What is needed to support the skilled health workforce in maternal, reproductive and child health in the Pacific?

Progress towards achievement of the Millennium Development Goals (MDGs) across the Pacific island countries (PICs), particularly for MDG 5, that targets maternal morbidity and mortality, has been patchy.¹Countdown to 2015 reports suggest that more can and should be done to address maternal, newborn and child health (MNCH), coverage of evidence-based interventions that require skilled health workers is critical.² It is clear that in the high-mortality-burden countries of PICs, to meet the clinical and public-health gaps, there is a need for an increased focus on training needs of MNCH health workers.^3,4

There are ongoing challenges in training, retaining and providing adequate professional development opportunities for skilled MNCH workers in PICs.^1,5 Many factors contribute to the health workforce constraints in PICs, including outward migration, poor retention incentives and a lack of opportunities for in-country training.

Chronic staff shortages often occur in areas with the highest levels of need and the fewest available skilled healthcare workers.⁵

Australia and New Zealand (ANZ), as high-income countries in the Asia-Pacific region, have a long history of involvement in providing training and support for health workers from PICs.^6,7 Substantial input from committed individuals and supporting organisations have built up a sustainable surgical program in PICs for example.⁸ We know from international evidence that availability of appropriately trained doctors, nurses and midwives is positively correlated with coverage of skilled birth attendance and therefore positive outcomes in MNCH.⁹ Yet, the critical issue of a local workforce in MNCH in PICs has not got the attention it deserves. We aimed to address this lacuna, through exploring the initiatives currently undertaken by ANZ peak bodies, in the area of training, support and collaboration for MNCH health workers in PICs.

Methods

We conducted semi-structured interviews by telephone with key informants (n=9) affiliated to the major medical and nursing educational institutions in Australia and New Zealand in MNCH and the two educational institutions in PICs that train MNCH workers, namely Fiji National University (FNU) and the University of Papua New Guinea (UPNG). The interview transcripts were thematically analysed then triangulated with the findings of the scoping literature review.

Findings

A recurring theme from all respondents, from ANZ peak bodies as well as UPNG and FNU, was the abundance of goodwill from individuals and agencies flowing towards PICs and health workers. Much of the support was informal and based on personal relationships and cultural ties. Table 1 lists the key activities undertaken by ANZ bodies in supporting health workers in MNCH.

Training as most visible form of support

RANZCOG offers a number of training and support programs and initiatives administered and monitored by the RANZCOG Asia Pacific Committee (see Table 1). Significant support for MNCH training at undergraduate level came from AusAID and New Zealand Aid through the support of Pacific medical and nursing schools.^3,10 Respondents suggested, however, that many training initiatives were ad hoc and poorly planned.

Limited human resources base

There is only a small pool of people who have the requisite qualifications to enter the healthcare workforce in PICs, attributed to the shortage of training facilities at a country level. A recent World Health Organisation (WHO) country report on Papua New Guinea (PNG)¹¹ noted, despite significant bilateral aid, there remain enduring gaps in healthcare resourcing, characterised by an ‘inappropriate distribution of healthcare staff’ and compounded by ‘education and training, which do not always meet the healthcare system needs’.¹²

A complex migration dynamic

There was agreement that migration from PICs of skilled health workers generally benefits ANZ. In the New Zealand context at least, losses of domestic nursing and medicine graduates to the overseas ‘market’, including Australia, render the human resource dynamic in the region much more complex to address. There are also concerns about the active ‘poaching’ of health professionals from PICs.

Lack of specific skills

Specific clinical skills shortages were acknowledged, such as in ultrasonography, laparoscopic surgery, gynaecology and vacuum- and forceps-aided delivery. Primary care, mental health input and public-health expertise were all felt to be lacking in PICs. Research skills in reproductive health were likewise a major lacuna, in spite of suggestions from regional WHO that ANZ research councils should provide support for research training opportunities in the Pacific.¹³

Lack of engagement with Pacific health needs

The issue of geographical inequity in relation to MNCH service delivery in PICs is most pronounced in PNG. The generally weak health infrastructure and support systems in PICs were often not factored in while planning or delivering health and support initiatives by ANZ teams.

Funding for MNCH initiatives

ANZ, through their respective aid agencies, have made significant financial contributions to the delivery of healthcare services and the construction of healthcare facilities in PNG and Fiji. A breakdown of MNCH-specific funding is difficult to derive however, in spite of both aid programs listing MNCH as priority.^14-17

Discussion: a call to action

Today there is a significant shortfall of skilled health workers required to meet the health MDGs by 2015, in our own region.¹⁹ We found that while a rhetorical commitment to providing support, training and collaboration opportunities to PICs exists within ANZ peak bodies, material plans and resourcing to advance these stated objectives are largely lacking, on the part of both major medical training bodies and government agencies in ANZ. As two of the most significant ‘receiving’ countries of regional health worker migration²⁰, ANZ have an ethical responsibility to respond to the challenges of delivering equitable and quality MNCH services in the region.

Although training initiatives loomed large in the scope of what ANZ bodies deliver and training is an important need for MNCH workers in PICs²¹, training is not always evidence-based or delivered in a planned, coordinated fashion. RANZCOG, as the regional training organisation for reproductive health, takes its role in PICs seriously. Indeed, RANZCOG’s sustained commitment not just to training, but also collegial support to MNCH health workers and initiatives in PICs, provides leadership and a way forward for other professional organisations. Respectful partnerships on an equal footing with PICs health workers and regional organisations are one way of achieving this. The Pacific Society for Reproductive Health (PSRH) as a regional organisation with a big mandate can be more effective if appropriately supported by ANZ governments, by tackling training and research needs in MNCH for the whole region.

Political will has been identified as a major factor, in either enabling or impeding the achievement of both the MDGs and reducing inequities in health and well-being.²² The challenge, as it stands, is therefore to optimally align the workforce needs of PICs and the political willingness that leaders in the public health field espouse, with available resources, to engage in capacity building initiatives that are mutually beneficial. We propose the following recommendations to address this ongoing dilemma; a call to action for ANZ peak bodies.

Recommendations

1. That there is closer alignment between the activities of regional professional training colleges involved in reproductive and child health and NZAid/AusAID bilateral programs.
2. That the national governments in Australia and New Zealand prioritise training within their own countries when domestic shortages of health professionals become intractable issues.
3. That aid and development agencies develop mechanisms to fund placements in high-need countries, in a sustainable manner, within a mid-term timeframe (five- to ten-year cycles).
4. That a regional body well supported by global health and development agencies and ANZ governments, take on the role of training in clinical skills and public health research in MNCH.This role can be taken on by PSRH, if appropriately funded.
5. That the following specific strategies to improve training, support and collaboration be implemented:
   • Sustained efforts in MNCH training, including more training opportunities and an increase in undergraduate
     training in medicine, nursing and allied health, supported by regional planning.
   • Increased professional recognition and opportunities for collegial engagement: modelled on the RANZCOG Associate Membership category and increasing reciprocal training arrangements.
   • Investment in midwifery: more direct investment in midwifery and training for midwives, based on a situational-learning model.
   • Targeted resourcing of MNCH: transparent investment in MNCH specific initiatives regionally planned and coordinated, particularly in frontline services.