Sydney (Australia) and Auckland (New Zealand) and, on three key international migrant groups in those cities: Fijians (including Fiji Indians), Samoans and Tongans. Initially the surveys were undertaken in the capital cities, but were later extended to smaller urban centres and more remote islands. In these towns and outer islands it was generally evident that pressures on SHPs, and the propensity to migrate, were somewhat greater, and demand for adequate health care was less likely to be satisfied. The final core element of the study focused on the immigration of doctors and nurses from other countries into the PICs themselves. The countries where immigrant numbers of SHPs were relatively high included Cook Islands, Fiji, Kiribati, Marshall Islands, Palau and Vanuatu. Over 450 questionnaires were completed within the countries of study and a further 70 outside. Overall 160 of the sample were return migrants and 62 were migrants from other countries. This reflects the actual overall structure of the health sector. More than two thirds of the sample were nurses, and relatively few had 'other' skills, while about 95 percent of the nurses were women, and about two thirds of the doctors were men, all a reflection of the structure of the health workforce in most PICs It is not yet evident that the migration situation in the Pacific can be described as a crisis, but the loss of SHPs is alarming to some - especially where the supply is not increasing - and

- 41 Annex 4

there have been major expressions of concern. Agencies such as the Asian Developme nt Bank and the World Bank have consistently raised the issue. As recently as November 2002 the Fiji Minister of Health, Solomoni Naivalu, stated at a graduation ceremony at the FSM; and quote: "It seems incongruous to me that government, development partners, individuals and institutions spend so much money, time and effort in educating a worliforce that then leaves so easily for greener pastw·es. The developed world faces a shortage of doctors and nurse to cope with ageing populoticms and fairer 1i•ork rosters. This means that the developing wur!J, which indudes the Pacific, will ultimately lose part of this workforce because of its inability to compete in terms of salaries and working conditions" end quote. The Minister concluded by telling the graduates who had been financially supported by Pacific island governments and funding agencies that they should stay and work in their own countries: 'You have financial, moral and ethical obligations to your governments and the taxpayers of the countries who financed your training to work for the communities your governments require you to serve'. This is one background to the survey. " end quote. Certain general conclusions can be made on the significance of migration in the Pacific region. Firstly, there is a shortage of skilled health practitioners in all the countries, even in those with the highest educational levels and, that shortage has had to be remedied by various strategies, including retaining staff after retirement age and recruiting doctors and other skilled personnel from overseas. Neither of these standard strategies are entirely successful. Even though there are other advantages with recruitment of expatriates such as newly imported skills, it is not sustainable and can be costly in the long run. The evidence suggests that the most serious losses of health human resources have come from the stock of doctors, and also from the much smaller stocks of such workers as pharmacists, radiographers and physiotherapists. The situation is less serious for nurses, but only because every country has comparatively many more nurses the majority of whom are nationals. Even in countries that are relatively well supplied with health personnel, the cost of referrals remains considerable and may even be increasing (as the wealthy demand certain standards that are unavailable at home), so making the task of financing and organising preventative health care more difficult. The cost of maintaining health services is substantial. The lack of SHPs has contributed to the less adequate delivery of health services, especially in remote areas. This is evident in frequent references, in the press and elsewhere, to overcrowded waiting rooms, unavailable health personnel, delays in attending emergency cases, lengthy waits and cursory examination and treatment, a situation that amounts to inequitable access to health care. Its ramifications are evident in the manner in which life expectancies have failed to increase and may actually be declining. For example, in Papua New Guinea and Solomon Islands there is evidence of an actual decline in the number of rural health facilities and in some facilities that are operational, there is uncertainty about the quality of care and services being provided. While the study did not examine the concerns of local populations and potential patients, it is evident that in many places there was considerable concern about access to good quality health care. Throughout the Pacific region people generally seek access to safe and the best health care possible, however, in many places there is concern that health care and services have declined rather than improved in recent years. In at least one place, members of rural communities were increasingly choosing to bypass their official designated clinics to ensure more adequate treatment at regional centres, thus paying considerable personal costs in gaining access to health care. Relative shortages of health personnel in remote and rural areas- and almost certainly less effective skills there - suggest that urban areas are better serviced.

-42Annex 4

Throughout the Pacific region the rural and remote areas are effectively 'out of sight and out of mind' and those who work and live there are often marginalised. Policy decisions rarely favour them and health management deficiencies limit the effective delivery of goods and services. In one small town, an SHP observed that 'we always get the rejects from central hospitals' and 'we are already isolated and then to be dumped with outdated equipment you feel more remote'. No countries provided any kind of salary supplement for those who work in rural and remote areas, and there is very little other real incentives for working there, other than for those who originate from these areas. Dissatisfaction was greatest among those who worked in provincial areas, except where these were their homes. As one nurse said 'In the work setting the support is not there. Transport is poor and I work here by myself and sometimes for months you don't see anyone. We are poorly supervised and poorly supplied with equipment'. The situation is worse in the more remote areas. In such places, which may actually be small towns no more than a couple of hundred kilometres from the capital, it is more difficult to attract skilled staff, unless they originally came from the area, partly because of cultural tensions in some places but more frequently because of the limited facilities that exist there, both within the health care system and within the wider community. This has meant that few workers stay long in remote postings, and seek to return to the centre or go overseas. The more highly skilled workers are the most likely to leave. Facilities are poorer, in terms oftechnology and supplies (especially where stock control and ordering systems are absent), and SHPs constantly complain over neglect- to the facilities and to themselves and thus their career prospects. This reflects inevitable economies of scale, the real difficulties of meeting the diverse needs of remote places and the task of organising an adequate structure of health care delivery in the face of staff shortages, restructuring and the regular mobility of personnel. It was nevertheless evident that some SHPs preferred to work in provincial or peripheral areas. One noted 'I'm the boss and I'm better able to make decisions and implement them'. Some degree of freedom from bureaucracy, a greater range of activities and challenges, extra responsibilities and lower costs were attractive to some. With adequate support there is no reason to assume that peripheral locations are all necessarily unattractive.

The migration of SHPs remains of considerable significance in the Pacific region, and no strategy that has been put in place has effectively resulted in any decline in the incidence of migration. Indeed few countries have sought to remedy it directly. Moreover, as has been the case in several countries, whenever there has been a crisis of some kind (whether economic or political), there is an acceleration in the rate of emigration, especially of those with skills, who can find good employment elsewhere. Widespread evidence points to the regional intensification of competition for skilled health practitioners with countries increasingly recruiting from each other, rather than addressing the more difficult causes of attrition and shortage that are linked to inadequate pay and working conditions. New Zealand hospitals have actively recruited nurses in Fiji. Moreover, some PICs have in recent years attracted health workers from other PICs that have comparatively lower or poorer conditions of service and other incentives. The migration system has become more global, more complex and more hierarchical, and so more challenging to the poorer countries, where wages and working conditions are usually least adequate. Economic and political problems in parts of the region have contributed to emigration, and this has been exacerbated by economic restructuring, reductions in the size of the public service, and deterioration in the working conditions of those who have remained. Work can be difficult and challenging. As one doctor said 'people need to be compensated for their hard work and after hours duty. At present work can be very stressful for those who are trying hard to improve

- 43 -

Armex4

the standards of health care. Why would one put in extra hours of work especially when they are underpaid? The 'good Samaritan' and 'Nightingale days are over'. Tensions between privatisation and public service, and repeated restructuring and 'downsizing', have rarely assisted in creating more effective health care systems. Wages and salaries for SHPs within the PICs are widely seen as inadequate, and the numht':r of rec.ent strikes in various countrieEJ iE> EJome te:Jtimony to the extent of dissatisfaction. The most obvious conclusion of the survey was that two thirds of all nurses and almost half (46%) of all doctors are primarily motivated to migrate for income reasons. A survey in 2000 by the Fijian Nurses Association found that for 88% of nurses the key influence on migration was higher wages. Moreover Tongans are more likely to migrate that Fijians or Samoans because of greater income differentials between home and international destinations. The importance of income, whether absolute or relative, cannot be underestimated. Perceptions of inadequate salaries and the obvious salary differentials between the PICs and metropolitan states, including a few territories such as American Samoa, were also key factors for migration moves. Moreover it is clear from almost every survey that has ever been done of the migration of SHPs, from the 1970s onwards, in every part of the world, that a loosely economic rationale dominates migration. Without superior wages, and the living standards and education (and, as some noted, access to health care) that these enable, migration would otherwise be very slight. The significance of income is firmly linked to the structure of promotion, that many see as being more about 'who you know that what you know' and about longevity in the system, a situation which also discourages innovation and change. As one nurse argued 'It's hard to make changes here. We try to make changes but other nurses pull you back, because they don't want to change, and think you're bigheaded', a situation that has also held back changes in other contexts. In a different sense, as another put it: 'this is not a conducive atmosphere for learning'. Reasonable and equitable opportunities for promotion and training are essential. Difficult conditions were also a key factor in influencing migration. Some SHPs resented long hours of overtime and double shifts, sometimes working on night shift or on weekends, that did not always receive proper income supplementation. This was particularly so in remote places where few staff were available, and for specialized jobs where there were no substitutes. Like patients, SHPs also disliked overcrowding, long queues, lack of supplies and inadequate facilities. In the 2000 Fiji survey exactly the same was true with 62% of nurses seeking 'better work conditions' and emphasising this as the second most important reason for migration, after income. The consistency of complaints about working conditions emphasises both that there are problems and that such problems stimulate migration. Repeatedly SHPs pointed to problems with inadequate technology, favouritism over long working hours, lack of support and respect, and so on. It is normal in most workplaces for some expectations to be unmet, especially where workplaces are small (so that chances of promotion are relatively few), but there was abundant evidence of the lack of good management that supports skilled workers in inevitably challenging situations. However, it is equally evident that this situation is true in a very wide range of contexts, both elsewhere in Pacific island countries and in the wider world. One global review of nurse migration concluded: 'In many countries employers have failed to address long standing deficiencies related to hours of work, salary, continuing education, staffing levels, security, housing and day-care facilities' (Oulton 1998: 126). Even where nurses and doctors remain in place such deficiencies are recognised. Difficult and unpleasant conditions have certainly resulted in qualified nurses being unwilling to work, producing what is in some part a 'pseudoshortage'.

-44Annex 4

Movements overseas have often been stimulated and facilitated by the presence of extended family and kin overseas, who have supported migrants and sometimes encouraged them. These overseas numbers have increased rather than declined. Indeed for some countries, such as the Marshall Islands, new overseas communities are presently being created where none existed before. Growing numbers emphasise renewed migration. Without significant changes in national policy on both publio houlth and migration in metropolitan recipient countries, any attempts to slow the migration of SHPs must come from inside the Pacific region since they are unlikely to come from outside it. For the Pacific region as a whole the context is one where the migration of skilled individuals is likely to continue to be of at least as much importance in the immediate future as it has been in the immediate past. The Survey results indicate that the principal reasons for migration, as expressed by individual SHPs, within and outside the island states, are likely to continue to be important in the future. Some of these reasons may increase in significance in the future. A large proportion of all migrants have moved overseas for the 'experience', which may relate to social, economic or a wide variety of personal issues. The nature of that experience, in early adulthood, has eventually led to an initially short term movement turning into a much longer and more permanent migration move, as evident in the experience of so many of the Tongan nurses in Australia. There is no obvious reason why such experiences should be any Jess welcome in the future. Like other migrants skilled migrants remain part of extended 'transnational corporations of kin' whereby their migration is encouraged or, at the very least, not discouraged by the financial needs of those family members who remain in the islands. Individuals rarely make decisions without taking into account the wider considerations of extended families. Wives and husbands make joint decisions. Doctors are almost twice as likely to migrate as nurses, partly because wage differentials are greater but partly because men tend to be the decision makers and most nurses are women. Migration occurs in an extended family context. There is a very strong social component in decisions concerning migration and nonmigration. Although economic factors certainly play a significant part in explaining migration, as part of an almost 'standard set' of criteria involving salaries, facilities, career prospects, and also satisfaction and prestige, they certainly do not account fully for it. The presence of close kin and perceptions of family obligations are major influences on migration as well. Most nurses are women and face particular constraints related to partners' careers and family obligations, which may make remote postings difficult. This may be emphasised by security considerations in remote locations, make the link with a career structure more difficult to achieve and increase the sense of frustration. Skilled migrants, including SHPs, make a substantial contribution to the economic wellbeing of those who remain at home, even compared with those unskilled migrants who profess the certainty of return migration. They have certainly not divorced themselves from the needs of those who stay. A part of their income continues to be welcomed by those who remain in the islands. Creating that income informs many migration decisions, and means that there are fewer family pressures to dissuade migration. It also means that there is always some possibility of return migration. Skilled migrants are more likely to stress social and lifestyle goals rather than the even more economic and educational goals of poorer and less skilled migrants. This indicates some sensitivity to any worsening of the local social environment and the high propensity for skilled migrants to move.

- 45 Armex 4

Migrants move to take advantage of superior wages and salaries, training opportunities and working conditions. They also move to better the lifestyles of their children in terms of access to education. These disparities have never substantially changed and may even have moved in favour of the metropolitan states, because of present economic difficulties in PICs, and so increased the propensity to migrate. While the costs of living are high in metropolitan states, that has always been so and has been no obvious (or at least no increasing) deterrent to emigration from the Pacific. Some of the strongest influences on migration have little to do with employment, or specifically the structure of employment in the country of origin, but have much to do with time honoured and universal attempts to improve the welfare and status of families in the long run. In that respect many SHPs entered the health professions less out of altruism, or a particular interest in medicine, but through a recognition that this might be the means to another end, that of maximizing or at least improving family incomes and welfare. Indeed that is sometimes why parents have encouraged their children to enter the profession. A number of SHPs indicated that they entered the profession since this was 'a job to get out of the country', very much like the situation in the Philippines. Employment in the health system thus enables migration as much as being an instigator of it. In tum this further suggests the continuity ofthe process of migration and, more importantly, its sometimes somewhat tangential nature to the health care system. There is growing evidence that fewer people are being attracted to health careers than was the case in the past. Wages and conditions in the public health sector are increasingly seen as deterrents to entry into the health workforce and other sectors are perceived as more attractive. Thus in the Cook Islands, the health sector was of enormous importance in the 195 Os and 1960s but by the 1980s the national focus had shifted towards tourism and private sector development and scholarship and training opportunities became fewer and less prestigious. To an even greater extent in the Marshall Islands and Palau, it is extremely difficult to attract any local nursing trainees, in part because there are international migration opportunities for the unskilled, which leads to additional costs to the health sector where the majority of nurses are immigrants. Many respondents noted how when they began their careers 'in those days' a job as a nurse was one of the few options available. The simple lure of uniforms is no longer enough. On the one hand prospective employees now perceive the frustrations of health workers, low salaries etc and, on the other hand, there is now a wider range of potential job options, alongside migration opportunities. A career in health is not now seen as having the prestige and salary that it once had. In some places nursing is now seen, not as an attractive and rewarding job but difficult and risky one with poor incentives. In other words some Pacific islanders may be becoming disdainful of a career in health, as are some of their counterparts in metropolitan states. At the core of the parallel problems of attrition and emigration are issues of management and human resource planning. Not all coungtries even have adequate systems to assess the capabilities of present staff, make projections for future employment needs and develop appropriate plans. Beyond this there are difficulties in even the best systems, of managing satisfactory and overt processes of promotion and placement. Managers are stretched and stressed where budgets and training facilities are limited. Less formally the personal contact that constitutes a valued 'human landscape' is sometimes absent, along with a working environment that champions respect and appreciation, and ensures that there are worthwhile things to do. In most places, it is clear that SHPs do not usually enter the profession for the income, but out of some desire to serve and thus be of value in the community, even where that 'community' is localised. However such feelings do not sustain a career, as they become frustrated by low pay, poor promotion prospects, lack of available resources, inappropriate workloads and inefficient support systems, especially in remote areas. In other words they find themselves unable to

-46 - · Annex 4

adequately meet the needs of the people they most seek to help. A consequence is that some leave the health service or emigrate. Wages and poor working conditions are necessary yet insufficient causes for migration, evident in the fact that SHPs (and other skilled workers) do stay in the region. Those who stay are often older or, conversely, very recent graduates, with strong local family ties. It is equally evident that thust: whu migrate art: primarily those who have been working for a relatively short time (around four or five years), and that, not surprisingly, the stayers are more senior workers, who obtain good salaries, certain privileges and work in favoured locations (including, some times, their home regions). Indeed some of these profess that they are now 'too old' to migrate. This has two implications: firstly, that many SHPs are likely to leave whatever the situation at home (and the evidence from migrants in Vancouver, Auckland and Sydney is supportive ofthat) and, secondly, that restructuring of career paths and promotion criteria would reduce migration rates. Social factors are both causes of migration, constraints to it (especially in terms of family structures) and some impetus to return. There is now a very established pattern of migration from several PICs, notably the Cook Islands, Tonga, Samoa and Fiji (but increasingly from other island states), to the extent that migration is a normal occurrence. Indeed the Cook Islands (like Niue and Tokelau) is experiencing an absolute loss of population. Island governments have not usually sought to intervene in the process of international migration, and are unlikely to do so in the future, partly because of the financial benefits that migration brings. As early as 1984, Fiji did commission a study aimed at devising means to reduce the skill drain, but nothing came from it. Bonding of students is the only policy directed at encouraging return migration, and there is good evidence from across the region that it works. Direct intervention in migration processes otherwise remains unlikely. The survey data demonstrate that return migration is not uncommon, but that without bonding the loss of SHPs would be much greater. Return migration is usually not without problems; returnees inevitably compare more lavish facilities, and wages, in the metropolitan states with those in their homelands, and though they recognise the problems of providing similar salaries and conditions in the Pacific are nonetheless frustrated by this. Many of those who have returned did so because they were able to invest in activities outside the health sector, usually in developing some form of business (often by or with their spouse), that would compensate for salary reductions. The implication of this is that Pacific island countries may need to encourage such investment opportunities to encourage return migration. Others returned because their spouse wished to return, or because jointly it was a valuable economic and social strategy. Frustrations exist beyond wage levels and facilities. As one returnee, who had moved out of the health sector before being attracted back said: "I never wanted to come back from Australia because it was not challenging enough but my husband wanted to return. It's not challenging. The case mixes are too few and it is not specialised here. I have to be a generalist and I don't like it. I'd like to go back again" . Many others stressed the nepotism and favouritism in the health care systems, alongside the frustrations of being unable to implement changes that work elsewhere. By contrast so many of those who had moved back emphasised the climate, safety or the more relaxed pace of life, or simply the familiarity of the home country, indicating again just how crucial social, political and economic stability is to return migration. By contrast many of the expatriate doctors came from countries that were beset with their own political problems and many of them argued that they would return home if the situation there became more favourable. Here the Pacific has gained at the expense of distant places, but

- 47 Annex 4

though that gain is slight in comparison with the extent of emigration it is not likely to disappear in the near future. To depend on the availability of relatively inexpensive overseas SliPs would however be a risky strategy. There are some minor health benefits from emigration. Some doctors and nurses, notably in New Zealand, work in hospitals that are attended by patients from the wider Pacific island migrant community, and the ability of these patients to converse with staff in their own language has proved to be of considerable benefit. Migrants also point to the new skills they will learn and the probability that they will take these skills back 'home' in due course, and this has certainly occurred. Migration occurs in a context where a number of metropolitan governments have implemented aggressive recruitment campaigns to attract doctors and nurses. Attempts to slow that migration in the Pacific region have focused on developing primary health care services, establishing regional medical schools and other training facilities, adapting medical curricula to local needs and enabling private practice to improve greater opportunities for local income generation. Despite such policies migration has continued, especially where SliPs graduated or went for further training overseas, in the absence of significantly higher wages (an impossibility for most Pacific island states), and improved working conditions. Growing perceptions of superior salaries and conditions overseas, and a greater intensity of recruitment, in a context where international migration was a familiar and accepted phenomenon, have emphasised this. Policies that redress most of these circumstances have proved difficult for small and poor PICs. However the present study has also emphasized that the skill drain has some potential gains through human skill transfers (with return migration), remittances and the investments of returnees. Hence policy formation concerning SliPs needs to focus on policies for recruitment, retention and also the encouragement of return migration, through providing appropriate investment opportunities and more adequate working conditions and promotion structures. When this survey first began, a Tongan public servant commented that there was little point asking Tongans why they had chosen to return to the country because all would simply say 'for God, King and country'! Even allowing for a considerable degree of exaggeration, such a perspective, which could be paralleled elsewhere, is indicative of the very powerful attachment to 'home', the strong social ties that link islanders to home and the manner in which the structure of community, at various levels, may influence return migration. It also suggests that the potential for return migration is significant. Despite what may seem to be gloomy conclusions, over continued losses, worsening health care provision and problems of recruitment and retention, it needs to be borne in mind that every health worker liked things about their job and many were very content. This was particularly true of nurses. What has been particularly successful in the region have been policies and practices, of upgrading nursing skills, so that nurses undertake a series of jobs otherwise undertaken by doctors. This has the dual advantage of both relieving even more hard-pressed doctors and giving greater job satisfaction to nurses. This must be examined further throughout the region, though there are both training and wage costs. A greater role for nurses within health care systems is both appropriate and effective, especially where nurses provide some curative services. Increasing the role of nurses reduces dependence on doctors, and scales down demands on them, while giving nurses additional status and prestige. While such a strategy would better use the skills of doctors presently in the PICs it is not evident that it would necessarily discourage emigration. Indeed the World Bank itselfhas noted that 'Recognition of the wider role to be played by the various categories of nurses should then be followed up by recruitment of new staff and related steps' (1994: 28). The implication is that such a strategy might encourage rather than discourage migration .

-48Armex 4

Skilled health workers, and other professionals in the PICs, feel and are isolated from trends in their profession and in the wider world and are conscious that they may miss out on new skills that will enable their professional development and, perhaps, further migration in the future. There is at least some indication that open learning and telehealth/telemedicine and other developments in information technology can reduce this problem in the future. Some of the strategies that are most appropriate for the development of more effective health care systems in the PICs tend not to be in the particular interests of the present SHPs in the region. Most of them are urban residents, with families who benefit from urban life, and are likely to resist relocation in rural areas or what might be seen as de-skilling in clinical fields and the loss of comparatively more comfortable and decent working environment with the necessary facilities and support services and a move towards PHC. It has been no less difficult to achieve the decentralisation of health services and the deployment of skilled workers, such as teachers, in developed countries such as Australia. The unfortunate implications of this, and perhaps one of the reasons for the failure to develop and implement strategies of such kinds, is that they appear more likely to weaken the health system, by attacking what might be seen as the privileges of those working in it in the major urban centres, and thus stimulate further emigration or simply attrition from the sector. While there is a need for more workers in intermediate, less skilled positions, all health care systems require a certain number of effective, skilled and centrally located individuals. The ability of PICs to pay salaries that are comparable with those in developed countries is very limited, without disrupting national salary structures and some notions of equity, even though the World Bank has recommended that 'Doctors should be paid at least as well as members of other professions (e.g. lawyers) and may need to be given additional allowances and bonuses, depending on labor market conditions and options for emigration' (World Bank 1994: 30). Elsewhere the Bank has observed that 'There is a need for authorities to develop both supply and demand side policies simultaneously to avoid staffing constraints. In particular there is a need to develop professional cadre salary scales and career paths which are not capped by reference to administrative cadre salary scales and career paths and which take account of the propensity to migrate' (1994: 324). The complexities of actually doing this have been apparent in the case of Samoa. Movements towards superior salary scales appear to be in conflict with other issues, especially the achievement of decentralization and PHC, though there is little doubt that this would discourage migration. It would also create a very well paid group of workers, whose existence might be problematic on other grounds, notably in the impact on other public service salaries, not only at the highest levels. This would be a drain on the budgets ofPICs. As the case of Samoa indicates, where salaries for doctors in Samoa are approximately a tenth of those in nearby American Samoa, let alone those in the metropolitan United States, most countries would not wish, or be able to, raise salaries to anything approaching a comparable level. Whilst salaries at the upper levels of the health hierarchy might be somewhat better, putting them close to par with metropolitan salaries is financially impossible. The growing shortage of SHPs in various countries has increasingly resulted in movement within the Pacific region, as some countries are able to offer better salaries, working conditionsand different experiences - and can thus instigate the regional migration of SHPs. There has also been some loss of individuals who, following training elsewhere in the region, have remained in those destinations rather than returning home. The World Bank noted that, in the case of Vanuatu's loss to Fiji and PNG, that it 'may be possible to reach agreement with its neighbours, that they will not recruit ni-Vanuatu doctors trained in these countries, at least until they have fulfilled their bond' (1994: 299). It is a measure of the entrenched nature of the problem of migration that this is becoming of considerable significance within the Pacific region. Even more

- 49 Armex 4

significantly it is indicative of the task of remedying the problem that, as in this case, the onus is seen to lie, at least in part, with the recipient I destination country as much as with the sending I source country. That poses complex political questions. In most PICs, there is a continued need to ensure that training and education are relevant to the particular situation of countries concerned, in terms of local constraints and requirements. Training in some parts ofthe Pacific region has rarely produced adequate numbers of skilled health personnel and this lack of numbers has then been exacerbated, where there is migration. One solution is likely to lie in the direction of creating more places for those who wish to become doctors, even though attrition rates are high and the cost of training is considerable. In several countries a familiar bureaucratic response has been 'train more people' and 'train them here'. This is crucial but it is expensive, particularly where, as in the Marshall Islands, the locally trained workers are mainly from other countries. A solution along these lines is certainly appropriate for nurse training, as with Samoa's recent establishment of a domestic nurse practitioner training programme. Numerous small, high-cost training programmes need to be upgraded and rationalised. Several of the region's nurse training programmes have fewer than 100 students and operate in inadequate facilities with high staff-student ratios. Low student numbers reflect a policy of limiting admissions, and high standards reflect the production of graduates with credentials that are marketable elsewhere. The Fiji School of Medicine has developed a Primary Practitioner course whose graduates would not be internationally marketable but, as the Bank observed, 'such initiatives need to be supported through appropriate actions by universities, medical and professional associations and policy makers in Australia and New Zealand' (1984: 30), but, above all, by the participants themselves. Currently there seems little evidence ofthis. The most consistent finding of the study, and almost every other survey of the migration of skilled workers, is that people who have been trained within their home countries are least likely to migrate. Though there may be a particular kind of selectivity amongst those who are trained at home (that already predisposes them to remain in the country) this does not challenge the need to provide more appropriate courses within country. Samoa has recently done this, again at considerable cost. High level local training is an extremely costly exercise, even though it meets the wishes of many countries to have prestigious tertiary training institutes within their countries. Conclusion and future directions Migration has occurred in a context of low remuneration, poor promotion prospects, inflexible and difficult hours, the lack of continuing educational opportunities, limited training facilities, shortages of supplies and equipment and a poor working environment, especially in rural and remote areas where health needs are least well served. Concerns over incomes and working conditions dominate every survey of SHPs ever conducted in the Pacific and in every other region of SHP emigration (such as the Caribbean and Commonwealth Africa). Such frustrations and uncertainties are universal. In PICs, this may indicate the need for effective bureaucratic management. Public spending cuts have made management more difficult, but even more crucial, hence the widespread Pacific aid focus on notions of 'good governance'. In contexts where emigration is quite common and even expected, governments have rarely sought to discourage it or intervene in migration processes. Moreover many close relatives of potential migrants are now likely to be overseas. This suggests that emigration is unlikely to be easily slowed, and also that it occurs outside the health sector.

-50Annex 4

There are significant differences in the structure of migration. The situation is most serious for doctors, especially young and good ones, and more serious in the smallest countries. Emigration rates for nurses are increasing. More parts of the Pacific are now being affected by skilled emigration. Migration is no overspill but a definite Joss. It remains true that Pacific counties should focus on preventative health care programmes as they meet very clear health needs in all the PICs and because the appropriate personnel needed for PHC are less costly to train and less likely to migrate.

In most countries there is an inadequate data base on the attrition rates and mobility of SHPs, which makes human resource planning and development more difficult. Few countries presently adequately monitor the migration of SHPs, though all are aware of the gravity of the situation. It would be valuable for each country to have a short questionnaire that could be given to all those who resign that would focus on the specific reasons for migration. Clearly this would, however, be of little value in the absence of a human resource plan for the health sector. It cannot be overstressed that in-country education, with locally focused curricula, is more effective than out-of-country education, since it is likely to be more appropriate and cheaper, recipients can be more rapidly integrated into the local work environment and the skills are not so easily transferable. Local graduates are certainly less likely to migrate. Providing adequate education in small PICs where the annual number of graduates required is also small indicates that the next best solution is likely to be education at a regional centre within the Pacific region such as in Fiji and PNG. This has clear implications for the strengthening of regional institutions, though that raises complex political questions. Where SHPs are educated outside the region, notably for further education, a system of bonding should be in place even if it cannot always be operationalised. In the Cook Islands and elsewhere this has been very effective. There must be flexible career structures that enable the probability of promotion for the most talented and committed, and that do not neglect those in rural area postings. In a situation where well over half of all health budgets are absorbed by labour costs, it is impossible for countries to pay 'market' salaries that are comparable with those in metropolitan states, hence it is even more important that a promotion structure be in place, to ensure that SHPs are not doubly disadvantaged. Similarly it is important that good performers be 'rewarded', such as with access to further training, and that work conditions be flexible. All SHPs must have some reasonable expectation of promotion and superior wages. The evidence from most countries is that remaining in rural areas and having both a reasonable salary and a 'career path' are incompatible. A clear career structure would make working in rural areas less obviously a form of banishment or punishment to be sent to rural and remote areas, but perhaps even a means of advancement, and at the very least indicates that there are career paths. However putting in place such a career structure is a complex process especially in places where human relationships are intricate and personal, and where the good middle management required to implement and monitor such policies is largely absent. It is essential that there be adequate procedures for reviewing salaries and other conditions of employment on a regular basis, and there is a proper and open process for reviewing grievances. In the context of Vanuatu it has been recommended that: 'career pathways for nurses and other health professionals be reviewed and career opportunities for staff be investigated fully within the constraints of the existing system so that staff who undergo further training receive recognition and career enhancement where possible and appropriate' (Hassall and Associates International 1999: 29). These are not new concJusions, hence it would be helpful to understand

-51 Armex 4

why similar recommendations along these lines in the past have never been implemented, and why it is so widely believed that 'nepotism' and 'favouritism' are prevalent. The most costly attrition and migration rates are amongst doctors and more specialised health professions, such as pharmacists and radiographers. If numbers of SHPs are to be increased through new or expanded training programmes, or even simply remain the same, the focus should be on nurses who are less expensive to train, less likely to migrate and perhaps more likely to be flexible in activity and location. At the same time there should be an emphasis on developing structures where nurses can graduate or be promoted to intermediate and senior positions. The greater probability of nurses remaining in place suggests that countries would benefit from developing intermediate categories of 'nurse practitioner', who are able to be involved in health assessments, screening, care planning, management and coordination, limited diagnostic and prescribing rights and other similar functions. This would simultaneously improve the status and perhaps the incomes of the best nurses, compensate for the loss of doctors and relieve the burden on those doctors who remain. Nurses were able to acquire greater motivation - being more convinced they have something worthwhile to do and contribute, services could be delivered at lesser cost, and emigration would be no more likely. Nurses who remain within the island health systems tend to be those with local kin and family responsibilities. They tend to be older than those who have migrated. If nurses were recruited rather later than at school leaving age (for example, in their thirties), from those women who are already settled in terms of local kinship systems, the likelihood of migration would probably decline. It may be useful to examine retirement ages. Fiji, for example, has effectively sought to extend the retirement age to 60 years from the current age of 55 to retain doctors who are still of great value and to remove the inefficient and costly requirement for doing annual contracts to keep such doctors in place. Parallel situations occur elsewhere and with other cadres of health workers. Improvements in working conditions such as appropriate working space, equipment, and laboratories, are essential for undertaking the work, boosting morale and increasing job satisfaction, but, unfortunately, there is no obvious reason to believe that governments will be more committed to this in the future or have the resources and skilled middle range bureaucratic labour to implement such measures than they have been in the past. There is considerable potential for the development of open learning and telemedicine. In most countries part of the problem lies in relatively small numbers entering the various health professional trainings- the supply side. Failures of recruitment have implications for education in high schools, which in some cases is inadequate for high school graduates to be confident of a career in the health system or for the health system to take them on after training. In the case of certain professions there is lack of understanding and familiarity amongst school leavers over what these are and what they might demand. Scholarships and other opportunities for potential high school graduates need to be better advertised and targeted - this situation is also usually true for other skilled activities. The provision of scholarships is essential both to the training of an adequate number of highly skilled health personnel, and to forming the basis for human resource planning Return migration is of some significance. In considerable part this results from conditions outside the health sector, such as investment opportunities rather than wages in the health sector, that imply that to achieve necessary increases in the return migration of SHPs, policy might

-52Annex 4

better be targeted at financial rather than health matters. That is potential return migrants need to be aware of business and investment opportunities as well as opportunities in the health sector. This would enable countries to develop programmes /recruiting drives in metropolitan states that might encourage return migration since return migrants are likely to be of greater utility to the health care system than more costly expatriates. The particular situation of SHPs in outlying areas needs to be examined in more detail since this is where health needs are less well met (and the cost of meeting them through referrals, etc is considerable) and where practitioners tend to be overlooked. This is likely to require the development of open learning and telemedicine (e-medicine) which will link remote centres to the mainstream, enable greater quality health care and let practitioners there keep abreast of new developments. Indeed open learning and telemedicine have particular potential for the continuing education of health workers, by enabling them to upgrade skills and access relevant and recent information, including those in urban and remote areas. It is likely to be some time before telemedicine is of use for clinical and diagnostic purposes, as there are important financial, operational and maintenance implications associated with telemedicine. Increasing the availability of adequate computer facilities is also likely to have a range of benefits, especially in more remote areas. Aid donors and development partners, such as AusAID, are presently supporting the extension of distance learning within areas such as health, but (as in Tonga) these opportunities are not proving easy to extend because of inadequate and expensive access to the internet. Providing additional support for rural SHPs is valuable in itself, but is particularly valuable in Pacific island countries where a wider commitment to rural development is essential for economic growth and national development. Countries need to consider the possibility of developing some forms of 'twinning'/linkage between national health care systems, and overseas institutions, that would link training in those institutions, with support from them for particular health care problems, on a short or long-term basis, in the event of a sustained shortage of human resources. A particular model has been proposed for the Cook Islands, based on the experience of the small Caribbean state of St. Lucia with short-term volunteers from the United States, and it has been recommended in other contexts. Emigration cannot take place without metropolitan states enabling this. There is a need for metropolitan recipient countries, such as Australia, Canada, New Zealand, and the United States, to review policies for international migration where these are a serious constraint to the retention of skilled workers in the Pacific island countries. The labour market within metropolitan countries suggests that this is unlikely. It may also be necessary for some Pacific island countries to examine their own recruitment practices where these affect others . This again emphasises the need for the strengthening of regional institutions so that they produce adequate human resources for the health sector. There may be a need for the development of legislation to regulate the role of recruitment contractors, particularly if these are prejudicial to human resource management in Pacific island countries, and to ensure that they adhere to such codes as the ICN Code for Ethical Recruitment and the Commonwealth Code for the International Recruitment of Health Professionals. It is doubtful that contracts could be linked to remittances as is the case in the Philippines. It may be necessary to develop more appropriate mechanisms to regulate the licensing and qualification requirements of immigrant SHPs, though the evidence suggests that, even with some disadvantages, they are making significant contributions.

- 53 Armex 4

Ultimately the achievement of better health in PICs, and therefore healthy islands, depends on the delivery of health services and the availability and utility of human resources. Human resources account for a high proportion of most budgets, yet human resource planning and management and 'good housekeeping' are all weak. Human resource policies only exceptionally address such key issues as the 'brain-drain', geographical inequalities, motivation andjob satisfaction. It is crucial that Pacific island governments recognise the significance of health, both in itself and as an input to economic growth, and fund health systems properly. Where governments are supportive of health systems, and give health workers adequate recognition and commitment, this is valuable for morale. At the core of revitalisation is the need for equal opportunities for all health workers, with more effective access to training and careers. This is likely to lead to more effective and equitable health care, more satisfaction with individual and sectoral performance, greater recruitment and less migration.

-54Annex 4

References Hassall and Associates International ( 1999) Vanuatu Health Sector Planning and Management Development Report, Canberra. Lewis, N .D. (1990) More Than Health Services: Health For Pacific Peoples, Regional Development Dialogue, 11 (4), 76-96. Lutua, K (2002) Salaries and Conditions of Employment for Nurses, Nurse Practitioners and Midwives- a Fijian Perspective, unpub. paper to 11th South Pacific Forum, Vila, August. Oulton, J (1998) International trade and the nursing profession, inS . Zarrilli and C. Kinnon, eds, International trade in health services: a development perspective, UNCTAD and WHO, Geneva, 125-133. World Bank (1994) Health Priorities in the World Bank' s Pacific Member Countries, World Bank, Washington World Health Organization (1999) Country Health Information Profiles, WHO, Manila.

- 55 -

ANNEX5

EVALUATION: MEETING ON MIGRATION OF SKILLED HEALTH PERSONNEL IN PACIFIC ISLAND COUNTRIES

The:re: W<'ls universal recognition that the aim of the oonferonco had been met in tenm; of the t:uw..:aliuual objectives of the meeting. Country representatives welcomed the opportunity to discuss a range of policy options related to migration, and appreciated learning from diverse experiences in other countries. Many believed that they had learned new approaches that could be developed in their own countries, and anticipated that this would happen, particularly in the context of developing a clearer understanding of the need for more effective human resource development and planning for health care. They were enthusiastic about the manner in which the meeting had enabled a positive linkage between Ministries of Health and Public Service Commissions in their particular countries (and more generally) that had enabled them to benefit even before they came to the meeting. In terms of the conduct of the meeting, country representatives were appreciative of the time available to present country experiences and to discuss, in relevant groups, their own and others experiences. They were satisfied that the working papers available provided an appropriate background for these discussions. They also believed that the recommendations were an accurate representation ofthe feeling of the Meeting. Representatives recognised that most of the papers, including the country papers, should be distributed more widely. They particularly believed that the papers/presentations given by the Consultant (HRDl/2003.2 ), the WHO Secretariat (both presentations) and the Commonwealth Secretariat should be circulated more widely. Most were also interested in seeing the final version of the paper presented by the Temporary Adviser on the Situation ofNurses in the Fijian Health Care system (HRD 112003.3). They were particularly appreciative of those papers that had developed a clear focus on practical issues and avoided academic jargon. Representatives believed that there was further role for WHO to play, in active support for the continuing human resource development context, notable in terms of support for health workforce planning initiatives and modes of more effective data collection. They anticipated that they would be seeking further technical assistance in this area. Representatives also indicated that they would welcome a subsequent meeting to examine how successful countries had been in implementing the recommendations developed during the course of the meeting. Country representatives were appreciative of the work undertaken by WHO to support the research that had gone into producing several of the papers, and their organisation ofthe meeting which they saw as addressing important issues in the region. They were particularly appreciative of the support given to them by the WHO Secretarial staff.