Human resources for health country profiles: Kingdom of Tonga

Human Resources for Health Country Profiles KINGDOM OF TONGA

Human Resources for Health Country Profiles KINGDOM OF TONGA Human resources for health country profiles: Kingdom of Tonga © World Health Organization 2023 ISBN 978 92 9062 033 4 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY- NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. 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The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Photo credits: © WHO/Mesake ‘Isileli Taukolo, cover, p. ix. iii Contents List of figures and tables v Abbreviations and acronyms vi Acknowledgements vii Executive summary viii 1. Introduction 1 1.1 Demographic and social background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1.2 Economic situation and macroeconomic indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.3 Summary of health indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 1.4 Health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 2. Health workforce supply and trends 9 3. Health workforce distribution 12 3.1 Gender distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.2 Age distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 3.3 Distribution of health workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 3.4 Sectoral distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3.5 Distribution of health workers by citizenship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 3.6 Skills distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 4. Health professionals’ education 17 4.1 Training institution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.2 In-service training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 4.3 Nursing education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 4.4 Postgraduate training in other health professions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 4.5 Funding for training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 4.6 Physical infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4.7 Technical capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4.8 Accreditation mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 4.9 In-service and continuing professional education (CPE) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 4.10 Future developments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 iv HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES 5. Human resources for health (HRH) utilization 25 5.1 Recruitment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 5.2 Deployment and distribution policies and mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 5.3 Unemployment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 5.4 Employment of health workers in the private sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 6. Financing HRH 30 6.1 HRH expenditure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 6.2 Health workers’ remuneration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 7. Governance of HRH 32 7.1 HRH policies and plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 7.2 Policy development, planning and management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 7.3 Professional regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 7.4 HRH information systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 7.5 Health workforce requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 8. Concluding remarks 36 Bibliography 37 Annexes 39 Annex A. Ministry of Health organizational chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Annex B. Proposed organizational structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 vKINGDOM OF TONGA List of figures Fig. 1. Gender distribution of MOH professional staff, 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Fig. 2. Proportions of health workers over age 49 by health occupation, 2021 . . . . . . . . . . . . . . . . . . . . . . 13 Fig. 3. Distribution of health workers by location, June 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 List of tables Table 1. Selected demographic indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Table 2. Selected economic indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Table 3. Selected health indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Table 4. Number of health workers at the national level in 2005, 2013 and June 2021 . . . . . . . . . . . . . . . . . . 10 Table 5. Number of workers per 1000 population; selected workforce categories, June 2021 . . . . . . . . . . . 11 Table 6. Proportion of health professionals located outside of Tongatapu . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Table 7. Doctor- and nurse-to-population ratios in the Islands Health Districts . . . . . . . . . . . . . . . . . . . . . . . . 16 Table 8. Formal training in overseas universities: graduated, ongoing with projected completion year, and new scholars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Table 9. Formal training accessed locally . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Table 10. Allowances available to public servants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Table 11. Vacant posts by division in June 2021 (Niuafo‘ou and Niuatoputapu combined) . . . . . . . . . . . . . . . . 29 Table 12. Average income levels by workforce category in 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 List of figures and tables vi HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Abbreviations and acronyms CEOH Chief Executive Officer for Health CPE continuing professional education DFAT Department of Foreign Affairs and Trade (Australia) ENT ear, nose and throat FNU Fiji National University GDP gross domestic product HR human resources HRH human resources for health HRMIS Human Resource Management Information System ICU intensive care unit JICA Japan International Cooperation Agency MCH maternal and child health MET Ministry of Education and Training MFAT Ministry of Foreign Affairs and Trade (New Zealand) MOH Ministry of Health NCD noncommunicable disease NHSP National Health Strategic Plan NZAID New Zealand Agency for International Development NZMTS New Zealand Medical Treatment Scheme PEHS Package of Essential Health Services POLHN Pacific Open Learning Health Network PQF Pacific Qualification Framework PSC Public Service Commission QSINAH Queen Salote Institute of Nursing and Allied Health SARS severe acute respiratory syndrome SDG Sustainable Development Goal T$ Tongan pa’anga THPF Tonga Health Promotion Foundation TNMNPB Tonga Nursing, Midwifery and Nurse Practitioner Board TNQAB Tonga National Qualification and Accreditation Board TQF Tonga Qualifications Framework WHO World Health Organization vii KINGDOM OF TONGA Acknowledgements This Human resources for health country profiles: Kingdom of Tonga was developed by the Human Resources and Workforce Development Section, Ministry of Health, Kingdom of Tonga, led by Ms Salote Puloka, Deputy Director for Human Resource and Workforce Development. Technical assistance was provided by Dr Graham Roberts and Mr Lee Ridoutt, Directors of Human Resources for Development Alliance Pty Ltd, Sydney, Australia, and Ms Deki, Technical Officer, Human Resources for Health, Pacific Health Systems and Policy, Division of Pacific Technical Support of the World Health Organization (WHO) Regional Office for the Western Pacific. Additionally, Dr Yutaro Setoya, Country Liaison Officer, WHO Tonga Representative Office, provided overall guidance and support. The Human resources for health country profiles in the Western Pacific Region are prepared under the logistical and editorial support of the Health Policy and Service Design Unit, Division of Health Systems and Services at the WHO Regional Office for the Western Pacific, coordinated by Dr Masahiro Zakoji, Technical Officer, Health Workforce Policy. viii HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Executive summary Tonga covers an area of more than 720 000 square kilometres and consists of 176 islands, 36 of which are inhabited. Tonga is an upper-middle-income country ranking 104 out of 189 countries on the Human Development Index. Its economy is heavily dependent on private remittances from Tongans living abroad, and from development partner support. Of the 100 179 inhabitants, 74.19% live on the main island of Tongatapu and 21.15% in urban areas. The islands are divided into six administrative districts: Tongatapu, Ha’apai, Vava’u, ’Eua, Niuafo‘ou and Niuatoputapu. The population is young, with 34.81% under 15 years of age. Life expectancy has increased by 11 years since 1960, although rates of obesity, diabetes and cardiovascular disease are among the highest in the world. The maternal mortality ratio has halved since 2010, from 110 to 55 per 100 000 live births, the largest improvement in the national health data. People living in the outer islands have poorer access to health services and to educational and economic opportunities, which drives a slow but continual internal migration to Tongatapu. The high rate of external migration has offset the relatively high birth rate, with population growth at −0.5% in 2016. The migration of skilled workers provides a significant budget contribution (37% of total revenue in 2019) through remittances that have been increasing annually. Foreign aid (36%) is a significant source of budget support. The Ministry of Health (MOH) is estimated to have received US$ 22.4 million in 2020–2021, the third largest (11%) share of the development budget. Women provide much of the social service and human support through their family roles and mutual cooperation, although their services are not recorded. In 2019, Dr Ámelia Tuípulotu was appointed by the King on the nomination of the Prime Minister as the Minister for Health. The Sustainable Development Goals (SDGs) call for a one-third reduction in noncommunicable diseases (NCDs) by 2030. NCDs accounted for 79.4% of all deaths in Tonga in 2019, an increase of 5% since 2008. The Tonga risk factors STEPS report 2017 placed the majority of the adult population within the obesity range: 82.8% of women and 66.8% of men were considered obese, indicating a continuing need for a concerted effort to address NCDs as a national priority. The Tonga Health Promotion Foundation supports the implementation of the National Strategy for the Prevention and Control of Noncommunicable Diseases. ix KINGDOM OF TONGA Health system. Although provided geographically in six districts, the MOH’s structure is centralized to the Chief Executive Officer for Health (CEOH) in Nuku’alofa. The MOH is committed to providing universal health coverage through the implementation of the Package of Essential Health Services (PEHS). The National Referral Hospital is at Vaiola in Tongatapu and there are three district hospitals: Prince Wellington Ngu’s Hospital in Vava’u, Niu‘ui; Princess Fusipala Hospital in Ha’apai; and Niu’eki Hospital in ’Eua. Each hospital has attached technical and public health services. There are 14 health centres and 29 maternal and child health (MCH) clinics across the island groups (20 MCH clinics are located within health centres, with nine functioning as stand-alone clinics). In 2021, Tonga had 0.32 beds per 1000 people, including the new hospital beds in the prison system. The intensive care unit at Vaiola Hospital is equipped with three beds and is being increased to five beds during the open-heart surgery camp that is conducted for a month every two years. Patients who need tertiary services not available in Tonga are referred for treatment elsewhere in Polynesia and the Pacific through the New Zealand Medical Treatment Scheme (NZMTS). Supply and trends. There were 1143 staff working within the MOH in June 2021. Compared to earlier enumerations (2005, 2013) health worker numbers have increased, particularly since 2013. Increases occurred in all professional The MOH is committed to providing universal health coverage through the implementation of the Package of Essential Health Services (PEHS). An aerial view of Nukuʻalofa, the capital city located in the main island of Tongatapu in the Kingdom of Tonga. Seen on the left hand side is the old Church of Tonga. x HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES occupation groups except health officers. In 2021 there were 5.82 health workers (doctors, nurses and midwives) per 1000 population, higher than the threshold of 4.45/1000 used in relation to universal health coverage and the broader range of health services. In 2018 Tonga had the highest nurse and midwife-to-population ratio (4.2:1000) among the Pacific island countries (for example, it was 3.4:1000 in Fiji and 2.5:1000 in Samoa). Workforce distribution. The distribution of health workers remains roughly comparable to the distribution of Tonga’s population, although the proportion of the health workforce in Tongatapu is 10% higher. This is due to the location of the referral hospital, specialist services and centralized administration, and also to the relatively small island populations. Health professionals’ education. The Queen Salote Institute of Nursing and Allied Health (QSINAH) offers the only health professional training programmes in Tonga. These are accredited by the Tonga National Qualification and Accreditation Board. QSINAH offers a Diploma in Nursing, a Bachelor’s Conversion Programme in Nursing (from the Diploma), plus several Advanced Diplomas in Nursing (Practice, NCD, Midwifery) and Diplomas in Medical Laboratory Technology, Pharmacy, Radiology and Dental Therapy. Further postgraduate training in the health professions requires travelling abroad, mostly to Fiji, Australia or New Zealand. Several international universities and organizations support postgraduate online training in Tonga, notably the Family Medicine programme at Fiji National University (FNU) and the Australian College of Emergency Medicine. Current policy discussion surrounds the potential to integrate QSINAH into the Tonga National University. This development will have staff development implications for QSINAH to ensure that all staff have qualifications appropriate to their teaching role. Human resources for health (HRH) utilization. Health workers trained in Tonga are employed by the Public Service Commission (PSC) upon enrolment and are automatically absorbed into the MOH upon graduation. In June 2021 there were 66 vacancies, 68% of which were in Tongatapu, with 32% located outside of the main island. Most of these vacancies were for less-skilled staff (ancillary ward workers, domestic services workers), with a small number being for doctors and nurses. There is a small private sector health labour market, mostly for doctors, pharmacists and some advanced nurses, but this accounts for less than 2% of the total health workforce in Tonga. The centralized health system structure and the lines of authority within it may limit staff members’ ability to identify career pathways. This may result in some people not advancing their careers or not moving into areas where their skills may be better utilized. Financing HRH. The MOH salaries budget has shown a steady annual increase in government allocations over recent years. The lack of an interface between human resource (HR) information and payroll systems is the most critical need for effective budget management. Overtime hours are remunerated Health workers trained in Tonga are employed by the Public Service Commission (PSC) upon enrolment and are automatically absorbed into the MOH upon graduation. xi KINGDOM OF TONGA financially and have significant effects on the budget, leading to the many virements between staffing and operational budgets that confuse the system and reduce operations. It is anticipated that significant donor inputs into the HRH information and management systems planned by the New Zealand Ministry of Foreign Affairs and Trade (MFAT) and the World Health Organization (WHO) in 2022 and beyond will significantly improve the management of HR and the HRH budget in the MOH. Governance of HRH. MOH staff are all employed by the PSC, and all appointments, promotions, disciplinary matters and terminations are made in accordance with PSC Act 2002. Subsequent amendments detail the accountabilities and functions of chief executive officers, notice of a code of conduct and the establishment of a public service tribunal (2010). Employees are subject to the procedural regulations of the PSC Policy Instructions 2010. Concluding remarks. Given the recent increases in levels of staffing across the system, the MOH can turn its attention to a more efficient use of the workforce. The next few years also present an opportunity to investigate salary inefficiencies and workforce mix investment, with a view to redirecting any savings to create a remuneration level sufficient to attract and retain medical specialists. The preparation of the next National Health Strategic Plan presents an opportunity to integrate HRH planning as an important component. As the numbers of staff and technical supporters appear to be historically at the highest levels thus far, more efficient and productive use of the workforce could be achieved through systems changes that better coordinate, lead and supervise HRH activities. The centralized yet divided Ministry structure and the streaming of advanced nursing education have produced unforeseen role divisions at the facility level, where tasks are allocated by role rather than shared as a team, and accountabilities are to centralized line managers rather than to local team leaders. The coordination of nursing cadres and public health workers at the facility level would be enhanced by the delegation of leadership authority that spans all of the facility’s cadre to a senior staff member. The introduction of a facility leadership and management programme could identify persons who, having completed the course, would receive delegations from the Chief Medical Officer to coordinate public health services at the facility level. The preparation of the next National Health Strategic Plan presents an opportunity to integrate HRH planning as an important component.

1KINGDOM OF TONGA 1.1 Demographic and social background Demography and geography Tonga covers an area of more than 720 000 square kilometres and consists of 176 islands, 36 of which are inhabited. Of the 100 179 inhabitants (Table 1), 74.19% live on the main island of Tongatapu, and around 21.15% live in urban areas. The islands are divided into six administrative divisions: Tongatapu, Ha’apai, Vava’u, ’Eua, Niuafo‘ou and Niuatoputapu. The population is young: 34.81% are under 15 years of age, which is attributable to the high fertility rate of 3.56 births per woman (2018) and the migration of working-age people. Life expectancy at birth was 73.4 years in 2019. Social environment The high rate of external migration has offset the relatively high birth rate, with population growth at −0.5% in 2016. Migration out of Tonga is mostly to New Zealand, Australia and the United States of America. The number of Tongans who live in Australia and New Zealand (92 352) is almost comparable to those at home, with 82 389 in New Zealand and 9963 in Australia (2016). The rate of migration has stabilized in recent years. In conjunction with external migration, rural-to-urban internal migration slowly increases demand for services and resources in Nuku’alofa, the nation’s capital. See Table 1 for demographic indicators. Adult literacy is high, at 99.41%, and is equal between men and women. However, women are not able to own land and are discriminated against in child support and inheritance, although women provide much of the social service and human support through their church and family roles and their mutual cooperation. The entry of women into the Tongan Parliament has been slow. Following the election by the legislature of the Honourable Pohiva Tu’i’onetoa as Tonga’s new Prime Minister in September 2019, Dr Ámelia Tuípulotu was appointed by King Tupou VI as the Minister for Health in the new Cabinet. Dr Tuípulotu previously headed nurse training at Vaiola Hospital in Tonga. Political environment Tonga is a constitutional monarchy. The governing structure is unicameral and comprises the Executive (Cabinet), Legislature and Judiciary branches. The Legislative Assembly comprises 17 people’s representatives, nine noble representatives elected by Tonga’s 33 noble titles, and up to four additional members appointed by the King on the advice of the Prime Minister. The King appoints the Prime Minister on the recommendation of the Legislative Assembly. The high rate of external migration has offset the relatively high birth rate, with population growth at −0.5% in 2016. 1. Introduction 2 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES 1.2 Economic situation and macroeconomic indicators 1 See World Bank online database: Tonga | Data (worldbank.org). Tonga is an upper-middle-income country ranking 104 out of 189 countries on the Human Development Index (United Nations Development Programme, 2020), with an economy heavily dependent on private remittances from Tongans living abroad, and from development partner contributions. By June 2021, Tonga’s domestic revenues totalled US$ 265 million, representing 27% of gross domestic product (GDP), a decline since 2019–2020 and lower than budget estimates, due to reduced tourism and travel (Tonga Ministry of Finance, 2021). Domestic revenues were projected to remain at 27% of GDP in 2022–2023. Remittances comprised 37.5% of GDP in 2019, a rapid increase from 19% in 2012. Agriculture (16% of GDP) and foreign aid (36%) are significant sources of revenue, with the country receiving approximately US$ 108 million net in international donor aid in 2019.1 The Ministry of Health (MOH) was estimated to receive US$ 22.4 million in 2020–2021, the third largest share (11%) of the development budget. The Ministry of Finance submitted a deficit budget for 2021–2022, predicting that the impact of COVID-19 and Tropical Cyclone Harold recovery would cause further contraction by 3.7% in 2022. Tonga has a significant debt burden and is vulnerable to environmental disruption. See Table 2 for economic indicators. The relatively high per capita GDP (US$ 5125 in 2020), high life expectancy and universal literacy rates contributed to Tonga’s Human Development Index rating of 0.73 and ranking of 104 of 189 countries in 2020. These were marginally lower than Fiji (0.743, ranked 93) and higher than Samoa (0.715, ranked 111). However, an estimated 27% of the population is considered “multidimensionally poor” (Tonga Statistics Poverty Verification Survey 2020 in Response to COVID-19). A total of 14% is considered “vulnerably deprived” (Tonga Statistics Department, 2018). The World Bank poverty headcount ratio estimated that in 2015, 1.8% of the population lived on less than US$ 2.15 a day, calculated in 2017 purchasing power parity (World Bank, 2023). Population density overall is 155 persons per square kilometre (km2) but varies widely, with the greatest densities in the island centres of Okoa in Vava’u (768 per km2), Kotu in Ha’apai (379 per km2) and in the capital Tongatapu (286 per km2). The outer islands have poorer access to health services and to educational and economic opportunities, which drives a continued internal migration to Tongatapu (see Table 1). Tonga is an upper-middle- income country ranking 104 out of 189 countries on the Human Development Index. 3KINGDOM OF TONGA Table 1. Selected demographic indicators Indicator Statistic Year Total population 100 179 2021 Urban population (%) 21.15 2021 Vava’u population 14 182 2021 Ha’apai population 5665 2021 ‘Eua population 4864 2021 Ongo Niua population 1148 2021 Population growth (annual %) −0.1 2021 Net migration rate (per 1000 population) −7.5 2016 Female (% of total population) 51.34 2021 Age < 1 year (% of total) 1.79 2021 Age 1–14 years (% of total) 33.02 2021 Age 15–59 years (% of total) 74.91 2021 Age 60+ years (% of total) 9.48 2021 Fertility rate, total (births per woman) 3.56 2019 Birth rate, crude (per 1000 people) 24.01 2019 Death rate, crude (per 1000 people) 7.1 2019 Literacy rate, adult total (% of people aged 15 and above) 99.4 2018 Life expectancy at birth 73.4 2019 Sources: Tonga Statistics Department, 2016; Tonga Statistics Department, 2021; World Bank, 2023. Table 2. Selected economic indicators Indicator Statistic Year GDP (US$) 510 million 2020 Per capita GDP (US$) 5125.0 2020 GDP growth (annual %) −0.5 2020 Health expenditure, total (% of GDP) 5.32 2020 Health expenditure per capita (US$) 248.04 2020 Out-of-pocket health expenditure (% of total expenditure on health) 10.2 2018 Public spending on education (% of GDP) 12.7 2021 Unemployment rate (%) 4.37 2020 Labour participation rate (%) 45.55 2020 Sources: World Data Atlas, 2020; World Bank, 2023. 4 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES 1.3 Summary of health indicators Mortality and life expectancy Life expectancy in Tonga (73.4 years) is marginally higher than the average for small Pacific states (70 years, 2017) and child mortality rates are among the lowest in the Pacific region. The under-5 mortality rate was 16.6 per 1000 population in 2019, while the infant mortality rate continued to decline to 11.6 per 1000 live births in 2021 (see Table 3). Neonatal mortality increased marginally from 7.2 per 1000 live births in 2010 to 7.4 in 2019. The 2019 crude death rate was 7.1 per 1000 population, a small but trending decrease since 2015. Life expectancy has increased by 11 years since 1960 (World Bank, 2023). The maternal mortality ratio has halved since 2010, from 110 to 55 per 100 000 live births, the largest improvement in the national health data set. Main causes of mortality and morbidity Noncommunicable diseases (NCDs) combined constitute the largest burden of disease. Rates of obesity, diabetes and cardiovascular disease are among the highest in the world. The top 10 leading causes of death per 100 000 population in 2019 (WHO) were ischaemic heart disease (83.9), diabetes mellitus (71.5), stroke (47.7), road accidents (33), lower respiratory infections (29.5), kidney disease (27.8), chronic obstructive pulmonary disease (25.4), respiratory cancers (21.1), liver cancer (18.7) and cirrhosis of the liver (16.2). Cause of death by injury has increased since 2015 from 5.5% to 9.5% of all deaths, now a higher rate than in Fiji. The Sustainable Development Goals (SDGs) call for a one-third reduction of NCDs by 2030. NCDs accounted for 79.4% of all deaths in 2019, an increase of 5% since 2008. The Tonga risk factors STEPS report 2017 presented a mixed picture of change compared to the 2012 STEPS data (reported in 2014), with some apparent continuing risk factor increases. These increases were possibly explained by the much improved rigour of the 2017 survey and its analysis. In comparison with 2012, 14 of the 27 indicators assessed showed a trending decline in public health, plus a significant increase in the percentage of people aged 25–64 years with three or more risk factors for NCDs: 57.1% in 2012 to 69.1% in 2017. The mean body mass index (35.0 kg/m2) of the Tongan population is slowly increasing and falls within the obesity range; 82.8% of women and 66.8% of men are considered obese. Almost one quarter (24.9%) of Tonga’s population over the age of 18 are daily smokers (unchanged since 2012), with more than twice the proportion of men smokers than women. Physical activity has decreased overall. These findings indicate a need for concerted public health education and early screening efforts to maintain and increase risk factor awareness, to identify disease early and to engage with local culture to effect widespread behavioural change. Life expectancy in Tonga (73.4 years) is marginally higher than the average for small Pacific states (70 years, 2017) and child mortality rates are among the lowest in the Pacific region. 5KINGDOM OF TONGA Increasing urbanization, imported processed foods, large servings, sedentary lifestyles and a change from traditional diets and farming − combined with progressive decreases in physical activity, the use of motor vehicles and population ageing − are all significant contributors to increasing the national NCD burden. Notably, admissions to mental health hospitals and prisons have increased. This is due to the use of illicit substances, particularly methamphetamine, previously associated with the deportation of offenders from New Zealand, but now widespread in the community. An outbreak of measles in 2019 affecting Tongatapu and Vava’u was successfully controlled by a vaccination programme. Hepatitis A and B are endemic, as are dengue and chikungunya virus, both spread by Aedes mosquitoes. There was a dengue outbreak in 2018. Typhoid fever is also known to occur. Tonga is not equipped to treat any more than four patients requiring ventilation, suggesting a need for vigilant border control and quarantine to prevent the importation of severe acute respiratory syndrome (SARS) viruses such as COVID-19. 1.4 Health system Governance structure The Minister of Health is guided by the National Health Development Committee and the professional boards (Medical and Dental Board; TNMNPB; Pharmacy Board) in providing direction to the MOH through the CEOH. The MOH is responsible for the administration and delivery of health services in Tonga and is split into five divisions: Clinical Services, Corporate Services, Public Health, Dental Services and the Office of the Chief Nursing Officer. All nursing staff are managed through either the Clinical Services or Public Health divisions, according to their posting. Each division is responsible to the CEOH for implementation of its services. Human resources (HR) are the responsibility of the Corporate Services division and the HR Workforce Development Section Head, with five senior administrator positions (three of which are currently vacant) and with 13 positions for clerical, computer and filing support staff. Table 3. Selected health indicators Indicator Statistic Year Life expectancy (years) 73.4 2019 Female 76.4 2019 Male 70.5 2019 Mortality rate, under-5 (per 1000 live births) 16.6 2021 Mortality rate, infant (per 1000 live births) 11.6 2019 Mortality rate, neonatal (per 1000 live births) 7.4 2018 Maternal mortality ratio (per 100 000 live births) 52 2017 Births attended by skilled health staff (% of total) 99.0 2019 Source: World Bank, 2023. 6 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Health services organization Government health services are free for all Tongan citizens. Although provided geographically, the MOH’s structure is centralized to the CEOH and division heads in Nukualofa and to the National Referral Hospital in Vaiola, where MOH administration is situated. Physical access to services is good for most of the population, except for small populations living on isolated islands who need to travel. The intended outcomes of the National Health Strategic Plan (NHSP) 2015–2020 remain: progressively achieving universal health coverage by implementing the Package of Essential Health Services (PEHS) across the nation geographically through the six Islands Health Districts, Tongatapu, Niuafo‘ou and Niuatoputapu (both supported from Tongatapu and the MOH), Vava’u, Ha’apai and ‘Eua. Services are funded through six programme budgets: Leadership and Governance (policy and administration), Preventive Health (public health), Curative Health (Vaiola Hospital and three community hospitals, Vava’u, Ha’apai and ‘Eua and the new Likamonu Extended Health Centre), Dental Health, Nursing Services and the Tonga Health Promotion Foundation (THPF). Public health services are provided across the Islands Health Districts but are managed centrally and separately from Vaiola Hospital by the Chief Medical Officer through six sections: Public Health Administration, Communicable Diseases, Environmental Health, Reproductive Health, the Health Promotion Unit, and Community Health (general medical, NCDs and Niuas Health Services). Within the Islands Health Districts these services are managed centrally and operate according to their centrally determined service objectives. The THPF was established as an autonomous body by a 2007 Act of Parliament to administer the Tongan Health Promotion Fund and any charitable donations it may receive. The Foundation supports the implementation of the National Strategy for the Prevention and Control of Noncommunicable Diseases (Hala Fononga), forecasts its annual plans and reports its achievements to Cabinet through the Minister for Health. The National Referral Hospital at Vaiola in Tongatapu (199 beds) provides clinical services through nine sections: Paediatrics and Special Care Nursery, Surgical, Medical, Obstetrics and Gynaecology, Mental Health, Anaesthesia and Intensive Care Unit (ICU), Ear-Nose-Throat (ENT), Emergency and Outpatient, and Ophthalmology. Clinical support services at Vaiola are in Nutrition and Dietetics, Laboratory, Pharmacy, Radiology and Physiotherapy. Vaiola Hospital also provides outreach clinics and hosts visiting specialist medical teams. A small 10-bed hospital unit at Hu‘atolitoli Prison was opened in 2019 and is used at times by the Mental Health Services to detain and treat violent male patients. The growing demand on hospital beds for mental health patients will increase the need for staff trained in psychiatric nursing and in harm minimization of substance and alcohol abuse. 7KINGDOM OF TONGA Three community hospitals – Prince Ngu’s Hospital in Vava’u (61 beds), Niu‘ui/ Princess Fusipala Hospital in Ha’apai (28 beds) and Niu’eki Hospital in ’Eua (20 beds) – serve the major island groups. District hospitals provide basic clinical, nursing and diagnostic services, the full range of public health and dental services, and are supported by corporate and maintenance staff. The new Likamonu Extended Health Centre on Niuatoputapu was funded by the European Union in 2018 to replace the damaged health centre. In 2021 Tonga had 0.32 beds per 1000 people, including the new hospital beds in the prison system. Rates of admission and bed occupancy in the community hospitals were reportedly low. Notable increases in hospital admission numbers to Vaiola Hospital since 2015 have been for mental health and paediatric services (MOH annual reports). The hospitals are supported by a network of 14 health centres: seven in Tongatapu, three in Vava’u, two in Ha’apai, one on Niuafo‘ou and the new Likamonu Extended Health Centre on Niuatoputapu, which provide both primary health care and preventive health services. Remote health centres have limited inpatient facilities. Each health centre is typically staffed by a health officer or senior health officer (except for Likamonu in Niuatoputapu, where a medical officer was posted in 2020) and one to three nurses, a dental therapist and support staff. There are 29 maternal and child health (MCH) clinics across the island groups: 16 in Tongatapu, five in Vava’u, three each in Ha’apai and ‘Eua and one each in Niuafo‘ou and Niuatoputapu. The majority of these (20) are located within health centres, with nine functioning as stand-alone clinics. Following the success of a concentration on reproductive health nursing services, in 2015 Tonga developed a new cadre of nurses to address its high rates of NCDs. Queen Salote Institute of Nursing and Allied Health (QSINAH) developed an Advanced Diploma in NCD Nursing Prevention, Detection and Management to support the implementation of Tonga’s NCD strategy. Eleven NCD nurses on the Ministry’s staff list are located in Tongatapu, including the NCD Nursing Supervisor; two are in Vava’u and two in ‘Eua. There is one male NCD nurse in Tongatapu. Patients who need tertiary services not available in Tonga are referred for treatment elsewhere in the Pacific through the Health Corridor Alliance, a New Zealand Medical Treatment Scheme (NZMTS) funded by the New Zealand Agency for International Development (NZAID) and New Zealand Ministry of Foreign Affairs. Alternatively, they are funded by a national scheme provided by the Government of Tonga to access specialist medical services elsewhere in Polynesia, New Zealand, Australia, Fiji and India. NZMTS also supports country visits from visiting medical officer specialists to support capacity- building. In 2019 nine children were referred to Starship Children’s Hospital in Auckland, New Zealand. Following the success of a concentration on reproductive health nursing services, in 2015 Tonga developed a new cadre of nurses to address its high rates of NCDs. 8 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Nine medical practitioners operate solely as private practitioners and another nine practise as dual MOH and private practitioners. Most dental practitioners are Ministry employees; one is a dual practitioner and one a private practitioner. Of the eight graduated nurse practitioners, two operate in private practices. There are eight commercial pharmacies in Tonga. New Zealand is providing funding for Tonga’s Dare to Dream Foundation establishment of a rehabilitation centre to support the integration of New Zealand deportees and vulnerable youth into society. Sources of funding The Tongan economy is dependent on external aid and remittances. The Ministry of Finance is the main source of health-care funding (64%), followed by international donors (36%) (Tonga Ministry of Finance, 2021). The Ministry of Finance submitted a deficit budget for 2021–2022 due to reduced activity and debt repayments, which placed downward pressure on the national wages bill. The MOH receives the second largest share (21%) of the government budget. The government was expected to receive approximately 52.2 million Tongan pa’anga (T$) from its development partners for 2021–2022 to assist in combating COVID-19 in all sectors. About 23% of this amount (T$ 12.5 million) was marked as in-kind assistance in goods and services provided to the MOH by WHO, the World Bank, the Asian Development Bank, and the governments of Australia, New Zealand, Japan and China (Tonga Ministry of Finance, 2021). The aid-funded project expenditure budget estimate for the MOH was US$ 22.42 million in 2021–2022, comprising 11% of the Development Budget. WHO, together with the Tonga Health Systems Support Program Phase 2 funded by the Australian Department of Foreign Affairs and Trade (DFAT), supported the National Strategy for the Prevention and Control of NCDs 2015–2020, overseen by the THPF, to combat NCDs, support systems improvements and implement the PEHS. The approved Tonga Health Systems Support Program Phase 3 Fund and the New Zealand Tonga Health Workforce Activity 2021 will strengthen the MOH’s Corporate Services Division. Health expenditure Health expenditure comprised 5.1% of GDP in 2018 and, along with Samoa’s, was the highest in the region. Per capita health expenditure was US$ 236 in 2018, the highest in the region, but lower than the average for middle-income countries (US$ 286). Domestic private health expenditure comprised 14% of all health expenditure, 11.8% of which was out of pocket (World Bank, 2023). 9KINGDOM OF TONGA The data presented in sections 2 and 3 cover public service staff as of June 2021. The data were collected through the MOH payroll database and personnel register. Classification of health worker posts into health occupational groups, or cadres, was based as much as possible on the International Standard Classification of Occupations used in the 2014 Human resources for health country profiles: Tonga, although in some cases the exact classification was difficult to determine from the post designation. Also, some staff were clearly undertaking a role that was inconsistent with the post title. However, this is a common occurrence with payroll data. There were 1235 positions in the Ministry’s staff establishment in June 2021, 64 of which were vacant and 28 of which had been abolished. Accordingly, there were 1143 staff working within the MOH in June 2021 (Table 4), although some of these were on extended leave, especially those studying overseas. Compared to earlier enumerations (2005, 2013), health worker numbers had increased, particularly since 2013 (an increase of 41%) after relatively flat growth in the previous years. Increases occurred in all professional occupation groups, apart from health officers, whose numbers had declined since the withdrawal of training, and student nurses due to QSINAH having no intake in 2021. The various categories of nurses (advanced, registered, student, midwife and nurse manager) now make up almost half (49.4%) of all health workers employed. There has been a significant increase (50%) in the number of registered nurses since 2013. The next largest group of health workers is doctors (generalist and specialist, at 9.4% of the total), a category that has almost doubled (increased by 94.5%) since 2013. Of the 27 doctors with specialist training, all appear to be in clinical roles. These specialists include three obstetricians and gynaecologists, five physicians, two ophthalmologists and two psychiatric specialists. There is one chief surgeon, a number of unspecified senior medical officers and three anaesthetists. Doctors with a master’s degree are elevated to the post of senior medical officer for four to five years, and then promoted further to a specialist-level post. The specialist areas of cardiology, pathology, radiology and oral surgery each have only a single specialist employed. The increase in the number of health workers and the relative stability of total population growth have resulted in an increase in the number of health workers per 1000 population. In 2021 there were 5.82 health workers (doctors, nurses and midwives) per 1000 population – above the 4.45 per 1000 population doctors, midwives and nurses needed to achieve 80% of deliveries by a skilled birth attendant. The measles immunization rate was 80%, as recommended by WHO in relation to achieving the SDGs. The various categories of nurses (advanced, registered, student, midwife and nurse manager) now make up almost half (49.4%) of all health workers employed. 2. Health workforce supply and trends 10 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Table 4. Number of health workers at the national level in 2005, 2013 and June 2021 Health occupation Year of data collection 2005 2013 2021 Generalist medical practitioners 37 36 80 Specialist medical practitioners 3 19 27 Health officers 31 20 13 Health promotion workers − − 21 Nurse managers (matron; supervising public health sister; principal QSINAH; supervising NCD and supervising nurse practitioner) 5 Advanced practice nurses 2 31 54 Graduate/registered/professional nurses (includes nurse managers) 318 256 384 Midwives 32 24 37 Student nurses - 97 89 Dentists (includes chief, principal & senior dental officers) Dental technicians and assistants 13 27 12 27 17 38 Pharmacists (includes principal) Pharmaceutical technicians and assistants 4 18 4 23 8 24 Medical imaging and therapeutic equipment technicians 11 7 18 Medical and pathology laboratory technicians 29 25 39 Allied health professionals/workers (includes physiotherapists, nutritionists and dietitians, psychologists) − − 14 Environmental health and hygiene workers 24 26 36 Health service managers (hospital administrators) 4 3 10 Health administration personnel (includes executive, non- health professionals, non-professionals) − − 50 Medical records and health information technicians 11 14 20 Personal care workers in health services not elsewhere classified/ancillary ward workers 6 13 16 Information and communication technology staff (computer operators) − − 4 Clerical support workers 13 41 18 Service and sales workers/maintenance workers 20 32 23 Domestic and support services (includes domestic services, drivers) 161 56 103 Total 810 809 1143 Source: Tonga Ministry of Health, 2021. 11 KINGDOM OF TONGA In 2019, Tonga, had the highest nurse and midwife to population ratio (4.3:1000) among the Pacific states – Fiji was 3.8:1000 and Samoa was 3.2:1000 (World Bank, 2019). These global comparison rates are only indicative of coverage of human resources for health (HRH), but are subject to context, access and other factors. Exceeding minimum thresholds does not therefore indicate that a country is effectively addressing all health issues. Table 5 presents the entire MOH workforce and the worker-to-population ratios for each category. Table 5. Number of workers per 1000 population; selected workforce categories, June 2021 Health occupation Number of workers Health workers/1000 population (population = 100 179) Generalist medical practitioners 80 0.80 Specialist medical practitioners 27 0.27 Advanced practice nurses 54 0.54 Graduate/registered/professional nurses (includes nurse managers) 384 3.84 Midwives 37 0.37 Dental workers 55 0.55 Pharmacy workers 32 0.32 Medical imaging and therapeutic equipment technicians 18 0.18 Medical and pathology laboratory technicians 39 0.39 Allied health professionals/workers 14 0.14 Environmental health and hygiene workers 36 0.36 Health service managers/administrators 60 0.60 Domestic, maintenance and support services 142 1.42 Total 1143 11.44 Source: Staff list as of 20 August 2021, Tonga Ministry of Health. 12 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES 3.1 Gender distribution The Tonga health workforce is highly feminized, with 68% of all professional health workers being women. Similar to many other countries, the markedly higher numbers of females than males in nursing categories is evident in Tonga and also occurs among dental and generalist medical practitioners and medical laboratory technicians (Fig. 1). Males form smaller majorities of specialist medical practitioners and medical imaging workers, while also filling two thirds of environmental health worker positions. Fig. 1. Gender distribution of MOH professional staff, 2021 Male Female 58.8 44.4 78.4 100 44.5 53.8 100 65.5 33.3 41.2 55.6 21.6 0 55.5 46.2 0 34.5 67.6 0 10 20 30 40 50 60 70 80 90 100 Medical practitioners Specialist medical practitioners Nurses Midwives Medical imaging workers Medical laboratory workers Advanced practice nurses Dental workers Environmental health workers % of workers in category Ty pe o f w or kf or ce Source: Staff list as of 20 August 2021, Tonga Ministry of Health. 3.2 Age distribution The Tonga health workforce is young, with 66.5% under 40 years of age. Since 2013 the workforce has become appreciably younger with an influx of nurse graduates and other trainees. In June 2021 only 16 persons (1.4% of all health 3. Health workforce distribution 13 KINGDOM OF TONGA workers) on the payroll were older than the compulsory retirement age of 60 years. Most of these (but not all) were highly skilled doctors (including five specialists) and advanced nurse practitioners. A selection of the key workforce categories is described in terms of the proportion over 49 years of age in Fig. 2. Not unexpectedly, the oldest workforce groups are advanced nurse practitioners, followed by the specialist medical practitioner workforce. Tracking health worker age allows for forecasting annual retirement numbers, identifying candidates for promotion to fill newly vacant positions, identifying the need to contract selected retirees where their positions are hard to fill, and preparing for particular training needs. The data below indicate a need to ensure the ongoing training of advanced nursing cadres and to continue to prepare suitable conditions of employment to attract and retain medical specialists, including those who are in training. Fig. 2. Proportions of health workers over age 49 by health occupation, 2021 45.3 30.8 27.8 20.5 14.5 10 10 0 10 20 30 40 50 Advanced practice nurse Specialist medical practitioner Environmental health worker Medical laboratory worker Dental workforce Medical practitioner Nurse % of workforce over 49 years old Ty pe o f h ea lth o cc up at io n Source: Staff list as of 20 August 2021, Tonga Ministry of Health. 3.3 Distribution of health workers The islands of Tonga are divided into six Islands Health Districts: Tongatapu, Ha’apai, Vava’u, ’Eua, Niuafo‘ou and Niuatoputapu. The majority (74.19%) of Tonga’s population lives on the main island of Tongatapu, with around 21.15% in urban areas. The distribution of health workers remains roughly comparable to the distribution of Tonga’s population, although the proportion of the health workforce in Tongatapu is 10% higher. Just over 84% of the health workforce is located on the main island (see Fig. 3), reflective of the location of the referral hospital, specialist services and centralized administration. In 2013, 80.1% of all health workers were located on Tongatapu, so the concentration of the health workforce in Tongatapu is slowly increasing. 14 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Fig. 3. Distribution of health workers by location, June 2021 961 88 51 32 5 4 Tongatapu Vava'u Ha'apai 'Eua Niuatoputapu Niuafo'ou Source: Tonga Ministry of Health, 2021. The location of the referral hospital and specialist services, plus the relatively small island populations, determine the distribution of skills across the island groups. Most of the highly skilled workers are based in Tongatapu, Vaiola Hospital and the MOH. A proxy method of quantifying skills distribution is the average salary for each location, which ranges from a low average of T$ 18 388 Tongan pa’anga (in Vava’u) to a high average of T$ 21 071 (in Tongatapu). The average salary in Tongatapu is 8% higher than the average for the rest of the divisions. Further proxy evidence of centralized skills is in the distribution of high-salary-band workers – salary band B to H income earners are almost exclusively located in Tongatapu. The proportions within the key professional workforce categories deployed outside of Tongatapu are listed in Table 6. Table 6. Proportion of health professionals located outside of Tongatapu Health occupation % Nurses 13.1 Advanced practice nurses 14.8 Midwives 21.7 Allied health professionals/workers 0 Environmental health workers 19.4 Health promotion workers 0 Medical practitioners 7.5 Dental workforce 16.4 Source: Tonga Ministry of Health, 2021. 15 KINGDOM OF TONGA 3.4 Sectoral distribution The THPF is a nongovernmental organization and a major partner of the MOH in the implementation of the national NCD strategy, and a direct recipient of public funds. The Tonga Village Mission Clinic in Nukualofa is a one-doctor clinic with a pharmacist and local nurse support. Generally, the private sector attracts some medical practitioners, dentists, pharmacists and advanced nurse practitioners, and can be expected to grow in line with the economy. There are eight registered generalist and specialist medical practitioners working solely in the private sector, plus another 10 working in dual roles as MOH employees and private practitioners. Most medical practitioners are employed in individual private practice, although a number are employed in not-for-profit organizations, including three non-Tongan nationals. There are two dental officers working in the private sector (one in a dual role) and two nurse practitioners in private practice. There are also eight commercial pharmacies in Tonga. 3.5 Distribution of health workers by citizenship As stated in the 2014 HRH country profile, Tonga is not reliant on foreign workers to fill positions, but there are no citizenship criteria. According to the latest medical practitioner registration roll, there are only two expatriate medical practitioners working in the public sector and another four in the nongovernment sector (three of those are at a mission clinic). The Medical and Dental Practice Act allows for registration and temporary registration of applicants who have met criteria in other jurisdictions. 3.6 Skills distribution There are approximately 4.4 nurses (general nurses, advanced practice nurses, midwives) for every doctor in Tonga. This statistic denotes a major change since 2013, when the ratio was 11:1. The high growth in medical practitioner numbers relative to nurses has reduced the ratio from the high 2013 levels. The nurse- to-doctor ratio varies geographically, ranging from 4:1 in Tongatapu to 11.7:1 in Vava’u and 10:1 in the other island groups combined. There are seven doctors deployed outside of Tongatapu; although this is a low number, it is an increase from 2013. There are no medical practitioners in Ongo Niua. Nationally, there are 4.7 nurses and 1.1 doctors for every 1000 people. The ratio varies from island to island. Outside of Tongatapu, the ratio of skilled clinical workers to population is much lower (see Table 7), but more dramatically so for medical practitioners than for nurses. There are approximately 4.4 nurses (general nurses, advanced practice nurses, midwives) for every doctor in Tonga. 16 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Table 7. Doctor- and nurse-to-population ratios in the Islands Health Districts Geographic area Population Nurse-to-population ratio Doctor-to-population ratio Total population 100 179 4.7 : 1000 1.1 : 1000 Vava’u population 14 182 2.5 : 1000 0.2 : 1000 Ha’apai population 5 665 3.6 : 1000 0.2 : 1000 ‘Eua population 4 864 3.0 : 1000 0.4 : 1000 Ongo Niua population 1 148 2.4 : 1000 0.0 : 1000 Source: Tonga Ministry of Health, 2021. Changes to postgraduate nurse training in QSINAH with the introduction of the Nurse Practitioner programme have resulted in a division of the nursing workforce, with some now designated as NCD nurses and others as reproductive health nurses. The 2014 HRH country profile identified shortages of nurses who were multi-skilled and able to respond to a range of health challenges, particularly in more remote and less supported service situations. Interviews undertaken for this HRH country profile confirm that this remains a concern and has cost and efficiency implications, whereby at least two nurses must be posted together to provide the full range of nursing services. Given that each type of nurse looks to different central authorities for direction and support, the disjuncture of services at the local level has become systemic. QSINAH is aware of the issue and is planning to revise curricula to integrate the advanced nursing qualifications to a greater degree. This issue has further service delivery implications, as the lack of leadership and coordination at the local level compounds difficulties in access to services for the community and may result in referral from one nurse to another. Up-skilling nurses to cover both skill areas would allow for task shifting and improve the opportunity to practise skills that might otherwise be lost. In this situation where coordination and cooperation are needed, the provision of training in front-line leadership and supervision would be valuable. 17 KINGDOM OF TONGA 4.1 Training institution Queen Salote Institute of Nursing and Allied Health (QSINAH) offers the only health professional training programmes in Tonga that are accredited by the Tonga National Qualification and Accreditation Board (TNQAB) and conform to the levels of the Tonga Qualifications Framework (TQF). The TQF is consistent with the Pacific Qualifications Framework (PQF). QSINAH only delivers programmes that are accredited by TNQAB. Current policy discussion in the Ministry of Education and Training (MET) surrounds the potential to integrate all tertiary training institutions into a Tonga National University. This development will have implications for QSINAH to ensure that all staff have qualifications appropriate to their teaching role. Accredited entry-level programmes (TQL Level 5) offered at QSINAH include: (a) Diploma in Nursing (b) Diploma in Pharmacy (c) Diploma in Medical Laboratory (d) Diploma in Diagnostic Radiotherapy (e) Diploma in Dental Therapy. Future programmes are planned for: (f) Diploma in Mental Health Nursing. QSINAH routinely engages external agencies (Auckland University of Technology; Burnet Institute) to review curricula and assist in their development. QSINAH is the focal point for all workforce training on COVID-19 and vaccination. 4.2 In-service training The MOH operates several non-accredited paramedical training programmes as the need arises, producing technicians and assistants at Vaiola Hospital departments in pharmacy, dentistry, radiology/imaging, medical laboratory and environmental health. Competition for entry to sporadically provided courses has historically been high and based on a pass in the Pacific Senior Secondary Certificate examination and interview. Current policy discussion in the Ministry of Education and Training surrounds the potential to integrate all tertiary training institutions into a Tonga National University. 4. Health professionals’ education 18 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Teaching is conducted in MOH facilities and is funded by departmental budgets. Conditions of employment are similar to those for nursing students at QSINAH. Training of health officers ceased in 2014 following the introduction of the Nurse Practitioner programme. Dental technicians were last trained in 2009. The next programme is scheduled for 2023, following a programme review. Twelve chairside assistants were trained in 2018 and a course is being considered for 2024. Ten pharmacy technicians and assistants graduated in 2018 and another course was planned for 2022 following a course review. There is no plan to run the radiology/imaging course again. A group of 10 trainee environmental health inspectors commenced the two- year on-the-job programme in 2020. The programme is being reviewed for accreditation by TNQAB. In addition, MOH staff gain experience through their participation in local and international short courses, attendance at conferences, and studies online in a wide range of activities associated with the Ministry’s responsibilities and affiliations. 4.3 Nursing education The TNMNPB regulates the nursing profession in Tonga and sets standards for the education and training of nurses, nurse practitioners and midwives. Courses provided at QSINAH are competency-based and students undergo exams upon completion of each academic semester. Tonga is an active member of the South Pacific Nurses Forum, benefiting from the developments occurring elsewhere in the region. Pre-service training Pre-service nursing education is delivered at QSINAH on the Vaiola Hospital campus. Acceptance to QSINAH is competitive and requires completion of a Pacific Senior Secondary Certificate (Form 6) with an aggregate mark of 14 or more in four subjects, including passes in mathematics, biology and English. Nurses wishing to re-enter the profession after five years’ absence are required to sit the TNMNPB exams. In the six years between 2014 and 2020 (no intake in 2017) QSINAH enrolled 235 students. From the programmes completed, 86% of students graduated in 2020; there were 32 in year three and 36 in year two, with no intake in 2021. Students gain practical experience on the wards of Vaiola Hospital. Enrolling students become employees of the MOH, are subject to Public Service 19 KINGDOM OF TONGA Commission (PSC) provisions, receive a small salary and are absorbed into the public service on graduation. Privately funded students are required to apply for vacant positions. Post-basic nurse training QSINAH offers post-basic courses according to need. Applicants must be registered nurses with a minimum of three years of clinical practice. Current TQF Level 6 programmes are: (a) Advanced Diploma in Midwifery (b) Advanced Diploma of Nursing in Prevention, Detection and Management of NCDs (c) Advanced Diploma of Nursing in Intensive Care (d) Advanced Diploma in Nursing Practice. The Advanced Diploma in Nursing programme was reviewed in 2018 by the University of Sydney and the Midwifery programme was reviewed by the Burnet Institute in 2020. The Nurse Practitioner programme was scoped for curriculum development to be completed by the end of 2021, for better alignment with the NCD programme and for the potential to offer it at TQF Level 8. 4.4 Postgraduate training in other health professions Further postgraduate training in the health professions generally requires a scholarship (although some are privately funded) and training abroad, mostly at Fiji National University (FNU) or in Australia or New Zealand (see Table 8). Several international universities and organizations support postgraduate online training in Tonga, notably FNU and the Australian College of Emergency Medicine (see Table 9). The challenge for online training is to introduce sufficient rigour and supervised case exposure into the instruction. Table 8. Formal training in overseas universities: graduated, ongoing with projected completion year, and new scholars Overseas programmes Scholarship University No. graduated No. ongoing Completion year Medicine Master of Surgery APA UMELB 1 TSA FNU 1 2022 Master of Medicine in Anaesthesia Japan Okayama University, Japan 1 NZPS FNU 1 2023 Master of Medicine in Ophthalmology Fred Hollows Foundation, New Zealand Pacific Eye Institute, Fiji 1 2022 20 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Overseas programmes Scholarship University No. graduated No. ongoing Completion year Master in Paediatrics TSA FNU 1 2022 Master in Family Medicine TSA FNU 1 2022 Master of Obstetrics and Gynaecology WHO FNU 1 2022 PG Dip in Obstetrics and Gynaecology Private RANZOG 1 2021 PG Dip in Emergency Medicine TSA FNU 1 2021 NZPS FNU 1 2022 PG Dip in Anaesthesia Science WHO UPNG 1 2021 PG Dip in Communicable Diseases Private FNU 1 2021 Bachelor of Medicine Bachelor of Surgery TSA FNU 1 2021 Private FNU 1 2022 NZPS FNU 1 2026 Nursing Master in Primary Health Care Nursing Lenity Scholarship USYD 1 Master of Advanced Nursing Practice Lenity Scholarship USYD 3 APA Institute of Health and Nursing Australia 1 2021 PG Dip in Nursing Leadership and Management APA FNU 1 2021 PG Dip in Mental Health Nursing APA FNU 1 2021 Private FNU 1 2021 WHO FNU 1 2021 NZPS FNU 1 2022 PG Dip in Midwifery NZPS FNU 1 Deferred Bachelor of Nursing NZPS Massey University 1 2022 NZPS FNU 1 2022 Private FNU 1 2022 TSA FNU 1 2021 TSA FNU 1 Deferred Diploma in Nursing APA Institute of Health and Nursing Australia 1 2022 Dentistry Doctorate in Dental Science JICA Kyushu University Japan 1 2023 Doctorate of Clinical Dentistry NZPS University of Otago 1 2022 Bachelor of Dental Surgery NZPS FNU 2 2023 Table 8. Formal training in overseas universities: graduated, ongoing with projected completion year, and new scholars (contd) 21 KINGDOM OF TONGA Overseas programmes Scholarship University No. graduated No. ongoing Completion year Allied health & related programmes Master in Health Service Management NZPS FNU 1 2021 Bachelor of Medical Laboratory Science APA FNU 1 APA FNU 1 2023 NZPS FNU 1 2024 Bachelor of Pharmacy TSA FNU 1 2023 Bachelor in Prosthetics & Orthotics Motivation Australia Mobility India (Australia-USC ) 1 2022 Bachelor of Physiotherapy NZPS FNU 1 2021 Diploma in Dental Technology NZPS FNU 1 2022 Public health Bachelor in Public Health Dr Tapa Scholarship FNU 1 2022 Master in Epidemiology APA UWS 1 PG Dip in Applied Epidemiology NZPS FNU 1 2022 Bachelor of Science (Computing Science and Information Systems) APA USP Fiji 2 2022 Master of Education (Learning & Leadership) APA UTS 1 2021 New scholars Bachelor of Medicine and Bachelor of Surgery (MBBS) APA FNU 4 Cuban Cuba 4 TSA FNU 8 Private FNU 1 Private Tbilisi, Georgia 1 Bachelor of Dental Surgery APA FNU 1 Bachelor of Pharmacy TSA FNU 2 Bachelor of Maths & Biology TSA USP Fiji 1 Foundation Science TSA USP Fiji 1 APA: Australian Postgraduate Awards; FNU: Fiji National University; JICA: Japan International Cooperation Agency; NZPS: New Zealand Pacific Scholarships; PG Dip: Postgraduate Diploma; RANZOG: Royal Australian and New Zealand College of Obstetricians and Gynaecologists; TSA: Tonga Study Awards; UMELB: University of Melbourne; UPNG: University of Papua New Guinea; USP: University of South Pacific; USYD: University of Sydney; UTS: University of Technology Sydney; UWS: Western Sydney University; WHO: World Health Organization. Source: Training database, August 2021, Tonga Ministry of Health. Table 8. Formal training in overseas universities: graduated, ongoing with projected completion year, and new scholars (contd) 22 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Table 9. Formal training accessed locally Programme Scholarship Institution Mode No. of students Completion date Master of Medicine NZMTS Online 1 2023 Certificate of Emergency Medicine NZMTS ACEM Online 2 2022 Master in Family Medicine TSA FNU Online 2 2022 PG Dip in Family Medicine DFAT FNU Online 4 2021 Master of Health Service Management NZPS FNU Online 1 2022 PG Dip in Health Services Management POLHN (WHO) FNU Online 1 2021 PG Dip in Health Resource Management POLHN (WHO) FNU Online 1 2021 Bachelor in Public Health Dr Tapa FNU Online 1 2021 International Certificate in Radiology Radiology Across Borders UBC Online 1 2021 Bachelor of Oral Health NZMTS FNU Online 2 2026 SDGs Global Leader Program JICA Online 2 2023 Certificate of Perioperative Nursing SPC FNU Online 3 PG Certificate in Child Health Nursing NZMTS FNU 15 2022 Bachelor of Nursing 27 Private 2 NZMTS QSINAH On campus 29 2021 Graduate Certificate in Acute Care Nursing DFAT QSINAH On campus 20 2021 PG Dip in Medical Microbiology No fee Royal College of Pathologists of Australia Online 6 2021 PG Certificate in Field Epidemiology SPC FNU Online 20 2021 ACEM: Australasian College for Emergency Medicine; DFAT: Australian Department of Foreign Affairs and Trade; FNU: Fiji National University; JICA: Japan International Cooperation Agency; NZMTS: New Zealand Medical Treatment Scheme; NZPS: New Zealand Pacific Scholarships; PG Dip: Postgraduate Diploma; POLHN: Pacific Open Learning Health Network; QSINAH: Queen Salote Institute of Nursing and Allied Health; SDGs: Sustainable Development Goals; SPC: The Pacific Community; TSA: Tonga Study Awards; UBC: University of British Columbia; WHO: World Health Organization. Source: Training database, August 2021, Tonga Ministry of Health. 4.5 Funding for training Tonga is reliant on donor support to the training programme due to its limited financial capacity. The MOH funds only pre-service training of nurses at QSINAH and provides a national scholarship for overseas study. The data presented in Tables 8 and 9 cover both scholarship-sponsored and privately funded students enrolled in health training programmes. Scholarships are negotiated through the Scholarships Unit of the MET. Applicants are selected through a competitive application and interview process conducted by the MET (with the CEOH on the review panel), or the MOH advertises scholarships following negotiations with donors. 23 KINGDOM OF TONGA 4.6 Physical infrastructure QSINAH was relocated in 2012 to a new building on the Vaiola Hospital campus, funded by the Japan International Cooperation Agency (JICA). The nearby Old Nurses Home has been demolished and the land prepared for constructing isolation or research facilities. In the event of a pandemic or outbreak surge, the building will be used by the MOH as a staff quarantine facility, an additional hospital ward or an ICU extension. At other times it will be used as a simulation and research support facility for training. It will provide greater access to computers, a library with Internet access, new teaching and simulation equipment, air-conditioned classrooms and tutorial rooms, plus other facilities for staff and student use. As there is no live-in accommodation available for students on campus, they live with their families during the school year. 4.7 Technical capacity In 2021, QSINAH had a principal and 16 teaching staff (inclusive of two staff studying abroad) and had the intention to increase staffing by two per annum until 2025. Six staff held master’s degree qualifications. All teaching staff are required to have a recognized nursing degree and several years of work experience. An arrangement for lateral staff transfer of MOH staff to support teaching when courses run is in place, but it needs to be formalized. Students can access electronic resources through the Pacific Open Learning Health Network (POLHN) computer room, which is booked by QSINAH two days per week. The facility developments (as described in the section above) will greatly increase access to information. Otherwise, students rely on textbooks in the library and notes provided by teachers in class. As allied health training is also situated at Vaiola Hospital, the students have access to a range of technologies and equipment on which they can practise. 4.8 Accreditation mechanisms Approval for the nursing programmes to run is granted following review by the TNMNPB for matters of professionalism and is submitted to the TNQAB for its review of compliance with set standards of staffing and facilities, and for allocation to one of the TQF levels. QSINAH has been working with the Auckland University of Technology to bring the Diploma of Nursing competency-based programme up to internationally comparable standards. 24 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES 4.9 In-service and continuing professional education (CPE) CPE and in-service training are planned by individual departments within the hospital or health area in the community. QSINAH receives support from donors to provide in-service training opportunities to nursing staff. These are run on a programme basis (for example, HIV, adolescent health) and the school collaborates with various nursing sections and donor agencies. QSINAH has been supported by JICA to develop a mechanism for identifying the training needs of reproductive health nurses. In-service programmes are factored into the QSINAH budget each year, with support funding provided by donors. Individuals can also complete their own CPE activities through the WHO- supported POLHN. These courses are completed online. Medical laboratory technicians can also complete online courses with the Pacific Paramedical Training Centre, which is based in New Zealand. 4.10 Future developments The Tonga National University Bill 2021 was passed by Parliament in August 2021 for the establishment of the Tonga National University. The University will unite post-secondary educational institutions and include the transfer of QSINAH from the MOH to the University and the MET. The MET has named the University as a priority project, and a working group (which includes the Dean of QSINAH) has been established to begin setting up an interim administration and governance structure. This establishment of a national university has widespread support, including from the Minister for Health, and is likely to proceed quickly. The establishment of the University is intended to overcome the financial and social difficulties experienced by Tongan students studying abroad. The immediate implication for QSINAH staff is for all teaching staff to obtain the standard of qualifications required by the TNQAB. The convention is that teachers must hold a qualification at a higher level than the programmes they teach. The Tonga National University Bill 2021 was passed by Parliament in August 2021 for the establishment of the Tonga National University. 25 KINGDOM OF TONGA The information reported in this section is largely consistent with that of the 2014 HRH country profile. Matters and regulations pertaining to public servants are contained in the Public service policy 2010 (Tonga Public Service Commission, 2010) based on the Public Service Act of 2002 (Tonga Public Service Commission, 2002), and are essentially unchanged by subsequent amendments. 5.1 Recruitment All public service workers and students in government training institutions are recruited centrally through the PSC, which issues instructions for hiring and advertises employment conditions. Access to entry-level tertiary study programmes requires successful completion of the Pacific Senior Secondary Examination Form 6. Vacancies are advertised to the public for at least two weeks. If more than one applicant meets the minimum requirements, the interview panel will shortlist five applicants using a recruitment checklist and obtain professional references. The results of the interviews are reported to the CEOH, and the successful candidate is offered an appointment letter by the PSC. All new appointees are required to serve six months of probation before their employment is confirmed. Given that Tonga has no surplus of health workers, those who are trained in Tonga are automatically absorbed into the MOH upon graduation, as they are employed by the PSC upon enrolment. Privately funded students at QSINAH and external universities can apply for vacant positions and are generally successful in finding employment after graduation. Students who study abroad are bonded on donor scholarships, ensuring that they will return to Tonga after graduation for a period of service. Appointments and promotions are merit-based. 5.2 Deployment and distribution policies and mechanisms Staff turnover and stability The health workforce has increased in recent years, reflecting new appointments, student and graduate intakes, and decreased resignation, retirements and dismissals. The workforce was relatively stable during the period of restricted international travel due to the pandemic, but has become more mobile since international travel restrictions were withdrawn. All public service workers and students in government training institutions are recruited centrally through the PSC, which issues instructions for hiring and advertises employment conditions. 5. Human resources for health (HRH) utilization 26 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Attrition Loss of more highly qualified health workers remains a risk. Comparative remuneration levels with New Zealand, Australia and the United States of America leave Tonga perpetually vulnerable to the migration of skilled staff. As in other Pacific countries, young professionals are attracted to study and work abroad in well equipped facilities. The MOH has previously increased salary levels by significant percentages across all levels of staff. As in Fiji, the rate of migration is highest among young technicians, whose training is sufficient for migration, for accessing further training and to achieve entry-level positions abroad. Average number of hours worked per week per HRH category The standard number of working hours prescribed for all public service workers is 40 per week. Overtime hours are remunerated financially and are reported to have significant effects on the budget, leading to the many virements between staffing and operational budgets that confuse the system and reduce operations. No data were provided to allow analysis of the level of overtime as a proportion of total full-time employment, but it represents an area of possible savings and efficiencies. Absenteeism No collated data are centrally available on absenteeism. This type of information may be collected to monitor work performance at the facility level, but is not reported. Motivation to migrate Migration of skilled individuals is part of a broad and long-standing tradition of Pacific migration and is valued as a source of remittances to families and for connection with previously migrated family members. External migration of Tongan health workers is reflective of the global situation in which health professionals are actively pursuing their careers and are increasingly internationally mobile. This has become a feature of regionalism in many parts of the world. The MOH’s response must be to find motivations for people to stay, by making jobs more interesting, increasing learning opportunities and challenges, and improving access to the Internet and modern communications technology to support family and professional connectivity. Leave entitlements All public servants are covered by terms and conditions set out in the Public service policy 2010. This details a range of leave entitlements: annual leave (20 days); outpatient sick leave (15 days); inpatient sick leave (30 days); maternity leave (three months); paternity leave (five days); leave without pay (20 days); and casual leave (seven days). Annual leave is not accumulated from one year to the next and must be used within the calendar year. A relocation allowance is given to health workers deployed to the Niuas group of islands, but no other financial incentives are available to help retain health workers in rural areas. External migration of Tongan health workers is reflective of the global situation in which health professionals are actively pursuing their careers and are increasingly internationally mobile. 27 KINGDOM OF TONGA Allowances form part of a health worker’s remuneration. These are summarized in Table 10. Management structure The MOH manages HRH according to perceived need, which has produced a flexible system of deployment and accounting. Comments within the MOH’s annual reports suggest that centralized control of staff may not meet the needs of specific functions that require opportunities for learning by experience, such as in the Accident and Emergency Unit. The annual variations in staffing budgets between programmes and over years suggest frequent use of virements from operational budgets according to the availability of funds, rather than a strategic HRH plan. It is anticipated that significant donor inputs into the HRH information and management systems by the New Zealand Ministry of Foreign Affairs and Trade (MFAT) and the World Health Organization (WHO) in 2022 and beyond will significantly improve the management of HR in the MOH. Supervision mechanisms Appraisal systems for health workers were introduced in 2012, with the intention that all public servants should undergo a yearly staff assessment using the civil service assessment form. Promotions are competitive, with applicants required to undergo performance appraisals and to be assessed by an interview panel. All promotions need to be authorized by the Minister for Health and the Secretary of the PSC. Table 10. Allowances available to public servants Allowance Scope Overtime allowance Payable to all health workers except the chief executive officer or higher. Staff are paid time-and-a-half (1.5 hours’ pay per 1 hour worked) for overtime on weekdays, and double time (2 hours’ pay per 1 hour worked) on public holidays and weekends. Time in lieu Employees may choose to take time off in lieu of the overtime allowance, but the time off cannot be accumulated for more than one month. Duty allowance Payable to the holder of a post while they are performing the duties of that post. Acting allowance Payable to a health worker whose actual salary is less than the starting salary of the acting post. An employee on acting appointment is paid an allowance equivalent to the amount they would receive if promoted to the higher grade. Charge allowance Payable to a health worker who is asked to carry out temporarily duties that are beyond the scope of their post and who does not possess the necessary qualifications for the post. The employee is paid their normal salary plus 10% of the minimum salary allowed for the post temporarily held. The rate is determined by the chief executive officer. Location allowance Payable to health workers posted in the following areas: ‘Atata and ‘Eueiki in Tongatapu; and outer islands of Vava’u, Ha’apai, Niuatoputapu and Niuafo’ou. The allowance is determined by the PSC and payable as part of an annual salary. Scarcity allowance Defined as “a set of knowledge and experience that are absolutely scarce with no immediate or medium-term replacement options and would have critical and/or dire immediate consequence on the key mandate of an agency and of grave national consequence”. Source: Tonga Public Service Commission, 2010. 28 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES The PSC proposed that the definition of “scarcity allowance” be precisely targeted and confined to a set of closed groups using the “absolute scarcity” criteria. A scarcity allowance of 25% of current salary was approved in 2018 by the CEOH for nine applicants who met the criteria for absolute scarcity (two internal medicine specialists and one of each of the following specialists: surgeon, obstetrician, paediatrician, psychiatrist, radiologist, ENT specialist, anaesthetist). Career pathways and job descriptions The centralized health system structure and the lines of authority within it may have advantages of policy clarity and management, but staff members’ ability to identify career pathways within it may be constrained, perhaps resulting in some people not advancing their careers. Compounded by job descriptions that are not updated to new roles and developments, this can lead to a confusion of relative responsibilities and a limited ability to control overall facility performance. The opportunity to develop leadership skills at the facility level will provide career development opportunities and a greater control over operations. Physical environment and access to essential equipment, supplies and resources Health facilities are gradually being improved across the country. The largest improvement project has been the redevelopment of the Vaiola Hospital complex and a rebuilt QSINAH, completed in 2012 and funded by JICA. Other improvements include the Likamonu Extended Health Centre facility and the new 10-bed hospital unit at Hu‘atolitoli Prison, opened in 2019. 29 KINGDOM OF TONGA 5.3 Unemployment Very few health workers are unemployed in Tonga. Those who are not formally employed would most likely be engaged in other family and social matters, or in private businesses. Vacant posts are shown in Table 11. Table 11. Vacant posts by division in June 2021 (Niuafo‘ou and Niuatoputapu combined) Workforce category Tongatapu Vava’u Ha’apai ’Eua Niuas Specialist medical practitioner 3 Generalist medical practitioner 3 1 Advanced practice nurse 3 2 Nurse 6 1 1 Health officer 2 Allied health professional/worker 1 Ancillary ward worker 0 2 2 1 Dental workforce 3 Pharmacy worker 2 Environmental health worker 1 2 Health administrator 3 Health information worker 2 Health promotion worker 2 Information and communication technology worker (computer operator) 1 Medical imaging worker 3 Medical laboratory worker 4 Domestic services worker 6 4 1 3 Maintenance 0 1 TOTAL 45 12 4 1 4 Source: Tonga Ministry of Health, 2021. At the time of the data collection and analysis there were 66 vacancies, 45 of which (68%) were in Tongatapu, and 32% were located outside of Tongatapu. Most of these vacancies were for less skilled staff (ancillary ward workers, domestic services workers), with a small number being for doctors and nurses. Vacancies represent less than 1% of the workforce, which may be in part due to travel restrictions during the COVID-19 pandemic, raising the potential for higher rates of migration once travel restrictions were lifted. 5.4 Employment of health workers in the private sector There are no private hospitals in Tonga. A small number of health professionals are engaged in private practice (see section 3.4). 30 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES 6.1 HRH expenditure The MOH’s annual recurrent budget increased by more than 30% in the financial year 2019/2020 to T$ 48 229 400 in 2020/2021 and decreased by 8% to T$ 44 031 700 in 2021/2022. These variations are attributable to variations in whole-of-government annual allocations, changes in the level of donor support to the development budget, and responses to the national health situation, including the COVID-19 pandemic. Similarly, the relative allocations between staffing and operational costs have varied within the MOH’s recurrent budget. Staffing costs as a proportion of recurrent budget were 76.8% (T$ 27 580 956) in 2019/2020, 60.5% (T$ 29 180 300) of a larger budget in 2020/2021, rising to 68.2% (T$ 30 022 600) of the budget in 2021/2022. Despite variations as a proportion of budget, the amount allocated to staff costs has steadily increased. Further variation occurred in the same period among the relative proportions of total MOH staff costs among the five main programmes (Leadership and Policy, Preventive, Curative, Dental, and Nursing Services), indicative of an increase in the curative programme. These variations within the MOH reflect the accounting system’s capacity for virement between parts of its main accounts, made in response to changing circumstances, including the full range of human resource issues from recruitment, study, travel, promotion, allowances and deployment. Variations are also due to returning graduates and unanticipated overtime allowances. 6.2 Health workers’ remuneration Health workers are paid their salaries and any allowances electronically. There are three types of health workers within the MOH: permanent, contracted and daily paid labourers/casuals. Health professionals are generally paid better than their public service counterparts. This imbalance exists because health professional salaries are now often a combination of basic salary and a duty or other form of allowance. Job performance is linked to remuneration, with performance reviews used to assess or reassess grading of a post. Salary scales are reviewed formally at least once every three years to consider salary variations and are adjusted periodically in response to cost-of-living adjustments. Health workers may receive a lump 6. Financing HRH 31 KINGDOM OF TONGA sum in lieu of a salary if they are at the top of their respective salary scales for outstanding performance. Alternatively, employees may receive a salary increase after attaining a substantive, high-level, relevant qualification from a recognized tertiary institution. Average annual salaries in 2021 are provided in Table 12, along with the minimum and maximum salaries within each workforce category. The salary range for many workforce categories is significant. This can partly be explained by the way the categories have been constructed from both professional and non-professional workers. For instance, the Medical Laboratory Worker category consists of professional-level medical scientists/technologists (average salary around T$ 40 000) to non-professional technicians (average salary around T$ 18 000). However, even in more homogeneous categories such as Generalist Medical Practitioners, the salary ranges from T$ 23 000 to T$ 60 000, or for Advanced Practice Nurses from T$ 12 500 to T$ 40 000. Table 12. Average income levels by workforce category in 2021 Workforce category Annual salary (in T$) Minimum annual salary Average annual salary Maximum annual salary Specialist medical practitioner 32 851 52 349.38 63 000 Health administrator – corporate 30 240 34 771.71 44 330 Generalist medical practitioner 23 520* 33 463.55 59 787 Advanced nurse practitioner 12 557 30 188.35 40 320 Midwife 14 611.5 27 537.81 36 108 Allied health professional/worker 11 760 25 144.71 36 624 Health officer 22 409 24 864.62 30 187 Hospital administrator 12 514 24 189.60 79 258 Dental workforce 7 560 23 351.31 58 916 Health administrator – accounts/finance 8 544 22 591.48 35 280 Nurse 11 171.5 22 155.20 55 527 Pharmacy worker 8 400 20 667.23 29 230 Health administrator – planning 19 490 20 342.80 23 238 Medical imaging worker 11 760 20 142.06 35 280 Information and communication technology worker (computer operator) 9 803 20 107.25 30 240 Medical laboratory worker 6 720 18 682.45 43 039 Health administrator – procurement 11 760 17 731.14 26 880 Health administrator – human resources 7 560 16 842.86 27 465 Health promotion worker 8 400 15 675.67 21 461 Environmental health worker 6 720 13 684.47 32 535 Health information worker 6 923 10 578.65 22 680 Clerk 7 788 10 577.17 15 985 Maintenance worker 6 720 9 826.96 13 731 Student nurse 6 720 9 362.69 15 120 Ancillary ward worker 6 720 8 116.18 9 316 Domestic service worker 6 720 7 709.56 12 434 Source: Tonga Ministry of Health, 2021. * A lower minimum salary than this was identified on the payroll, but this seems to be an outlier. 32 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES 7.1 HRH policies and plans MOH staff are all employed by the PSC, as established by the Public Service Act 2002, Subsection 12, wherein: “All appointments, promotions, disciplinary matters and terminations in respect of the Public Service shall be made in accordance with this Act” (Tonga Public Service Commission, 2002). Subsequent amendments detail the accountabilities and functions of chief executive officers, notice of a code of conduct and the establishment of a public service tribunal (2010). Employees are subject to the procedural regulations of the PSC Policy Instructions 2010. Many HRH planning and advisory inputs have been conducted since Dr Dewdney’s scoping of the task in the Draft national health workforce plan 1998–2020, with many conducted on a professional discipline-specific basis. Following the publication of the Human resources for health country profiles: Tonga for 2014, WHO supported the preparation of a draft national health workforce strategic plan 2014–2020, which identified human resource issues for the MOH to consider in forward planning. The National Health Strategic Plan (NHSP) 2015–2020 Key Result Area 2 included strategies of relevance to HRH planning: notably 2.1.11, “To fully implement the computerized Human Resource Management Information System (HRMIS) to assist workforce planning and resource allocation”. This task is yet to be achieved (see section 7.4). The process of informing policy is effective, as individual disciplines identify specific staffing and policy needs in relation to their practice, and Vaiola Hospital’s departments identify staffing issues and forecast requirements in MOH annual reports. The MOH is preparing the next NHSP and has the opportunity to integrate HRH planning into it as an important component. The nursing profession and QSINAH submitted the Tonga Nursing Strategic Direction 2013–2023 and QSINAH has recently revised its Action Plan for 2019– 2023 in preparation for transfer to the proposed National University and to retain access to MOH clinical staff by lateral transfer during courses. Many HRH planning and advisory inputs have been conducted since Dr Dewdney’s scoping of the task in the draft National Health Workforce Plan with many conducted on a professional discipline-specific basis. 7. Governance of HRH 33 KINGDOM OF TONGA 7.2 Policy development, planning and management PSC policy governs all health workers. HRH is managed by the MOH’s Corporate Division and the Human Resource Workforce Development Section Head with five senior administrator positions (three of which are vacant) and with 13 positions for clerical, computer and filing support staff. The Human Resource Development Committee is the high-level decision-making forum for HRH policy development, planning and management. The Committee meets monthly, is chaired by the CEOH, and membership comprises representatives from MOH divisions, with the Deputy Director for Human Resource & Workforce Development serving as the member-secretary. Discipline- and departmental-specific work units manage the staff rostered to them through the divisions: Clinical Services, Corporate Services, Public Health and Dental Services. Nurses are managed through the Clinical Services and Public Health divisions to which they are assigned, while the Nursing Leadership Division oversees regulations, standards and policy matters related to nursing governance. The structural division between nursing sections of the Public Health Division will require a policy and practice review to determine whether health services to the general community with common health concerns are compromised by nursing role divisions at the facility level. 7.3 Professional regulation Regulation and registration to practise are managed by the Medical and Dental Practice Board; the TNMNPB; and the Pharmacy Board. The health professionals required to be registered to practise include doctors, health officers, dentists, dental technicians, nurses, pharmacists and pharmacy assistants. All other paramedical health workers are unregistered. Medical and dental practitioners Medical practitioners, health officers, dentists and dental technicians are required to be registered with the Medical and Dental Practice Board, established by the revised Medical and Dental Practice Act 2016. The Act empowers the Board to register practitioners, deal with disciplinary matters, set standards for education and training, maintain standards of practice and conduct, remove persons from the register and advise the Minister on related matters. Practitioners who have ceased to be registered for five consecutive years may be declined registration until they have met the examination standards required by the Board. Provisional registration can be awarded for a period of two years at the discretion of the Board. Temporary registration for a period of three months is 34 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES available for practitioners qualified in other jurisdictions. This feature permits the clinical work of visiting medical specialists. Annual registration fees must be paid by 31 October each year. All newly graduated doctors undergo an 18-month internship programme in Tonga under the auspices of the Internship Supervisory Committee chaired and coordinated by the Medical Superintendent of Vaiola Hospital. Dental graduates undergo a 12-month internship programme. Nursing personnel The TNMNPB is enacted under the Nurses Act (Amendment) 2014. The Act outlines the Board’s responsibilities for setting education standards, training nurses and midwives, maintaining practice standards, and reviewing disciplinary matters consistent with the Public Services Policy 2010. Annual registration fees must be paid by 31 October each year. Nurses or midwives who have not practised for five or more continuous years (either in Tonga or elsewhere) must pass a Board examination to be re-registered. New graduates of the pre-service Diploma programme must pass the registration examination to receive a licence to practise. Foreign nurses are allowed to practise in Tonga only if they have practised overseas in the previous five years. The potential introduction of a Diploma in Mental Health Nursing will initiate a review of and potential redrafting of registration requirements. Pharmaceutical personnel Pharmacists and pharmacy assistants must be registered with the Pharmacy Board, which is enacted under the Pharmacy Act 2001. The Principal Pharmacist is the Chair of the Board. Similar to the other health professions, the Board is responsible for setting education and training standards, maintaining practice standards and reviewing disciplinary matters. Annual registration fees must be paid by 31 October each year. Pharmacists and pharmacy assistants who have not practised for five or more continuous years (either in Tonga or elsewhere) must pass an examination to be registered again. 7.4 HRH information systems The MOH is yet to use a modern HR management system. Currently, information on all personnel is stored on an Excel spreadsheet that is updated as required by clerical staff entering new information. The spreadsheet covers only public servants and includes information such as age, sex, post and qualifications. A key problem with this method is that there is no link to payroll records, resulting in different calculations of staff numbers and internal disparities. The capacity to generate up-to-date information quickly to track the real costs of HRH by service type is severely limited. 35 KINGDOM OF TONGA The MOH and MFAT endorsed and signed the Tonga Health Workforce Activity to commence in 2023, with resources and expertise to be allocated for supporting the development of an HRHMIS with links to payroll and other features. The need for such a system has been evident for many years. Those associated with the direction of this proposed health information system are keen to ensure that the platform set up is fit for purpose and simple enough to be easily sustained in Tonga. 7.5 Health workforce requirements As the population is expected to be relatively stable over the next decade and staffing levels are relatively high, HRH activities will be best directed to addressing the national priorities of NCD prevention and control. This should include improving mental health services, improving skills levels by multi-skilling advanced nurses, by continued review and, where appropriate, strengthening the medical specialist workforce, reviewing training programmes and improving the quality of services. To support staff retention and professional growth, the active use of communications technology to better integrate the workforce and provide learning opportunities will address the needs of staff who may find their deployment isolating. This HRH country profile is primarily focused on health workforce supply. Multiple factors need to be examined when planning for and projecting workforce demand, including: • understanding the epidemiology and the direction of future health services (in an NHSP); • confirming workforce standards and requirements through workload studies; • determining efficient deployment by role clarification and location; • identifying staffing gaps; • assessing and responding to training needs; and • costing future salary projections. An immense amount of groundwork has already been largely completed to allow service needs-based workforce projections. The PEHS details five levels of health service delivery, with the minimum staffing level for each type of health facility specified. The MOH has initiated the implementation of WHO’s Workload Indicators of Staffing Need methodology to: • optimize the available health workforce by reviewing the deployment of staff based on the actual workload; and • determine the health workforce requirements based on the service functions outlined in the PEHS. As the population is expected to be relatively stable over the next decade and staffing levels are relatively high, HRH activities will be best directed to addressing the national priorities of NCD prevention and control. 36 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES If assessed by health worker-to-population ratios, the HRH situation in Tonga compares well to its regional neighbours. Two constant realities are that Tonga will remain subject to the migration of skilled technical and professional staff, and that Tonga is unable to compete with salary levels and professional opportunities in its larger neighbours, Australia, New Zealand and the United States. Pressure on national revenues and national debt repayments place a downward pressure on the potential for salary increases. The preparation of the next NHSP provides an opportunity to integrate HRH planning within it. The extent to which Tonga employs medical specialists depends on demand and the ability to provide attractive remuneration and conditions. Currently the cost of accessing overseas services is subsidized by New Zealand, while DFAT subsidizes specialist salaries in Tonga. These costs need to be factored into future national budgets and assessed against the cost of overseas medical transfers. Given the recent increases in the levels of staffing across the system, the next few years present an opportunity to investigate options to restructure the workforce to obtain greater cost efficiency and to redirect savings to attract and retain specialist health workers. In this situation, Tonga also needs to address conditions of employment factors that contribute to the loss of both generalist and specialist staff, and to enhance its systems of communication with and among staff. The numbers of generalist health staff and technical support staff appear to be at the best levels for many years, and the workforce appears stable (though with some gaps to be filled, particularly in mental health). The management focus for HRH could therefore shift to systems changes that maximize their utility and coordinate their activities. The centralized yet divided MOH structure, along with the streaming of advanced nursing education, has produced unforeseen role divisions and service “silos” at the facility level, where ideally tasks would be allocated on the basis of local needs and shared as a team. As a brake on further entrenching nursing staff role delineations, there are opportunities to identify common functions in job descriptions that lead towards collaboration. For example, three of the sections in the Public Health Division (Community Health, NCD nurses and Reproductive Health nurses) share the objective of providing health services to the general community. The coordination of HRH at the facility level would be strengthened by the delegation of leadership authority to a senior staff member who spans all of the facility’s cadre. Exercising such authority when staff can refer back to their central section head would be difficult and require policy support for local-level coordination from the Ministry executive. The introduction of a facility leadership and management programme could identify persons who, having completed the programme, would receive delegations from the Chief Medical Officer for Public Health to coordinate public health services at the local level. The extent to which Tonga employs medical specialists depends on demand and the ability to provide attractive remuneration and conditions. 8. Concluding remarks 37 KINGDOM OF TONGA Bibliography Global Health Observatory [online database] (2023). Global health estimates: Leading causes of death. Geneva: World Health Organization (https://www.who. int/data/gho/data/themes/mortality-and-global-health-estimates/ghe-leading- causes-of-death, accessed 20 June 2023). Tonga Medical and Dental Board (2016). Medical and Dental Practice Act. Nuku’alofa: Kingdom of Tonga (https://tonga.tradeportal.org/media/ MedicalandDentalPracticeAct_2.pdf, accessed 20 June 2023). Tonga Ministry of Finance (2021). Government of Tonga Budget Statement for year ending 30th June 2021. Nuku’alofa: Kingdom of Tonga (http://finance. gov.to/sites/default/files/2020-09/Budget%20Statement%202020-2021_0.pdf, accessed 20 June 2023). Tonga Ministry of Finance (2022). 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Geneva: World Health Organization (https:// apps.who.int/iris/bitstream/handle/10665/250368/9789241511131-eng.pdf, accessed 20 June 2023). World Health Organization Liaison Office for Tonga and Tonga Ministry of Health (2017). Tonga NCD Risk Factors Steps Report. Suva: World Health Organization (http://www.health.gov.to/drupal/sites/default/files//public_docs/Tonga%20 STEPS%202017.pdf, accessed 20 June 2023). 39 KINGDOM OF TONGA Annexes Annex A. Ministry of Health organizational chart MINISTER OF HEALTH CHIEF EXECUTIVE OFFICER FOR HEALTH Minister of Health National Health Development Commitee Technical Sub-Committee (NHDC-TSC) Divisional/Operational Committees CMO FOR PRINCE NGU HOSPITAL DENTALPUBLIC HEALTHCLINICAL SERVICES CHIEF MEDICAL OFFICER CHIEF SUPERINTENDENT CMO FOR PUBLIC HEALTH DIRECTOR OF CORPORATE SERVICES CHIEF DENTAL OFFICER CHIEF NURSING OFFICER Outer Islands Communicable Disease Budgeting and Finance (incl. NHA) Curative Nursing Policy, Leadership & Management Community Health Planning, Research and Reporting Preventative HPU & NCD Facilities & Transport Management Inpatient Eye Care Medical Referral ENT Hospital Support Quality Assurance Environmental Health HR & Workforce Development Public Health Outreach International Standard Nursing EducationReproductive Health ICT and Data Management Dental Education & Training Administration Quality Improvement & Customer Liaison Procurement and Contract Management Outpatients Theatre, Anaesthesia & ICU Diagnostic Services Visiting Specialists Allied Health Leadership of Medical & Dental Board NURSING CORPORATE SERVICES CMO FOR NIU’UI HOSPITAL SMO FOR NIU’EIKI HOSPITAL Nursing, Midwifery and Nurse Practitioner Board Note: The organizational structure is currently under review and is not yet formalized – see the following page for the proposed structure. Source: Tonga Ministry of Health annual report 2018–2019. 40 HUMAN RESOURCES FOR HEALTH COUNTRY PROFILES Annex B. Proposed organizational structure MINISTER OF HEALTH CHIEF EXECUTIVE OFFICER FOR HEALTH Medical and Dental BoardNational Health Development Commitee DENTALPUBLIC HEALTHCLINICAL SERVICES CHIEF MEDICAL OFFICER MEDICAL SUPERINTENDENT CMO FOR PUBLIC HEALTH DIRECTOR OF CORPORATE SERVICES CHIEF DENTAL OFFICER CHIEF NURSING OFFICER Outer Islands Communicable Disease Budgeting and Finance (incl. NHA) Curative Nursing Policy, Leadership & Management Community Health Planning, Research and Reporting Preventative HPU & NCD Facilities & Transport Management Inpatient Eye Care Medical Referral ENT Hospital Support Quality Assurance Environmental Health HR & Workforce Development Public Health Outreach International Standard Nursing Education Reproductive Health ICT and Data Management Dental Education & Training Administration Quality Improvement & Customer Liaison Procurement and Contract Management Outpatients Theatre, Anaesthesia & ICU Diagnostic Services Visiting Specialists Allied Health Leadership of Medical & Dental Board NURSING CORPORATE SERVICES Nursing, Midwifery and Nurse Practitioner Board CMO: Chief Medical Officer; ICU: Intensive Care Unit; ENT: Ear, Nose and Throat; HPU & NCD: Health Promotion Unit and Noncommunicable Disease; NHA: National Health Accounts; HR: Human Resources; ICT: Information and Communication Technology. Source: Tonga Ministry of Health, Corporate Plan 2021/2022–2023/2024).