Health workforce governance, policy and management are required for sustained workforce contributions to improved population health outcomes, including HRH capacities to address disasters [18, 19]. Governance has been described as a determinant of adaptive capacity of the health sector for disaster response [1, 35]. This requires clear policies and a cross-sectoral national coordination or formal mechanisms of governance including health planning, stakeholder coordination, registration and coordination of in-coming overseas health workforce. Management capacity-building policies and structures should be in place and networks and partnerships of relevant committed leaders and stakeholders should be established and under pinned by the relevant operational processes [15, 18, 19].
Health-care management systems
One of the key concerns expressed by both Australian and the PIC respondents was the coordination and registration of in-coming international health personnel in times of disasters. This was necessary to ensure timely external assistance, minimize duplication of scarce resources, provide a transparent process, and maximize effectiveness of health personnel. Studies have revealed that these elements are essential for the effectiveness of international disaster responses, and require the development of policies and agreements against agreed criteria as part of disaster preparedness on an international, bilateral and national level .
There were different approaches to the coordination of incoming international health personnel in the four PICs. In the Cook Islands, guidelines for the coordination of in-coming health personnel require clarification. In normal times in-coming personnel follow a registration protocol; however, in times of disaster the process was reportedly unclear. This has resulted in a recent review of legislation around international disaster response, calling for stricter regulation in this area . For instance, according to one respondent, the request for international health staff goes through the Disaster Council and the Disaster Committee, who would then advise the Ministry of Health (MOH) of who is coming. However, another government respondent felt that while the requests go through the health ministry, the process can sometimes be informal and can result in fragmented communication, as evidenced by the following quote. “Informally all requests [for] incoming health workers go to the MOH; [however]it doesn’t always work as it can be an informal process across most sectors, which can lead to lack of sectors talking to each other”. According to Bremer , policy making related to disaster response must be conducted in the disaster planning phase in both receiving and donor countries, since there is little time for policy making and implementation of rules during the acute phase of a disaster. These policies should be carefully developed to guide interventions that are based on commonly agreed upon criteria .
However, the absence of policies to guide international HRH in some PICs could be due to the fact that in recent times there has not been a need for international health personnel to assist with disaster response. The infrequency of larger scale disasters impedes the development of an evidence base to inform public health preparedness strategies . One recent example of a disaster requiring overseas health workforce support in the Pacific was during the 2009 tsunami in Samoa . The Pacific Humanitarian Team (PHT) includes, as members all organizations that have a mandate and the capacity to respond to a disaster in the Pacific region. The PHT provides support to government coordination efforts during a disaster response following a request for assistance, and was a key player in the 2009 tsunami response . Both Vanuatu and Fiji respondents indicated that they relied on the PHT/UN Cluster system to assist with provision of health personnel in times of disaster. Samoan respondents indicated that a system was in place for the registration of in-coming health professionals. However, problems have been reported with this process, mainly because some NGOs were either unaware of the need to register or chose to bypass the system. One Samoan respondent suggested that an acceptable approach would be that medical NGOs and volunteers coming from overseas should link directly with the local MOH for a centralized approach in order to avoid duplication of roles. However, there is “[n]eed for a new fast circuit approach to facilitate the registration and checking of qualifications of health workers at the time of disasters” (OUM, Samoa).
In trying to address issues with in-coming health personnel, disaster response stakeholders have put forward a recommendation that the relevant Emergency Management Office should work closely with the UN Office for Coordination of Humanitarian Affairs (UNOCHA) and other external organizations to ensure that all personnel are registered and that a proper register of in-coming support is maintained. This will ensure that in-coming personnel are properly screened and facilitate quicker immigration and customs processes . International donors and Australian NGOs indicated that their provision of HRH for humanitarian response is guided by minimum global standards. Ministries of Health in each country should work with external partners to manage registration of incoming health personnel effectively.
The other critical issue of governance involved limited systems for the protection and management of health staff affected by disasters. This was identified as impacting the health workforce’s ability to respond effectively, since they were usually first responders in all countries, and had to conduct disaster initial assessments.
Some international organizsations recognized that disasters impact individual health workers when their families, friends or homes are directly affected, placing additional demands and challenges on health workers . Appropriate support systems would ensure that health workers are cared for and motivated in conducting this essential health function. Efforts and alternative sources that are being investigated to support human resource capacity were described by participants. In Samoa, for example, “private doctors and nurses are called in to assist in times of disasters” (Govt. Rep, Samoa).
The pre-existing HRH shortage in the Cook Islands reportedly resulted in existing personnel working extremely long hours. However there was no financial support or benefits for working overtime. Additionally, staff were not insured, so in the event of injury or death in the line of duty there was no redress. Similar issues were identified by respondents from Fiji and Samoa who indicated that health personnel were among the first responders, arriving in the disaster area while it was still relatively unsafe. Since health personnel are usually among the first responders to disasters, there needs to be stronger support systems in place to protect their wellbeing during times of disaster. This does not only have implications for response personnel’s job security, but also for occupational safety and health, insurance and indemnity [41, 42]. The provision of adequate pay and adequate indemnity for health-care staff involved in disaster response have been identified as essential motivators for Australian relief personnel . Unfortunately these realities do not translate to their Pacific Islander counterparts due to pre-existing disparities in health-care financing and staff incentives. Efforts should be made to improve conditions for PIC counterpart health workers.
Health-care policy environment
Interviews in the four PICs revealed evidence of a mixed policy environment across countries for the coordination of HRH for disaster response. For example, in Fiji a contingency plan for disaster response and coordination of health staff was in place, including legislation to empower key individuals to make decisions in times of disasters. In the Cook Islands, a health disaster policy was in place to provide directions for both on-duty and off-duty staff during disasters, however there was limited knowledge of policies due to high staff turnover rates. The Samoa National Health Service (NHS) has a disaster plan which outlines staff responsibilities, which is disseminated down to the divisional level of the health sector that work closely with communities. The Samoan NHS plan makes provision for the involvement of the private medical practitioners and the Samoa Red Cross Society. Conversely, there was a lack of clear policies and guidelines for health workforce coordination during disasters in Vanuatu. Unfortunately, there was little evidence of strategic planning to ensure that health-care needs were adequately represented in wider planning for climate-related disaster response. This extended to a lack of strategic planning for HRH to meet current and future needs, and may reflect a wider lack of attention to the HRH strategy development process . A good quality strong evidence base is needed for the development of adequate disaster response policies, plans and procedures to guide HRH response. Unfortunately despite a substantial amount of publicly available international literature relating to emergency response planning, the validity and generalizability of these to the Pacific context remains unclear .