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hrh issues and challenges
HUMAN
RESOURCES
FOR HEALTH
ISSUES AND CHALLENGES IN
13 PACIFIC ISLANDS COUNTRIES
2011
Jennifer Doyle, Augustine Asante and Graham Roberts
www.hrhhub.unsw.edu.au

Acknowledgements
The authors would like to acknowledge
Temarama Anguna (Cook Islands), Ben Jesse
(Federated States of Micronesia), Oripa
Niumataiwalu (Fiji), Veronica Taake Binoka
(Kiribati), Marissa Cook (Nauru), Bob Tunifo
Talagi (Niue), Merlyn Basilius (Palau), Russell
Edwards (Republic of the Marshall Islands),
Pelenatete Stowers (Samoa), Coldrine Kolae
(Solomon Islands), Kele Lui (Tokelau), Tu’Akoi
Ahio (Tonga), Markson Tetaun (Vanuatu).
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Suggested citation:
Doyle, J et al. 2011, Human resources for health (HRH) issues and
challenges in 13 Pacific Islands countries, 2011, Human Resources
for Health Knowledge Hub, Sydney, Australia.
National Library of Australia Cataloguing-in-Publication entry
Doyle, Jennifer
Human resources for health (HRH) issues and challenges in 13
Pacific Islands countries, 2011 / Jennifer Doyle, Augustine Asante
and Graham Roberts.
9780733430749 (pbk.)
Public health personnel—workforce issues—Pacific Island countries
Public health personnel—education and training—Pacific Island countries
Public health personnel—working conditions—Pacific Island countries
Public health personnel—migration—Pacific Island countries
Asante , Augustine.
Roberts, Graham.
University of New South Wales. Human Resources for Health
Knowledge Hub.
362.1099
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Contents
2 Acronyms
3 Executive summary
3 Introduction
4 Section 1. Overview of participating Pacific Island countries
7 Section 2. Methodology
9 Section 3. Perceived HRH issues and challenges
11 Section 4. Needs and priorities
12 Section 5. Discussion
14 Section 6. Policy implications
16 Conclusion
17 References
19 Appendix Table 1. Selected infant mortality rates (IMR), under age 5 mortality rates
and maternal mortality rates (MMR)
22 Appendix Table 2. HRH issues and challenges by country
LIST OF FIGURES
7 Figure 1. HRH roadmap
List of Tables
5 Table 1. Selected demographic and socio-economic characteristics
6 Table 2. Selected expenditure and health indicators
9 Table 3. Summary of HRH issues and challenges
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
1

Acronyms
AusAID
BNPL
CHIPS
DFaT
FSM
GDP
Govt.
HIV
HRH
IMR
IOM
JICA
MBBS
MDG
MMR
MoH
NZAID
OECD
PC
PHRHA
PICs
PNG
POLHN
PRISM
RMI
SPC
THE
UN
UNICEF
UNFPA
USD
WB
WHO
WPRO
Australian Agency for International Development
Basic Needs Poverty Line
Country health information profiles
Department of Foreign Affairs and Trade, Canberra
Federated States of Micronesia
gross domestic product
Government
human immunodeficiency virus
human resources for health
infant mortality rate
International Organization for Migration
Japan International Cooperation Agency
Bachelor of Medicine/Bachelor of Surgery
Millenium Development Goal
maternal mortality rate
Ministry of Health
New Zealand Agency for International Development
Organisation for Economic Cooperation and Development
per capita
Pacific Human Resources for Health Alliance
Pacific Island countries
Papua New Guinea
Pacific Open Learning Health Network
Pacific Regional Information System
Republic of the Marshall Islands
South Pacific Commission, Noumea
total health expenditure
United Nations
United Nations Children’s Fund
United Nations Population Fund
United States dollars
World Bank
World Health Organization
Western Pacific Regional Office of the World Health Organization
A note about the use of acronyms in this publication
Acronyms are used in both the singular and the plural, e.g. MDG (singular) and MDGs (plural).
Acronyms are also used throughout the references and citations to shorten some organisations with long names.
2
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

EXECUTIVE SUMMARY
INTRODUCTION
Background
In February of 2011 the Pacific Human Resources for Health
Alliance (PHRHA) met in Nadi, Fiji, where representatives
from 13 Pacific Island countries (PICs) discussed current
issues and challenges in human resources for health (HRH),
and identified needs and priorities to address them.
Focussing on participants’ presentations, this paper
documents their perspectives and understandings and
presents policy recommendations arising from discussions.
In addition we present selected country comparative
demographic, socio-economic, health expenditure and
health status indicators to characterise the variable health
service contexts among the participating countries.
Methods
Contributions in the form of PowerPoint presentations from
each of the participating countries were structured according
to pre-arranged format and have been tabulated to identify
common themes. Country comparative indicators have been
compiled from source documents.
Results
Five challenges emerged from the presentations and
discussions:
1. health workforce issues (skills shortages, retention,
recruitment and workforce ageing)
2. the lack of effective HRH policy, management and
information systems;
3. education and training for HRH production;
4. public sector working conditions, and
5. migration of Pacific health personnel, both internally
and internationally.
Participants agreed that education and training, and policy
and management issues, should be given priority. Essential
elements for addressing these needs were seen as national
workforce planning, financial support and technical assistance
from donor countries and other stakeholders. The fulfilment
of needs was also seen to require political commitment and
strong leadership of Ministries of Health (MoHs) capable of
advocating for support from other key stakeholders.
Conclusions
Policy implications emerged for action at three levels:
national governments, regional training institutions, and
donor organisations.
The roles of the PHRHA 1 are to help identify and address
HRH challenges experienced by PICs, to assist in the
implementation of strategic policy and planning, and more
generally, to facilitate the strengthening of national HRH
capacities within the Pacific region. Its supportive activities
include the organisation of forums to facilitate discussion of
HRH issues and concerns amongst stakeholders. This paper
presents the results of one such meeting.
Representatives from 13 PICs (Cook Islands, Federated
States of Micronesia (FSM), Fiji, Kiribati, Nauru, Niue, Palau,
Republic of the Marshall Islands (RMI), Samoa, Solomon
Islands, Tokelau, Tonga and Vanuatu) came together at a
PHRHA meeting held in Fiji in February 2011 2 to present
what they perceived to be the key HRH challenges currently
being faced within their respective health sectors.
This paper considers current HRH issues within PICs from
the perspectives of people who manage HRH within their
country health ministry. The aim of this paper is to document
and highlight their key areas of common concern expressed
at the forum.
Section 1 presents selected key demographic and socioeconomic
indicators for each country, Section 2 focuses on
the methods used for participants to prepare for the meeting
and the methods we have used to identify and synthesise
the themes emerging from the presentations, Section 3
describes issues currently being experienced within each
country, Section 4 focuses on perceived needs and priorities,
Section 5 presents discussions of the key themes emerging from
participants’ contributions and Section 6 presents the policy
implications arising.
1
Membership of PHRHA includes all PICs, key development partners,
representatives of health training institutions, professional associations,
Pacific regional organisations, and WHO. The PHRHA Secretariat is
currently housed at the WHO sub-regional office in Suva, Fiji.
2
The meeting, Draft Framework for Action on HRH 2011-2015: Country
Situation on Human Resources for Health (HRH), was held in Nadi, Fiji,
February, 2011.
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
3

SECTION 1. OVERVIEW OF PARTICIPATING
PACIFIC ISLAND COUNTRIES
Table 1 presents key demographic and socioeconomic
indicators for each of the 13 participating PICs. Given the
lack of reliable data for many of the countries, comparisons
such as these must rely on relatively basic and traditional
indicators such as population, urban/rural proportions and
gross domestic product per capita (columns 1, 2 and 3).
The final column (column 4) presents the percentage of
each population estimated to be living below the Basic
Needs Poverty Line (BNPL). This measure provides a broad
comparative indication of the proportion of the population
who are unable to fulfil minimum dietary needs and do not
have enough income for basic non-food needs such as health
care, housing, education, transport, and community and
kinship responsibilities and obligations (AusAID 2009).
Given that the notion of basic needs is relative, with
definitions varying from country to country, it should be
treated with some caution. However, the BNPL is a useful
descriptive measure that serves the purpose here of providing
a contextual indication of the relative experience of poverty
among peoples of the participating PICs.
Although the populations of most PICs are relatively small,
there is some variation across the region. Niue, Tokelau,
Nauru, Palau and RMI qualify as ‘micro-states’ (defined
as populations below 50,000 (Docquier & Schiff 2009) 3
and represent just 3.7% of the total population of the 13
countries, while Fiji and the Solomon Islands combined
represent 60%. The second column shows that Tokelau,
Solomon Islands, Samoa, FSM, Tonga and Vanuatu are the
least urbanised with a quarter or less of their populations
living in urban areas. The most urbanised of the developing
countries are Nauru, Palau, Cook Islands and RMI.
Column 3 indicates GDP per capita for each country. The
lowest producing countries among the 13 are Solomon
Islands, Kiribati, Nauru and FSM, while the highest are Cook
Islands, Palau and Niue. At well over $14,000 per capita
the Cook Islands is the highest ranking, due in part to an
extensive reform process begun in the mid-1990s (Cook
Islands Government Online, 2011).
per capita are presented in columns 1 and 2, with proportions
of government spending on health and the contribution of
individuals (out-of-pocket expenditure) presented in columns
3 and 4. Column 1 shows that Fiji (3.8%) has the lowest
health expenditure as a percentage of GDP. Niue has the
highest health expenditure as a percentage of GDP at almost
18%, and has the highest per capita health expenditure
(column 2) at $1,408. Column 4 shows the contribution that
out-of-pocket expenditure makes to THE, with Tonga as the
highest at almost 28%.
Columns 5 to 8 present selected health indicators for each
country; again our purpose being to illustrate the differing
experiences of participating PICs. Life expectancy varies
considerably, ranging from a low of 53 for men and 58 for
women in Nauru, to 72 and 74 years in Samoa. The under-5
mortality rate per 1000 live births (column 6) ranges from 7.1
in Cook Islands to 48 in Kiribati.
Maternal mortality rates (column 7) also vary considerably,
although caution is required when interpreting maternal
mortality rates as a small number of deaths in any particular
year can significantly affect the annual rate in small
populations. Samoa has the lowest rate at 3.0 per 100,000
live births, followed by Fiji at 27.5. Palau has the highest rate
at 366.3, followed by RMI and Nauru at 324.15 and 300.0
respectively.
Column 8 presents the prevalence of diabetes among the
13 participant countries. Most noteworthy is that Nauru has
the highest diabetes prevalence rate at almost 31%.
(While our purpose here has been to make country
comparisons to demonstrate selected indicator variance
across the participating PICs, we also show (in Appendix
Table 1) that infant mortality rates, under-5 mortality rates
and maternal mortality rates from a variety of sources show
little consistency regarding the year to which they refer, and
provide few explanations of how the estimates have been
derived and adjusted).
Niue and Vanuatu have the smallest proportions of people
living in poverty, while Kiribati, Fiji, FSM and the Cook Islands
have the largest proportions within the 13 countries.
Table 2 shows health expenditures for each country, our
purpose being to illustrate that PICs have significantly
different levels of commitment to health expenditure. Total
health expenditure (THE) as a percentage of GDP and THE
3
Elsewhere a micro-state has been defined as a country with a population
under one million (Firth 2005); in which case all Pacific Island countries
except PNG could be described as micro-states.
4
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

TABLE 1: SELECTED DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS
Population 4 Urban Population 5
(%)
GDP 6
(USD pc)
Basic Needs Poverty Line 7
(% below)
Cook Islands 13,300 8
(2009)
72
(2006)
$14,322
(2008)
28.4
(2006) (p)
FSM 110,000
(2010)
22
(2010)
$2,183
(2007)
29.9
(2005) h
Fiji 890,000
(2010)
51
(2007)
$3,715
(2011 est)
34.3
(2003) h (p)
Kiribati 100,000
(2010)
44
(2005)
$1,536
(2011 est)
50.0
(1996)
Nauru 9,771
(2009)
100
(2006)
$2,042
(2007)
n/a
Niue 1,514
(2009)
36
(2006)
$8,216
(2006)
13.0
(2004)
Palau 20,397
(2009)
77
(2005)
$8,911
(2008)
24.9
(2006) (p)
RMI 54,065
(2009)
65
(1999)
$3,130
(2008)
20.0
(1999)
Samoa 182,000
(2010)
21
(2006)
$3,293
(2002)
20.4
(2002) h
Solomon Islands 531,000
(2010)
16
(1999)
$1,296
(2011 est)
22.7
(2006) (p)
Tokelau 1,537 9
(2001)
0
(2006)
n/a 10
n/a
Tonga 103,000
(2010)
23
(2009)
$2,983
(2011 est)
22.3
(2002)
Vanuatu 247,000
(2010)
24
(2009)
$2,955
(2011 est)
15.9
(2006) i (p)
4
Source: DFaT country fact sheets unless otherwise indicated. URL: http://www.dfat.gov.au/geo/index.html Downloaded 22 March 2011.
5
Source: Secretariat of Pacific Community, PRISM Phase 1 Release. http://www.spc.int/PRISM/urbanrural-growth-a-household-size Downloaded
11 April 2011.
6
Source: DFAT country fact sheets. URL: http://www.dfat.gov.au/geo/index.html Downloaded 22 March 2011.
7
Source: AusAID (2009) Tracking Development and Governance in the Pacific, Annex 2, Table 2, p. 63. (p) = provisional; h indicates an increased
percentage from previous estimate; i indicates decrease in percentage from previous estimate.
8
More recently the Cook Islands Statistics Office has estimated the resident population for the September quarter 2010 to be 11,400. URL: http://www.
stats.gov.ck/CurReleases/popnestVital.htm Downloaded 17 March 2011.
9
Source: SPC Population characteristics. Info submitted by Tokelau Statistics Office. URL: http://www.spc.int/prism/country/tk/stats/Social/Population/
age_sex_.htm Downloaded 22 March 2011.
10
Latest GDP is $A478 estimated in 1980 Source: Government of Tokelau website URL: http://www.tokelau.org.nz/Tokelau+Government/Economy.html
Downloaded 7 April 2011.
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
5

TABLE 2: SELECTED EXPENDITURE AND HEALTH INDICATORS 11
Total health
expenditure (THE)
Govt health
expenditure
Out-of-pocket
expenditure
Life expectancy Under-5 MR Maternal MR
Diabetes
prevalence 12
(% of GDP) (USD pc) (% of THE) (% of THE) (male/female) (per 1000 live births) (per 100,000 live births)
1 2 3 4 5 6 7 8
Cook Islands 4.30
(2008p)
457.75
(2008)
91.50
(2008p)
7.69
(2008p)
70/73
(2009 est)
7.10
(2009)
–
5.7
FSM 13.60
(2008p)
304.00
(2008p)
97.90
(2008p)
4.20
(2008p)
68/69
(2005-10 est)
39.00
(2009)
–
5.3
Fiji 3.80
(2008p)
162.45
(2008p)
68.40
(2008p)
24.77
(2008p)
68/72
(2007)
23.60
(2008)
27.50
(2008)
9.1
Kiribati 15.00
(2008)
136.97
(2008)
82.70
(2008)
0.99
(2008)
65/70
(2008 est)
48.00
(2008 est)
158.00
(2005)
6.6
Nauru 15.20
(2008p)
707.00
(2008p)
71.00
(2008p)
24.48
(2008p)
53/58
(2008)
37.90
(2003-07)
300.00
(2002)
30.9
Niue 17.90
(2008p)
1408.45
(2008p)
98.90
(2008p)
0.00
(2008p)
67/76
(2001-06)
– –
4.6
Palau 10.80
(2008p)
957.00
(2008p)
78.40
(2008p)
8.70
(2008p)
66/72
(2005)
25.64
(2009)
366.30
(2009)
9.1
RMI 13.40
(2008p)
351.00
(2008p)
97.20
(2008p)
2.80
(2008p)
67/71
(2004)
46.00
(2009)
324.15
(2009)
9.1
Samoa 5.15
(2008p)
153.86
(2008p)
84.80
(2008p)
10.96
(2008p)
72/74
(2006)
13.00
(2003-04)
3.00
(2005-06)
6.7
Solomon Islands 5.26
(2008p)
67.51
(2008p)
93.37
(2008p)
4.42
(2008p)
65/67
(2007)
37.20
(2007)
103.00
(2007)
2.3
Tokelau n/a n/a n/a n/a n/a n/a n/a 8.6
Tonga 4.00
(2008p)
109.04
(2008p)
68.70
(2008p)
27.27
(2008p)
67/73
(2008 est)
26.00
(2008)
76.10
(2008)
11.6
Vanuatu 4.06
(2008p)
96.94
(2008p)
79.25
(2008p)
14.86
(2008p)
68/70
(2008 est)
31.00
(2008)
70.04
(2006)
2.4
Notes
– indicates rate of 0.00; p = provisional; n/a = not available.
11
Source: WHO Western Pacific Region (2010), Country Health Information Profiles, 2010 Revision, unless otherwise indicated.
12
Source: International Diabetes Federation, Prevalence Estimates of Diabetes mellitus (DM) 2010 – Western Pacific, Table 1.37 URL: http://www.diabetesatlas.org/content/prevalence-estimates-diabetes-mellitusdm-2010
Downloaded 18 April 2011.
6
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

SECTION 2. METHODOLOGY
Prior to the February 2011 PHRHA forum participants
were provided with an ‘HRH ROADMAP’– a schematic
framework of HRH management to assist in the identification
of problematic areas. Reproduced below, the guide focuses
on three broad areas – entry (preparing the workforce),
workforce (enhancing worker performance), and exit
(managing attrition). Within each of these were example
categories such as planning, education and recruitment
(entry); management & supervision, lifelong learning (existing
workforce); migration, health and safety (exit), and so on.
figure 1: HRH ROADMAP
Entry
Preparing the workforce
Planning: Workforce Planning Policy; Information
Systems
Education: Pre-Service Education; Basic Training
Recruitment: Policy; Tools
Human resources for health
Workforce
Enhancing worker performance
Exit
Managing attrition
Management and Supervision: Job Descriptions;
Tools
Compensation: Salary Structure and Level; Payment
Mechanisms
Regulation and Legislation: Scopes of Practice;
Standards and Competencies; Quality Assurance and
Improvement
Lifelong Learning: In-Service and On-The-Job
Training; Continuing Professional Development;
Polhn
Migration: Codes of Practice; Bilateral Arrangements
Career Choice: Change of Occupation or Activity
Health and Safety:
Retirement: Succession Planning
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
7

Rather than forcing responses to the questions
of issues, challenges, needs and priorities into
given categories, we have focused instead on
their substantive content and identified themes
as they emerge from the data.
Towards the end of the forum Chan (2011a) 13 reported
back to participants with a brief impressionistic overview
of the country presentations. Elsewhere (2011b) 14 he has
summarised issues raised at the meeting according to the
entry/existing workforce/exit framework suggested by PHRHA.
With regard to the present discussion, it is noteworthy that
the table he provides shows that at least seven countries felt
the need to identify one crucial and fundamental issue not
explicitly covered by the framework; that of staff shortages.
Responses within each theme, as well as across themes,
have been compared to ensure consistent subject
categorisation. Areas and themes, however, are not mutually
exclusive and there is considerable overlap between many of
them. For example, among its Needs and Priorities responses
Vanuatu identified ‘the development of training’. Within
our analysis this item has been categorised in the Policy,
Management and Information subject area. Nevertheless,
there are clear links with the Education and Training area.
As noted earlier the data have been derived from each
participant’s PowerPoint presentation. Not surprisingly,
this has occasionally resulted in fragmented and cryptic
responses. Data have been excluded from the analysis where
the meaning is not clear.
In regard to the approach adopted in this paper, we have
taken our cue from the participants. First, we have made no
assumptions about the adequacy of workforce numbers or
otherwise, and as a consequence, second, have temporarily
set aside the suggested HRH framework. Rather than forcing
responses 15 to the questions of issues, challenges, needs
and priorities into given categories, we have focused instead
on their substantive content and identified themes as they
emerge from the data. Adopting this approach has broadened
the scope of the analysis and allowed for in-depth discussion
of issues and needs to be based on country responses.
Analysis of the data began by grouping responses into broad
subject areas (for example, workforce, education and training,
migration). Themes within each area were then identified (for
example, within the subject area of workforce themes such
as staff shortage, recruitment, and so on). They were then
aggregated and ranked to indicate which were of most concern
overall. Patterns and thematic trends were also identified in
this way within the Needs and Priorities responses.
13
Chan, Eric (2011a) Reporting Back, paper presented at meeting Draft
Framework for Action on HRH 2011-2015, 10 February 2011, Nadi,
Fiji. Powerpoint presentation.
14
Chan, Eric (2011b) Draft Framework for Action on HRH 2011-2015, 10
February 2011, Nadi, Fiji. Powerpoint presentation.
15
The term response is used throughout this paper to refer to participants’
identification of issues, challenges, needs and priorities as specified in
their PowerPoint presentations.
8
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

SECTION 3. PERCEIVED HRH ISSUES
AND CHALLENGES
Table 3 and Appendix Table 2 have been compiled from the
13 country reports presented at the forum. Table 3 presents
a summary of country contributions, while Appendix Table
2 provides more detail. Participants had been asked to
nominate at least five HRH issues and five HRH challenges
that were currently being experienced.
Given that the notions of issue and challenge are overlapping
and that formal definitions of each were not provided by
PHRHA, for ease of reading the participants’ perceptions
have been collapsed into one table and grouped according
to broad subject focus. The following five areas of concern
emerged: health workforce; HRH policy, management and
information; education and training; public service conditions
of employment; and emigration.
Health workforce
One of the most nominated areas of issues and challenges
was that of the health workforce (column 1), with all countries
nominating at least one sub-topic within this area (see
Appendix Table 2). Of most concern to participants was
current shortages of skilled, qualified and experienced health
workers (nominated by seven countries), followed by the
retention of health workers (nominated by six countries), the
recruitment of health workers and an ageing workforce and
population (both nominated by four countries). Kiribati cited
current staff shortages resulting in 53 unfilled positions within
its nursing service. Niue also referred to shortages of not only
locally trained nurses and doctors, but also pharmacists,
radiographers, physiotherapists and laboratory workers.
The remaining areas of concern in this domain were: limited
finances and funding, skills imbalances, difficulties imposed
by geographic distance, heavy workloads, and the negative
impact of government reforms on workforce numbers. With
regard to the challenge of geographic distance, Kiribati, for
example, drew attention to how large geographic distances
between islands increased the costs of relocating staff, citing
an instance where relocation costs for one staff member and
their family amounted to AUD$2,000.
TABLE 3: SUMMARY OF HRH ISSUES AND CHALLENGES
Health
Workforce
HRH Policy, Management
and Information
Education and
Training
Public Service
Conditions
Emigration
1 2 3 4 5
Cook Islands ü ü ü ü
FSM ü ü ü ü
Fiji ü ü ü ü
Kiribati ü ü ü ü
Nauru ü ü ü ü
Niue ü ü ü ü
Palau ü ü ü ü
RMI ü ü ü ü ü
Samoa ü ü ü ü ü
Solomon Islands ü ü ü ü ü
Tokelau ü ü ü ü ü
Tonga ü ü ü ü
Vanuatu ü ü ü
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
9

HRH policy, management and information
Equally nominated were issues concerned with HRH policy,
management and information (column 2) with concerns
mostly being expressed in terms of ‘lack’ or ‘absence’. Most
nominated (9 countries) was the absence of an effective
workforce plan or strategy. Closely related to the issue of
workforce planning was the need to establish effective
information systems, including updating job descriptions and
developing performance management systems (nominated
by at least three countries).
In addition, issues around exit management, succession
planning, research into the most effective use of limited
resources, and the lack of trained experienced leadership
were also nominated. The absence of, or inadequacy of,
standards, regulations and competency frameworks were
identified by five countries. Developing health workforce
policies and operationalising workforce management
strategies are considered difficult to implement, as the
participant from the Cook Islands commented, having spent
a couple of years developing and drafting a workforce plan,
they were denied funding by their own government in 2010
and by NZAID in 2011.
Education and training
The area of education and training (column 3) was also
nominated by all countries (although FSM only briefly referred
to this issue with the phrase ‘trained staff’). Six countries
(Niue, Kiribati, Vanuatu, RMI, Tokelau and Cook Islands)
focused on student numbers and courses currently on offer
as areas of concern. Other issues identified included small
numbers of people applying to study, low intake numbers,
and small numbers of graduating students. Closely related
were issues concerned with poor pre-vocation educational
preparation in secondary schools (nominated by Nauru,
RMI and Samoa), restrictive entry requirements, and length
and costs of completing courses. Another group of training
issues identified by participants were those concerned with
access to education. Absence of local training colleges
and institutions, limited access to health courses, limited
in-service training and professional development were
nominated by six countries. Finally, at least five countries
focused on funding and planning of courses and future
training as important issues. FSM, for instance, described a
dental program as a new program which was in need of both
technical and financial support.
Public service conditions of employment
Working conditions within the public health sector were
nominated by nine countries. Attention focussed primarily
on the issue of salaries for health workers (nominated by
six countries), with concern expressed about current levels
of salaries and the need for incentives. RMI, for instance,
described its salary structure as ‘ancient and inflexible’.
The negative effects of a low retirement age on the health
workforce, the absence of incentives, and poor working
conditions more generally were also identified.
Emigration
While all the categories described thus far have been
relatively straightforward, the same cannot be said of the final
category of emigration. Of the seven countries who nominated
emigration, only two indicated the precise nature of their
concerns. In the case of Samoa, it was not emigration itself
which was seen to be the problem but that the qualifications
of Samoans working abroad were not being recognised and
that destination countries appear to be ignoring the conditions
of bilateral agreements. In the second case, the Solomon
Islands, with minimal emigration (Connell 2010) identified
the movement of health workers from rural to urban areas
(internal migration), difficulties encountered when ‘posting’
people to outlying areas, and attraction ‘to the bright lights’.
The contributions of the remaining five countries display
varying degrees of ambiguity. First, given that Tokelau does
not exhibit a rural/urban distinction and that it has a very
small population, it seems reasonable to assume that it is
emigration, along with career changes, which is impacting
on Tokelaun HRH. Second, despite nominating migration,
neither FSM nor Tonga indicated whether their concerns
were with out-migration, internal migration, movement from
public sector to private sector, or some combination of these
different forms of ‘migration’; or indeed, whether, like Samoa,
it is not migration itself which is at issue, but a particular
aspect of the process. Third, the two remaining countries
(Cook Islands and RMI) indicated unambiguously that
emigration was an issue they currently face; however, again
it cannot be said with absolute certainty what aspect/s of
emigration is/are of concern. Nevertheless, it is worth noting,
that the Cook Islands referred to ‘competition from highincome
countries’, pointing to the disparity between levels
of local HRH salaries and those on offer overseas, and its
impact on their health sector.
10
HRH issues and challenges in 13 Pacific Islands countries: 2011
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SECTION 4. NEEDS AND PRIORITIES
Having described a selection of current HRH situations,
obstacles, issues and challenges, each country then identified
what they believed was needed to help alleviate problems
within their health sector. Participants focussed primarily
on two areas – health workforce policy, management and
information; and education and training.
Twelve of the 13 countries identified at least one aspect of
health workforce policy, management and information where
it was felt that some sort of action was needed. In one way or
another most countries nominated workforce planning as an
area requiring attention. This was followed by management
needs such as addressing leadership issues, strengthening
management skills, and developing policies and procedures
(five countries).
Similar numbers of participants focussed on stakeholder
and donor support, with FSM suggesting the World Health
Organization (WHO), Japan International Cooperation Agency
(JICA) or PHRHA provide in-service training. Kiribati requested
technical assistance with workforce plan analysis, Vanuatu
stressed the need for increased political commitment and
advocacy, and Niue highlighted the importance of establishing
a sustainable funding mechanism. Palau identified their need
for an AusAID volunteer for two years to assist in the creation
of an HRH office staffed with appropriate personnel.
FSM, Samoa and the Solomon Islands focused on the need
to develop reliable information systems, while Tonga and
Vanuatu sought to revise regulations, develop competencies
and standards and establish an accreditation mechanism to
facilitate health worker movement. Remaining needs drew
attention to raising the age of retirement to 60, reviewing
compensation levels, and conducting gap analysis.
Slightly fewer (10 countries) nominated education and training
as an area of need. Five countries focussed on training in
general, drawing attention to such issues as the need to
develop programs, to build capacity and to address an ageing
workforce. Intake numbers were nominated by three countries,
with the Cook Islands wanting to increase the undergraduate
nursing intake to 12 per year for five years, and Kiribati hoping
to increase its medical assistant intake from 9 to 12. The
provision of scholarships, and professional development were
each nominated by three countries. Again the Cook Islands
focused on maintaining the number of Bachelor of Medicine/
Bachelor of Surgery (MBBS) scholarships at two per year, and
the RMI wanting to create a scholarship scheme. Finally, RMI
highlighted their need to increase the number of nurses at
bachelor and master degree levels.
Participants focussed primarily on two areas
– health workforce policy, management and
information; and education and training.
The issue of pre-service education was identified (again
by three countries) as an important area in need of review.
Upgrading skill levels of students leaving high school and
revising high school curriculum to reflect HRH course
entry requirements were among the needs identified by
RMI, Niue and Samoa. Closely related to the issue of prevocational
education was that of obtaining support funding for
improvement of high school education and training programs
as suggested by Kiribati.
Not surprisingly, priorities for the PHRHA to assist with
tended to mirror the needs previously identified, although
greater emphasis was placed on education and training (8
countries) compared to policy, management and information
(4 countries). The most distinctive feature, however, was
the call for support from PHRHA in obtaining technical
assistance (8 countries) and funding (4 countries) in order
to fulfil their education and training, and policy, management
and information needs.
Participants concentrated on the need for support in
establishing partnerships, developing networks of local
personnel of member countries to assist each other, and
establishing links with relevant advisory experts, trainers and
resource personnel. Participants also sought assistance in
developing training programs, establishing workforce plans,
carrying out succession planning and establishing standards
and competencies.
Despite six participant countries identifying salary levels and/
or structure as an issue of concern, only three (Fiji, Niue and
Tokelau) made specific reference to it in their needs and
priorities. Given that participants had only a short amount of
time allotted in which to outline their concerns and needs,
as well as limited space (overheads), it could be that this
issue, and the overarching issue of working conditions more
generally, were included within other categories (for instance
RMI specified the more inclusive need to develop career
pathways for each health worker). Similarly, in regard to the
issue of migration, only Tonga included it among its needs
and priorities, and then only in a very general manner.
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
11

SECTION 5. DISCUSSION
Health sector data for Pacific Island countries are often
out-dated, unreliable or simply not available (Feeny & Clarke
2008); a situation which only serves to make the contributions
of each country representative, based as they are on personal
and first-hand experience, all the more important.
Although all health sector characteristics identified do
not apply to every country, they nevertheless provide a
composite picture which speaks to each country on some
level. Thus, we have a health sector characterised by
staff shortages, recruitment and retention problems, skill
gaps and imbalances, uneven distribution, and an ageing
workforce; a health system characterised by insufficient
financing (sometimes the result of government reforms or
restructuring), out-dated (at best) workforce plans, strategies
and policies, inadequate information systems, inadequate
standards and competencies, regulations and legislation, and
untrained and/or inexperienced leadership and coordination.
To this mix can be added disjuncture between pre-service or
pre-vocational education levels and those required to enter
health training, small student intakes, unattractive salary
levels, and few career prospects for the individual health
worker. Some countries have also imposed government
reforms which have resulted in reduced health expenditures,
fewer health workers and deterioration in the provision of
health services.
Certainly, there are a number of examples of in-country
responses to the sorts of problems described above. Vanuatu,
for instance, has directed attention to increasing its nursing
intake to 60, doubling its intake for nurse aids and increasing
opportunities for postgraduate studies overseas. Health
partnerships with countries outside the region have been
negotiated. For example, Kiribati, Samoa, Tonga and Solomon
Islands have established links and bilateral relationships of
varying duration with Cuba for the training of medical staff.
In regard to education and training there have also been
a number of initiatives such as the Pacific Open Learning
Health Net (POHLN) which offers online courses to skilled
health workers in the Pacific region.
In Palau the MoH developed a bridging program to assist
high school graduates qualify for entry into health training.
Similarly, a bridging course is currently underway in Vanuatu.
Within nursing and midwifery education and training, WHO
and various Ministries of Health have negotiated a number
of partnerships with institutional counterparts in developed
countries (for example between the Cook Islands School of
Nursing, Auckland Institute of Technology and Manukau
Some countries have also imposed government
reforms which have resulted in reduced
health expenditures, fewer health workers and
deterioration in the provision of health services.
Technical Institute; between the Fiji School of Nursing and
James Cook University; between the National University
of Samoa, Nagano University, University of Technology,
Sydney, and Charles Darwin University; between the Tonga
Queen Salote School of Nursing and Auckland University of
Technology) in order to facilitate the sharing of resources and
capacity building.
The Health Assistants Training Program, a program equipping
indigenous people of RMI with sufficient skills to become
mid-level health assistants capable of providing health care
in the absence of a doctor, was developed in response to
staff shortages in the outer islands of RMI (Keni 2006). In
2007 the Australia-Pacific Technical College was established
to provide vocational training at internationally recognised
standards across a range of industry sectors, including health
and community services (although so far the emphasis has
been less on health with certificate and diploma courses
focussing on children’s services and community welfare) 16 .
Nevertheless, it is clear from participant responses above,
that if workforce numbers are to be significantly increased
and working conditions improved, then much more needs
to be done to develop workforce plans and accompanying
policy, create professional management systems, develop
career pathways, and devise appropriate education and
training programs. Importantly, developing and maintaining
strong leadership in MoH which can reach out and
effectively engage key stakeholders outside the health sector
(for example, education and finance), obtaining political
commitment, and securing financial and technical support,
are all high-order priorities for fulfilling these needs.
The importance of carrying out workforce planning, especially
within the context of international emigration, internal mobility
from rural to urban areas, and the movement of skilled
health workers from the public to the private sectors, is only
strengthened when one is reminded that the most recent and
16
See http://www.aptc.edu.au/courses/health/dipl_community.html.
12
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Most discussions of the precise impact of
emigration and the nature of its relationship to
HRH shortages within Pacific region countries
are hampered by the lack of even the most
basic data regarding numbers of emigrants,
immigrants and returnees, relying instead on
‘back of the envelope’ estimates.
comprehensive examination of health workforce numbers in
the Pacific region was conducted more than 20 years ago
(see Rotem & Dewdney 1991, referred to in Connell 2009b.)
It is not surprising then that a common feature of the country
presentations is the need for workforce plan development;
a finding which supports the observation that even though
workplans have been developed in some countries, they are
unused because they have been neither costed nor funded
(Nukuro 2010).
Also noteworthy is the way in which the impact of migration
has been viewed by participants. Given the emphasis each
country has placed on staff shortages, recruitment and
retention problems within their respective health sectors,
it is curious that an emphasis of similar magnitude has
not been placed on the issue of migration. Although it is
a phenomenon thought to be deeply implicated in the
development of staff shortages within countries of origin, and
particularly so for small countries (Khadria 2010), participants
have not given it the attention one might have expected. As
noted earlier, seven countries nominated emigration as an
issue or challenge, and only one (Tonga) included it among
its needs and priorities.
This should not be taken to mean, however, that emigration
does not impact on the remaining countries. Indeed, the
significance of emigration (in all its forms) for the Asia Pacific
region, where health systems are often fragile, has been a
consistent theme within the literature for some time. (See
for instance Iredale et al. 2003, IOM 2010, WPRO 2004).
Unfortunately, however, most discussions of the precise
impact of emigration and the nature of its relationship to
HRH shortages within Pacific region countries are hampered
by the lack of even the most basic data regarding numbers
of emigrants, immigrants and returnees, relying instead
on ‘back of the envelope’ estimates (Connell 2009b).
Nevertheless, one thing is certain - the steady loss of skilled
health workers through continuing international migration,
internal mobility and movement from the public to private
health sector places increasing pressure on already limited
resources and struggling public health sectors. This is
especially so where skilled health workers from other
countries who can substitute for those who have emigrated
cannot be found (Forcier et al. 2004) and where the loss of
only a small number of skilled health workers makes a crucial
difference to efficient and effective functioning of a health
system (Pak & Tukuitonga 2006).
A possible clue as to why emigration has not been nominated
is to be found in the comment of a participant from Fiji who
noted that they produce 200 nurses per year to compensate
for staff losses due to migration and retirement. Such a
response clearly indicates that there is the expectation that a
certain proportion of nursing graduates will migrate at some
stage. Elsewhere, the General Secretary of the Fiji Nursing
Association has been quoted saying that to work overseas is
regarded as a ‘privilege’ because of the financial and other
returns it provides to relatives at home (Lutua 2002 quoted
in Connell 2007: 70). There are also examples of countries
actively encouraging their citizens to work and train overseas
(eg. KANI – Kiribati).
The question of motivations to migrate is one which has
occupied researchers exploring the global migration patterns of
people from the Pacific region. (For some recent examples see
Barcham et al. 2009; Gibson et al. 2010; Lee 2009, Opeskin
& MacDermott 2009.) It is also a topic which is to be found in
most discussions of migration patterns of skilled health workers
within the Pacific region. (See for instance Brown & Connell
2006, Henderson & Tulloch 2008, Oman 2007, Rokoduru
2008, WPRO 2004.) A full exploration of this literature is
well beyond the scope of this paper. What is important to the
present discussion, however, is the central place economic
considerations occupy (including the family responsibilities
and kinship obligations to contribute to household income
through remittances) in decisions to migrate.
Connell’s extensive and enduring research into migration has
led him to conclude that a culture of migration is in evidence
within many Pacific Island cultures and that migration, far
from being regarded as a problem to be removed, has come
to serve a crucial economic role. Indeed, remittances have
become an integral component of GDP within a number of
PICs (Connell 2009a). Remittances to Tonga, for instance,
the leading recipient of remittances, represent approximately
45% of GDP (Lin 2010). Such a sizable proportion reflects
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
13

SECTION 6. POLICY
IMPLICATIONS
The migration of health workers is part of a
larger exodus (sometimes temporary, sometimes
permanent) of skilled and unskilled workers in
search of employment.
the important role migration plays in the production of
remittance flows and the way in which the ‘transnational
corporation of kin’ has become a structural feature of many
Pacific Island economies.
At the micro level, migrating overseas to secure relatively wellpaid
employment has become a purposeful strategy practiced
within many families as a means of supplementing household
income. At the macro level, economies like Tonga’s have
become heavily reliant on the flow of remittances from those
who have migrated and are now regarded as remittance
economies. In short, the migration of health workers is
part of a larger exodus (sometimes temporary, sometimes
permanent) of skilled and unskilled workers in search of
employment. Having come to play a vital economic role for
individuals, households and families, as well as national
economies, it is unlikely that international migration will
diminish in the near future.
That many participants did not identify emigration as a
problem, instead focussing on labour market conditions
(workforce conditions and salaries, workforce planning and
workloads, unfilled positions, inadequate funding, worker
shortages and so on), is also consistent with the observation
that health worker migration is often a response to difficulties
in establishing and maintaining principles of fairness and
equity for those working within health systems (Buchan 2008)
and to social and economic difficulties encountered outside
health systems (OECD 2010). It follows that collaborative
efforts by government and stakeholders focussed on
recognising the skills of health workers and deploying them
efficiently within health systems would go some way towards
reducing the negative effects of migration.
The perceptions and understandings of participants indicate
an acceptance of skilled health worker migration and a strong
desire to manage staff shortages, recruitment and retention
problems by developing sound policy and appropriate
education and training structures either locally or within the
Pacific region. They also indicated the need to develop and
maintain partnerships which would support the fulfilment of
needs and priorities. There are three groups of stakeholders
for whom policy implications arise; national governments,
regional training institutions, and donors, agencies and
international organisations.
National governments
National governments have a role to play in developing
evidence-informed policies which have the potential to
influence the numbers and distribution of HRH within the
health system.
The crucial issue for national governments is to be proactive
in the areas of health workforce planning and production,
recruitment and retention, career progression and establishing
acceptable terms and conditions of employment.
For instance, when posting health workers to rural and remote
areas, and to avoid them leaving the service as a consequence,
key questions need to be appropriately addressed:
• Have appropriate incentives been designed by
government to help overcome the perceived
disadvantages attached to a non-urban posting?
• Have mechanisms been developed which take into
account the financial and physical security of the health
worker and their families?
• Has adequate housing and access to continuing
education been provided?
These are just some areas where compensatory measures
could be developed and implemented by national governments
to help offset some of the disincentives associated with
working in non-urban areas and to strengthen health
workforce retention overall.
Policies and initiatives such as these which actively promote
and encourage a return to rural areas have the potential not
only to impact positively on the distribution of health workers,
but to help address equity issues. Disparities between urban
and non-urban populations could be reduced as rural
populations, traditionally disadvantaged by poorly resourced
health services and more recently by internal migration of
health workers, have increased access to health care services.
14
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

Developing bridging courses and outreach
programs in schools may go some way towards
increasing the skill level of high school graduates
and increase their likelihood of gaining entrance
to tertiary health professions education.
This is not to suggest a ‘one-size-fits-all’ approach to
addressing the challenges of staff shortages, deployment,
recruitment and retention. Indeed, building equity and
developing human capital within health systems require
localised solutions which take local conditions and contexts
into account. Nevertheless, national governments have a
role (albeit one restricted by limited financial resources,
small populations, and economies dependent on overseas
aid and remittances) to play in pursuing policies which have
the potential to promote and advance HRH. A recent review
of HRH migration from six PICs (Samoa, Cook Islands, Fiji,
Solomon Islands, Vanuatu and PNG) (Roberts et al. 2011)
revealed that none of these countries conduct exit interviews
of staff leaving service, nor do they assess the impact of skills
migration on services.
Accordingly, it is recommended that national governments
develop costed workforce plans in conjunction with their
Ministries of Finance that include financial incentives for
rural placement, career progression options, opportunities
for continuing professional development and a system of exit
interviews to ascertain the reasons for people leaving public
sector service and their home country for alternative careers.
Regional educational institutions
The area of pre-vocational education warrants greater
attention in many of the smaller PICs, where access to
education is often offshore. A number of countries have
expressed concern over the small numbers of young people
entering health sector training; a situation believed to be
largely due to too few high school graduates meeting the
standard of science and maths required for entry into training
programs 17 . Developing bridging courses and outreach
17
It is also worth noting that some education systems within Pacific Island
countries, like their health system counterparts, are now beginning to
experience growing rates of international teacher migration and staff
shortages (Voigt-Graf et al. 2007; Iredale et al. 2009).
programs in schools may go some way towards increasing
the skill level of high school graduates and increase their
likelihood of gaining entrance to tertiary health professions
education. In addition, the numbers of medical graduates
from the Fiji School of Medicine, traditionally the region’s
medical graduate supplier, although recently increased, have
not been sufficient to contain the emergence of new medical
schools within the region, nor to deter PICs from entering into
training agreements with Cuba.
Managing the return of Cuban trained medical graduates
and the integration of graduates of new medical schools
into national health systems presents issues of establishing
regional standards and internships, and requires planning
for funding and resourcing. Accordingly, it is recommended
that health professions educational institutions work
with national governments to propose and prepare for
regional examinations and internship programs that can
accommodate graduates from a range of training institutions,
including those recruited from Asian countries, many of
whom are already working within PIC health systems.
Donor, agencies and international aid organisations
With relatively small and in some cases declining health
expenditures, it is difficult to see how health workforce
recruitment can be adequately increased without significant
increases in financing. As Connell (2010) notes, success
primarily depends on international agencies and aid donors
realising that achieving Millennium Development Goals (MDGs)
requires an efficient and productive health workforce. In
this sense, health needs to be regarded as a ‘special case’
(p.19) deserving of adequate funding from aid organisations.
Furthermore, given the very real limits on the numbers and types
of measures Pacific Island governments can initiate to alleviate
workforce, policy, education, training and migration challenges,
support from the international community is required.
There are opportunities for donors to provide technical and/
or financial assistance in a number of areas. HRH data
inadequacies across the region have been well documented.
Mobility and attrition rates, although fundamental elements
required in devising appropriate retention strategies and
workforce planning, are largely matters of guesswork.
Technical and financial assistance in developing practical
methods of recording the internal mobility of skilled health
workers (ie movements to and from public to private health
sector, rural to urban areas, and movement out of the health
sector altogether) and the emigration and return migration of
skilled health workers, would provide a sound evidence base
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
15

CONCLUSION
on which to develop well-thought-out workforce plans and
recruitment and retention strategies.
Accordingly, it is recommended that donors and international
agencies provide technical and financial support to assist in
building HRH information systems within the Pacific region.
In response to the expressed concerns over the quality
of secondary school leavers, donors and international
agencies could strengthen the potential for national HRH
capacity building by supporting secondary education and
pre-vocational education systems in providing adequately
prepared students for health care education programs.
This analysis has identified common issues and needs,
as presented by PHRHA participants, which need to be
addressed if health systems are to be strengthened through
HRH strategies. While the issues and contexts identified
varied from country to country, broad agreement was
achieved on measures and strategies which would alleviate
shortages of trained and experienced health workers and
reduce the exit of health workers from the health sector.
A proposed initiative for donors support could focus on
developing connections between the Pacific Island diaspora
in Australia and New Zealand by establishing registers of
‘deployable’ health workers willing to contribute to health
systems in their home country on short, medium or longer
term assignments. Current and reliable information on the
Pacific Island health diaspora populations would provide
some of the necessary input required to develop realistic
re-engagement strategies and mechanisms designed to help
ease staff shortages within PICs.
To expand the capacity and potential for Pacific regional
health professions training will require substantial support
from donors to meet the costs of travel, student allowances
and course fees.
16
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Marshall Islands’ in John Connell (ed), The International
Migration of Health Workers, Routledge, New York,
pp 172-181.
Rotem, A & Dewdney, J 1991, The Health Workforce, South
Pacific Island Nations, University of New South Wales,
Kensington, NSW.
Voigt-Graf, C, Iredale, R & Khoo, S E 2007,’ Teaching at home
or overseas: teacher migration from Fiji and the Cook Islands’,
Asian and Pacific Migration Journal, 16 (2), pp 199-224.
WHO Regional Office for the Western Pacific (WPRO) 2004
The Migration of Skilled Health Personnel in the Pacific
Region: A Summary Report, World Health Organization
Regional Office for the Western Pacific, Manila, Philippines.
18
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

APPENDIX 1
TABLE 1: SELECTED INFANT MORTALITY RATES (IMR), UNDER AGE 5 MORTALITY RATES
AND MATERNAL MORTALITY RATES (MMR)
IMR (per 1000 live births)
UNICEF (2009)
(1)
WHO (2008)
(2)
WB (2009)
(3)
UNFPA (2007)
(4)
CHIPS (2009)
(5)
Cook islands 13
14
(2005)
- 16 7.1
FSM 32 32 32 33 13.5
Fiji 15 16 15 16
Kiribati 37 38 37 46
13.1
(2008)
52.0
(2005)
Nauru 36
Niue –
38
(2005)
19
(2005)
– – 37.9*
– - -
Palau 13 13 13 - 21.97
RMI 29 30 29 49 34.0
Samoa 21 22 21 22
Solomon Islands 36 30 30 53
20,4
(2006)
44.3
(2008)
Tokelau – - - - -
Tonga 17 17 17 19
Vanuatu 14 27 14 28
16.4
(2008)
27.0
(2008)
Australia 4
4
(2009)
4 –
4.10
(2008)
New Zealand 5
4
(2009)
5 -
4.79
(2007)
Notes
Column:
(1) Source: URL: http://www.unicef.org/infobycountry/index.html).
(2) Source: WHO Global Health Observatory. URL: http://apps.who.int/ghodata/?theme=country
(3) Infant mortality rate is the number of infants dying before reading one year of age, per 1,000 live births in a given year. Source: Level & Trends in Child
Mortality. Report 2010. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA,
UNPD) URL: http://data.worldbank.org/indicator
(4) Source: UNFPA Country Profiles for Population and Reproductive Health: Policy Developments and Indicators 2009/2010,United National Population
Fund and Population Reference Bureau, 2010. URL: http://www.unfpa.org/public/countries
(5) Nauru: 2003-07. Source: WHO Western Pacific country health information profiles: 2010 Revision (CHIPS), WHO, 2010.
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
19

Under Age 5 MR (per 1000 live births)
UNICEF (2009)
(6)
WHO (2008)
(7)
WB (2009)
(8)
UNFPA (2007)
(9)
CHIPS (2009)
(10)
Cook islands 15
16
(2005)
– 18 7.1
FSM 39 39 39 40 39.0
Fiji 18 18 18 18
Kiribati 46 48 46 63
23.6
(2008)
48.0
(2008)*
Nauru 44 47 – – 37.9*
Niue – 24 – – –
Palau 15 15 15 - 25.64
RMI 35 36 35 54 46.0
Samoa 25 26 25 27
Solomon Islands 30 36 36 70
13.0
(2003-04)
37.2
(2007)
Tokelau – – – – –
Tonga 19 19 19 23
Vanuatu 16 33 16 34
26.0
(2008)
31.0
(2008)
Australia 5
5
(2009)
5 –
4.92
(2008)
New Zealand 6
6
(2009)
6 –
6.05
(2007)
Notes
Column:
6) Source: URL: http://www.unicef.org/infobycountry/index.html).
(7) Source: WHO Global Health Observatory. URL: http://apps.who.int/ghodata/?theme=country
(8) Under-five mortality rate is the probability per 1,000 that a newborn will die before reaching age five, of subject to current age-specific mortality rates.
Source: Level & Trends in Child Mortality. Report 2010. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF,
WHO, World Bank, UN DESA, UNPD) URL: http://data.worldbank.org/indicator
(9) Source: UNFPA Country Profiles for Population and Reproductive Health: Policy Developments and Indicators 2009/2010,United National Population
Fund and Population Reference Bureau, 2010. URL: http://www.unfpa.org/public/countries
(10) Kiribati: estimate. Nauru: 2003-07 Source: WHO Western Pacific Country health Information Profiles: 2010 Revision (CHIPS), WHO, 2010.
20
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

MMR (per 100,000 live births)
UNICEF
(11)
WHO
(12)
WB (2008)
(13)
UNFPA
(14)
CHIPS
(15)
Hogan (2008)
(16)
Cook islands
6
– – – – –
FSM
270 317
(2003)
– – –
127
[48-279]
Fiji
34 31
(2007)
26 210
[55-720] (2005)
27.5
(2008)
85
[32-194]
Kiribati
56 158
(2005)
– –
158.0
(2005)
–
Nauru –
300
(2002)
– –
300.0
(2002)
–
Niue – – – – – –
Palau – – – –
366.3
(2009)
–
RMI
74 –
–
– 324.15
(2009)
–
Samoa
29 3
(2006)
–
–
[8-30] (1995)
3.0
(2005-06)
104
[39-236]
Solomon Islands
140 100
(2008)
100 22
[65-580] (2005)
103.0
(2007)
284
[102-638]
Tokelau – – – – – –
Tonga
140 37
(2007)
– –
76.1
(2008)
113
[42-250]
Vanuatu
150 70
(2006)
–
[16-65] (1995) 70.04
(2006)
178
[66-400]
Australia
8
(2008 adj)
8
[6-10] 2008)
8
–
8.4
(2003-05)
5
[4-6]
New Zealand
14
(2008 adj)
14
[12-15] (2008)
14 – 11.61
(2006)
8
[6-11]
Notes
Column:
(11) Rates (2005-09) as reported by country. Not adjusted by UNICEF for underreporting and misclassification. Adjusted rates are available for only two
countries, Fiji and Solomon Islands; 26 and 100 respectively. Source: URL: http://www.unicef.org/infobycountry/index.html).
(12) Country reported estimates. Interagency estimates are available for only two countries, Fiji and Solomon Islands; 26 [14-48] (2007) and 100
[44-240] (2008) respectively. Australia, New Zealand – interagency estimate. Source: WHO Global Health Observatory. URL: http://apps.who.int/
ghodata/?theme=country
(13) Modelled estimate. Maternal Mortality ratio is the number of women who die during pregnancy and childbirth, per 100,000 live births. The data are
estimated with a regression model using information on fertility, birth attendants, and HIV prevalence. Source: Level & Trends in Child Mortality. Report
2010. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation (UNICEF, WHO, World Bank, UN DESA, UNPD) URL: http://
data.worldbank.org/indicator)
(14) Source: UNFPA Country Profiles for Population and Reproductive Health: Policy Developments and Indicators 2009/2010,United National Population
Fund and Population Reference Bureau, 2010. URL: http://www.unfpa.org/public/countries
(15) Source: WHO Western Pacific Country health Information Profiles: 2010 Revision (CHIPS), WHO, 2010.
(16) Source: Hogan, M. C., Foreman, J. J., Naghavi, M., Ahn, S. Y., Wang, M., Makela, S. M., Lopez, A. D., Lozano, R. & Murray, C. J. (2010) “Maternal
mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5” Lancet 375(9726): 1609 – 1623.
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
21

APPENDIX 2
TABLE 2: HRH ISSUES AND CHALLENGES BY COUNTRY
Health Workforce
Policy, Management
and Information Education and Training Public Service Conditions Emigration
(1) (2) (3) (4) (5)
Cook Islands • Ageing
• Recruitment: difficulty recruiting for
outer islands
• Lack of HRH ... planning/
investment/professional development
• Limited financial resources
• Lack of funding for MoH Workforce
Development Plan 2010-2020
• Establish Health Professionals
Council
• Update legislation for Health
Practitioners Competence Assurance
Act covering registration, monitoring,
credentialing and disciplinary
processes for all health practitioners
• Small numbers completing
professional training
• Nursing education and training
to be strengthened
• Increase focus on training with
specialist visits
• Migration: outward/global: young
HWs (competition from highincome
countries)
Federated States
of Micronesia
• Geographic dispersal of small islands
– transport and communication
difficult
• Shortage of health staff
• Retention of trained staff
• Lack HRH policy • Trained staff • Migration
Fiji • Must have knowledge and attributes
• How can degreed nurses be best
utilised?
• Research – academic; how to use
resources, time and space
• Policy
• Training
• Education specific to HR
development
• Training trainers (mentors/
couches)
• Salaries structured according
to grades – no consideration of
merit for nursing – no incentives
Kiribati • Shortage of nursing staff
• Nursing workload (eg. nurse-patient
ratios)
• Geographic dispersal of islands –
high relocation costs
• Succession planning – lack of
continuity as trained/qualified
replacement staff not available
• Limited/declining budget for Nursing
Services
• High staff turnover: high cost of
relieving staff (maternity leave,
retirement, long leave)
• Limited intakes into health
courses – classroom too small
– dormitory refurbishment
required
• Low retirement age (50)
Acronyms
HRH human resources for health HW health worker MoH Ministry of Health
22
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

Health Workforce
Policy, Management
and Information Education and Training Public Service Conditions Emigration
(1) (2) (3) (4) (5)
Nauru • Lack of skilled local personnel
(paramedics, medical, nurses)
• Shortage of HR: government reform
(budget)
• Retention: turnover of staff
(e.g.expat, maternity leave cover)
• Shortage of qualified personnel
• Shortage of experienced personnel
• Infrastructure – lack of support for
training, limitation of internet access
and computers (e.g. POLHN)
• Leadership: lack of trained
experienced leaders
• Care of equipment overseas
dependent
• No training institution, academic
prerequisite
• Poor education preparation at
pre-vocation level
• Continuing education – donor
dependent (multiple providers)
• Salaries (physician, graduate
physiotherapist)
• Remuneration capped
Niue • Shortage of trained local doctors,
nurses, paramedics (pharmacy,
radiography, laboratory,
physiotherapy)
• Ageing workforce
• Ageing population
• Ongoing recruitment from overseas
• Generalist versus specialist skills?
• Retention: unable to retain skilled
workers leading to brain & skills
drain
• High medical staff turnover
• Getting the right person to do the job
• Retention of staff
• Understaffed
• No common understanding of and
attitudes towards work performance
due to age gaps between staff (i.e.
young vs old)
• Difficulties recruiting interested
overseas personnel
• Ineffective HRH plan
• Limited success of succession
planning
• Employment authority
• Poor diversity in health services
provided
• Non-medical staff in authoritative
positions; little understanding of
Health Dept and services – not seen
as a priority
• “Employers fail to recognise and
acknowledge work done”
• No standards or quality assurance.
Requires regulations
• High patient expectations
(technology/internet/referral to
centres/small community)
• Clinical activity vs maintaining
competency
• NZ citizens
• Lack of communication between
Department and national training,
unavailability of national HRH plan
• “Long gaps in training for new
trainees to fill future position”
• Limited training opportunities
for staff
• Poor support for CME in all
areas
• Slow intake from high school for
health training
• No funding for future training
• Level of remuneration
unattractive – difficult to keep
and retain trained local staff
long-term
• No key financial incentives to
retain health staff
Acronyms
CME Continuing medical education
HR human resources
HRH human resources for health
POLHN Pacific Open Learning Health Network
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
23

Health Workforce
Policy, Management
and Information Education and Training Public Service Conditions Emigration
(1) (2) (3) (4) (5)
Palau • Workforce development (through
College of Health)
• Skill imbalance (will be addressed
through the College of Health)
• Policy development 18
• Limited education and training
• Decision-making process
(distance, off island)
• Lack formalised HRH plan 19
• Lack strategic plan 20
• Service development
• Poor work environment and
service conditions 21
Republic of the
Marshall Islands
• Shortage of local health care
professionals
• No established plan regarding
training doctors and other
professionals
• Level of science and maths for
students graduating from both
public and private schools
• Lack of access to medical and
allied health education (besides
nursing school and health
practitioner training on site)
• Relatively small intake numbers
into health courses
• Inadequate funding for planning
relevant training programs
• No well-qualified science
teachers in elementary and
middle schools
• Low salaries
• Minimal incentives
• “ancient and inflexible salary
structure” for MOH professional
staff
• Outward migration: professionals
and wel--trained seeking
opportunities overseas (USA)
Samoa • Shortage of HRH (especially nurses,
midwives, doctors, dentists)
• Ageing (especially nurses &
midwives)
• Traditional HW see column (2)
• Private health sector growing and
stretching available HRH
• Information system
• Slow production of HRH to feed or
replace services
• Traditional HWs (inclusion,
recognition, credentialing,
monitoring) - establish standards for
safety of practice
• Managing exits: shortage of
qualified staff - succession planning
challenging
• Pre-service education: quality vs
access issues (university entry
requirements restrictive/length
of study too long?/too costly for
some
• Salary structure and levels
unattractive
• Compensation – relativities in
salary structure and levels not
reflective of true value of HRH
• Migration “slow but steady
migration” (esp nurses and
doctors)
Qualifications not recognised
in destination countries
CsoP/bilateral agreements do
not appear to be observed/
recognised
18
AusAID volunteer to begin in March 2011.
19
AusAID volunteer to assist with this task.
20
AusAID volunteer to work with MoH.
21
Healthy workplace initiative commenced late 2010.
Acronyms
CsoP Codes of Practice
HRH human resources for health
HW health worker
24
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

Health Workforce
Policy, Management
and Information Education and Training Public Service Conditions Emigration
(1) (2) (3) (4) (5)
Solomon Islands • Very long process of recruitment: (55
steps)
• Freeze on recruitment
• Nursing supply increasing, but less
being absorbed into public sector
• High demand of health service vs
population – 2013 first group of
Cuban doctors
• Job descriptions outdated
• Work activities unstructured
• Lack of performance management
systems
• Poor timekeeping, attendance/
absence records
• Upgrade health infrastructure in
provinces and outer rural areas
• Training does not link to HR
department
• “Retirement low and dissenters,
accommodations, pay/pension
and social”
• “Posting”: movement of HWs
from rural to urban areas
• Migration: “to the bright lights”
• Migration of HWs
Tokelau • Recruitment of locum health staff
with knowledge of local protocols
• Regulation of HWs in accordance
with clinical governance policies and
guidelines
• Robust and effective workforce
planning
• Robust and effective succession
planning
• Establish continuous Professional
Development Program linking into
clinical governance framework
• Maintain links between national and
local levels to ensure quality health
service
• Lack of health succession plan
or effective mechanism to ensure
provision of health staff at all levels
and in all services
• Limited numbers school leavers
choosing to train in health field
– competing study opportunities
from other areas of public
service.
• Budget constraints limiting
training opportunities
• Salary structure and
compensation levels
• Migration (resulting in staff
shortages)
Acronyms
HR human resources
HW health worker
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.
25

Health Workforce
Policy, Management
and Information Education and Training Public Service Conditions Emigration
(1) (2) (3) (4) (5)
Tonga • Staff turnover as result of migration • Workforce planning/projections
(career paths, professional
management system, succession
planning)
• HRH Information System
• Competencies and standards
• Capacity levels (finance and HR)
• HR Management and Policy (new
act brought about changes)
• Effective performance management
system to measure staff performance
• Continue professional
development
• In-service and on-the-job
training
• Address migration issues
Vanuatu • “Aging and redundant workforce that
needs to be replaced by a modern
workforce”
• human resources – understaffed
• National strategic planning required
to help meet national staffing targets
• Increasing population demands
that the MoH increase training
programs (rather than merely
replacing aging workforce)
• Nursing program 22 : limited
places within nursing program
and other training programs
• Limited space for training
22
For example, recently the general nursing program had an intake of 30 despite receiving close to 500 applications..
Acronyms
HR human resources
HRH human resources for health
26
HRH issues and challenges in 13 Pacific Islands countries: 2011
Doyle et al.

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