Review Article - (2016) Volume 3, Issue 1
Consultant, Leadership Strategies, Pty Ltd, Australia
Director of Operations and Development, WHO Collaborating Centre University of Technology Sydney, Australia
Received date: December 28, 2015; Accepted date: January 27, 2016; Published date: January 30, 2016
Citation: Deborah R, Michele R. An Innovative Approach to Supporting Health Service Delivery in the Pacific Appears to be Ticking Health Policy and Development Boxes. Health Syst Policy Res. 2016, 3:1.
Background: Good news stories about effective aid approaches are often buried under piles of reports about challenges, problems, weaknesses and leaders demanding new ways of working. In practice though, hearing that something has worked well and why, can inspire, motivate and policy reforms and improving practices in service delivery.
Conclusions: In the health sector, a well-conceived and coherent program of leadership capacity strengthening for Pacific nurses and midwives has been taking place over recent years. The program was recently identified as a strong approach by Associate Professor Joel Negin. This article reflects on why the approach taken by a team within the University of Technology Sydney (UTS) to increase skills and confidence for this group, has been working well.
Recommendations: The article highlights that many factors need to be taken into account and many approaches need to be integrated at multiple levels. It also suggests that in this context, an innovative approach may simply be achieved through applying lessons learned from global and local practice in a steadfast and respectful way.
Keywords
Capacity development; Pacific health; Nursing midwifery training; Leadership; Mentoring
Contributing to Leadership and Empowerment of Women in Pacific Health Policy Implementation
‘The foundation of this [Health System Strengthening Nursing and Midwifery Leadership in the South Pacific] program is to produce excellent, strategic, visionary nursing and midwifery leaders who are committed to sustainable positive health outcomes for all populations.’ – Amelia Afuha’amango, Chief Nurse & Midwifery Officer, Tonga
‘We don’t need to reinvent the wheel; we can learn from each other, have a shared agenda… [but] there is no one-size fits all to get the desired outcomes.’ – Rosemary Bryant, Chief Nurse & Midwifery Officer, Australia [1-3].
We don’t need international agencies to tell us that high quality nurses and midwives are essential for any effective health service – it’s obvious to anyone when we require medical or health care. However, international agencies do have a great deal of expertise in pulling together evidence about global patterns and issues and how to address them at many levels. Unfortunately those nursing and midwifery leaders are not always involved in policy development processes. It requires highly skilled and confident leaders to be involved in and implement policy and practice changes as the evidence informs them about the best ways to address myriad chronic and new health challenges. In Australia, this was recently recognized in a report on Leadership for the Sustainability of the Health System [4], which found that ‘At the national level there are major reforms foreshadowed or underway, and strong leadership capacity will be required to guide the workforce changes required to support national reforms. Effective leadership will build and support capacity for innovation and change.’ In other countries, the same links apply between leadership capacity and reform. This was highlighted most recently at a side-meeting of the July 2015 Financing for Development Conference in Addis Ababa [5].
In many Pacific countries, the numbers of senior health practitioners are very small and the opportunities for high quality in-service training are few and far between. The Report of the Tenth Pacific Health Ministers’ Meeting in 2013 confirmed this reality [6]. There is clear demand in the Pacific for experienced nurses and midwives to step up to leadership roles and address diverse, chronic and emerging health policy and practice issues. However, the capacity to achieve this at national levels in a sustainable manner is constrained by a myriad of other calls on limited resources in the health sector. For leadership to achieve developmental change, Andrews et al. [7] found that congruence between three capacities is required: acceptance of the need for change, ability to bring about improvements and authority to make decisions. Thus programs which seek to contribute to developmental change in this context, need to focus not just on the leadership skills of nurses and midwives, but also the understanding within the broader health sector that changes are required as well as increased recognition that informed and authoritative decision-making is critical and must be followed through in practice.
With ongoing resource challenges and increasing complexities associated with the implementation of health policies and the delivery of all levels of health care, greater leadership and constant upgrading of skill is required of nurses and midwives across the world [8]. While this may appear obvious, insufficient attention has been afforded to this area to date. This is the focus of WHO’s Global Strategy on Human Resources for Health, currently under development, to be called Workforce 2030 [9]. In the meantime, in low-resource countries of the Pacific region, with increasing demands on national government budgets, how can this priority are addressed? And when we know that aid funding is unpredictable in the face of changing policy priorities by donor countries and reducing aid budgets, how can endure partnerships to address this reality be funded? This article considers a strategic and resourceful approach used by the World Health Organization Collaborating Centre for Nursing, Midwifery and Health Development at University of Technology Sydney (WHO CC UTS) in this context.
Most Pacific countries struggle to provide sufficient high quality pre-service nurse training, let alone in-service training for senior practitioners and leaders [10]. For example, the 2013 Pacific Health Ministers Meeting noted that ‘several Pacific island countries and areas (PICs) have health worker-to-population ratios well below the World Health Organization (WHO) recommended minimum threshold of 2.3 per 1000 population’ [6]. Many face external labour market forces that make it difficult to balance health workforce demand, supply and affordability with existing and emerging population health needs [11]. For example, in PNG, the level of health worker to population ratio is 0.6 [12].
To respond to this situation, over 100 senior health professionals from 12 Pacific Island countries have completed, as Fellows, innovative and highly targeted leadership studies over the past 5 years. The program has been delivered within an ongoing collaborative partnership between the WHO CC UTS, the South Pacific Chief Nursing and Midwifery Officer Alliance (SPCNMOA) and Pacific Ministries of Health, a partnership that has been built over 10 years. Since 2010, funding support has been provided by a series of Australia Awards Fellowships from Australia’s Department of Foreign Affairs and Trade (DFAT) (previously AusAID).
The efforts of WHO CC UTS, working collaboratively with Pacific and international stakeholders, has contributed to building a cohort of nurses and midwives who, in evaluations, now report greater confidence as health sector leaders and increased ability to navigate and promote priority health policy reforms across the region. A qualitative study is currently underway to analyze the impacts of the leadership program on Fellows. We already know the current most senior nursing and midwifery officials in most South Pacific countries have participated in SPCNMOA and this program, with most having achieved seniority since their participation. Also, WHO CC UTS has refined its approaches since 2010 to incorporate lessons learned and contemporary approaches to leadership development, capacity development, cross-cultural collaboration [13] as well as nurse and midwifery professional development (Table 1).
| 103 Fellows (85% female, 15% male) from 12 countries completed 7 programs held over 6 years. |
| Program includes 14 days of targeted training in Sydney covering: contemporary health policy, leadership, partnership and contemporary nursing and midwifery approaches |
| Program includes: • Access to some of Australia’s leading health experts and trainers • Support for mentoring • Provision of workbooks • Pre-program support • Post-program follow-up. |
Table 1: Facts and Figures.
At the policy level, there are two key features of the work undertaken by WHO CC UTS. First, the program is closely aligned with international and regional health policy strategy principles and priorities, reflecting strong connections both with the WHO and the SPCNMOA [9,14-17]. Second, the program has responded to national policies in Pacific countries by supporting Fellows to undertake projects on priority issues in their respective agency.
Other success factors include: systematic selection of potential emerging leaders; a suitable mix of learning processes for a customized approach including mentoring; and strategic use of funding and other resources.
Alignment with international, regional and national policy frameworks
The Nurse and Midwives Leadership program is clearly focused on implementing improvements in health service delivery, consistent with internationally agreed and locally relevant policy agendas [16,18]. Ongoing relationships between WHO CC UTS and the regional and national health agencies in the Pacific region have maximized relevance and alignment of the program and ongoing support for systemic policy and practice changes. At the global level, contemporary support for health policy development and health sector strengthening is expected to reflect WHO resolutions [19]. Relevant WHO resolutions focus largely on achieving universal health coverage and the strengthening of human resources for health services. The latter will be the focus of Workforce 2030 mentioned above. The WHO CC UTS team is well-placed in the Asia Pacific region in this area of work. Table 2 below lists the relevant WHO resolutions which have been taken into account in designing this Pacific program, illustrating the diversity of inter-related issues.
| WHA63.16 WHO Global Code of Practice on the International Recruitment of Health Personnel |
| WHA64.6 Health workforce strengthening |
| WHA64.7 Strengthening nursing and midwifery |
| WHA66.23 Transforming health workforce education in support of universal health coverage |
| WHA67.10 Newborn health action plan |
| WHA67.12 Contributing to social and economic development: sustainable action across sectors to improve health and health equity |
| WHA67.13 Implementation of the International Health Regulations (2005) |
| WHA67.14 Health in the post-2015 development agenda |
| WHA67.24 Follow-up of the Recife Political Declaration on Human Resources for Health: renewed commitments towards universal health coveragein support of universal health coverage |
Sources: All documents available from World Health Organisation website.
Table 2: World Health Assembly Resolutions.
Relevance to the Pacific
For Australia-based training generally, there are always risks that learning will be irrelevant for those who go home to organizations with different cultural values and resource bases. In this case, the levels of alignment and relevance have been high because of WHO CC UTS’ close connections with Pacific networks and understanding of the contexts in which participants actually work. The program is developed with SPCNMOA. It includes Fellows developing an action plan with their SPCNMOA mentor, the most senior nurse in their particular country context, based on their own national health priorities and plans. The program then supports nurses, midwives and mentors over an 18 month process to implement their chosen project. For this to work well, all stakeholders need to have a deep understanding of the context, priorities and effective processes, as well as lessons learned from other experiences of the same issue. This is possible through long-standing, trust-based and respectful partnerships which take years to form and effort to sustain.
The fact that WHO CC UTS is the Secretariat to the SPCNMOA illustrates the importance of strong relationships. In this context, mutual respect and trust have meant that selection of candidates is carried out with SPCNMOA leaders and ensured that projects are well-pitched (see below). But, more than this, long-standing relationships have meant that WHO CC UTS has deepened its understanding of the influence of Pacific cultural values on learning processes, so both content and pedagogy are highly culturally relevant. Sessions on the influence of cultural values (such as those related to power hierarchy, collectivist decisionmaking, maintenance of harmonious relationships within groups, and comfort with uncertainty [20] are included in the training programs as these are clearly related to leadership and change [21] and partnerships [22,23]. This helps Pacific Fellows understand and work effectively with people from other cultures, not just lecturers on the program. One Fellow noted the value of learning with participants from other Pacific countries and from professionals who are committed to a quality program. She said ‘for us to meet all the different countries and the professionals who have come here to share their expertise… this program has widened my mind to political awareness and the importance of getting stakeholders’ buy-in’ - Cook Islands Fellow, 2013.
Continuous monitoring of participating nurses and midwives has identified consistently positive feedback about the program’s quality, relevance and benefits. Program participants have reported a range of outcomes on their return to work. For example, one Fellow from Papua New Guinea, 2015, noted ‘I have learnt a lot of things which will help me to improve my workplace to help nursing and midwifery services to be delivered to our people.’ Overall, Fellows identified increased knowledge and skills, greater self-awareness, confidence and motivation, in addition to new and specific information about nursing and midwifery practices. Fellows also reported they have stepped up to new roles as leaders, supervisors, coaches, mentors or general motivators to other team members. For example, one Fellow commented ‘This program is a very rich and diverse one, incorporating not only the core issues of leadership and management but also a range of related and equally important matters in any leadership style. I now feel very much empowered to make meaningful change in my organisation.’ – Solomon Islands Fellow, 2011.
Fellows’ country-specific projects, supported by the program, have addressed a diversity of health reforms, issues and challenges. These have not only helped improve skills in health service delivery but also strengthened confidence and leadership capacity. One Fellow for example said ‘Coming [to this program] has been difficult but it is an honor for me. The project we have taken up [is to address] a long term problem. What I have learnt in two weeks has taught me how to see my way through. We have learned to use evidence, and translate evidence to practice. I also now understand how to look at policy, not just my project. This has given me the confidence to go back and drive things through. I can’t find better words to express my thankfulness, it has been so relevant. I have learned a great deal.’ - Solomon Islands Fellow, 2013.
Success factors
So why has this particular program ticked so many boxes? A complex set of factors has influenced success, beyond the alignment issues mentioned above. It seems to be unusual for an Australia-based agency for which core business is vocational teaching to have applied sound international developmental approaches to the program at a practical level. For example, the team sought to collaborate with Pacific leaders in the process, particularly through having SPCNMOA as a partner, both contributing to and making the most of existing and ongoing strong relationships within the region. The program sought to respond to the specific learning priorities of the participants rather than deliver off-the-shelf Australian packages suitable for completely different settings. Program design and delivery applied contemporary ideas about capacity-strengthening practice in a resourceful, culturally respectful and responsive way [24].
To maximize relevance and recognize Pacific Islanders’ preference for collective approaches to learning, for example, two Fellows from each country are included in the courses and are encouraged to plan together before flying to Australia. First, Fellows are asked to identify a shared policy or practice priority to address in an Action Plan, both during the training and over 6-18 months afterwards. Second, the program includes a country-led daily review each day allowing each country’s Fellows a voice, along with sessions to help Fellows to understand the role of cultural values in their ways of working (contrasting with ways of working in countries where most international policy agendas are set). This understanding is particularly helpful for those Pacific health organizations which work in partnership with international agencies, enabling them to interpret and navigate others’ approaches for their own contexts. Leadership approaches are particularly linked to cultural values, so participants develop understandings of the principles and practices which will support high quality leadership in their own countries. One Fellow said ‘I thought I understood leadership but this training has given me a bigger picture on how to move ahead in delivering good services. The program links from one session to another and links with our country’s realities.’ - Cook Islands Fellow, 2013.
Third, Fellows are required to develop a project relevant to their own country and consistent with local priorities before arrival in Sydney for the training. Support is provided for conceptualizing and planning for implementation, while participants learn about different health policy and practice topics, approaches, ways of thinking and working. Project implementation on return is supported through mentoring from previous Fellows in leadership roles and the respective country’s most senior nurse, someone who is well-known to the WHO CC UTS team from the SPCNMOA regional network. This recognizes that culturally-appropriate and contextually-specific mentoring is much more likely to be effective than that provided by people from outside the context [25,26].
Finally, to support the importance of ongoing learning, the WHO CC UTS team follows up with program participants back in their home countries, through SPCNMOA. This involves meeting with their colleagues and supporting continuous improvement. Program staff often recount their experiences of visiting Pacific health services for other meetings and finding that previous Fellows run up to them to share stories of their applied leadership, changed approaches, reforms to health service delivery and benefits to their communities. One staff member recalled: ‘I was on a remote island in PNG when a senior nurse appeared. She was very excited to see me and explain that although she had attended the program two years before, she had remembered never to stop looking for new ways to implement her work. She mentioned that a few months before, a new member of staff had started at the hospital and this had provided an opportunity to reinvigorate her project, which is now progressing well.’
Other success factors include WHO CC UTS team’s resourceful approach to securing repeat grant funding through the Australian Government’s Australia Awards Fellowship even though such fellowships are usually conceptualized as one-off in nature. This means that most senior leaders in nursing and midwifery across the region have now participated in the program, creating a cohort of people with shared leadership understanding and skills. Related to this approach, has been the appropriate selection of program participants. The selection process has meant that all those participating have been energized, motivated and engaged in the collaborative learning process and committed to strengthening their own leadership capacity. Enduring and collaborative relationships across the region support this process – something that is often not possible in short-term one-off training.
The mix of learning methods has also been effective. Country focused projects, group classroom learning led by Australian and Pacific senior health leaders, visits to New South Wales Health Department and other activities have been carefully selected and adjusted to respond to monitoring feedback each year since 2010.
Conclusion
In summary, increasing capacity for leadership and health reform takes sustained, long-term collaboration and partnership in areas prioritized by local leaders, rather than one-off training or other short-term inputs driven by external agendas. The team WHO CC UTS have been resourceful in tapping into annual funding to deliver a coherent program and linking it with other resources to build effectiveness. To use a health metaphor, based on evidence of effective approaches, multiple doses of short-term inputs have been administered, in this case funded by annual Australia Awards Fellowships between 2010 and 2015. This wellconceived, aligned, sustained and systematic regional approach to leadership development in this sector over 5 years has meant that a very high proportion of leaders are now better placed to implement contemporary health policy reforms. This effective contribution to groups of senior women and men health sector leaders has integrated lessons learned from the health policy context and development practice over many decades. Further research into the perceptions of Fellows and Mentors of the program is underway.
Recommendations
‘There are two winners in this situation – they are the patients and the community and the nurses and midwives themselves. For the latter, gaining such skills equips them to demonstrate leadership wherever they may work in years to come.’ – Rosemary Bryant, Chief Nurse & Midwifery Officer, Australia (AAF Poster).
Support for leadership development in the health sector is an important contribution to women’s empowerment in the Pacific, since most health workers are women and their roles as leaders can inspire others, bring about changes and contribute to gender equality more broadly.
Australian organisations working internationally need to build sustained, culturally-respectful and policy-based partnerships within which development processes are implemented, rather than the other way around.
Australian organizations working as development partners need to respond to national policies in Pacific countries by supporting participants to undertake projects on priority issues in their respective agency.
Consistent with this approach, efforts to support health workforce development in Pacific countries need to recognise that each country has its own priorities and resource bases and thus a onesize fits all approach is inappropriate. However, there are shared cultural values between most Pacific contexts as well as some shared policy opportunities, so a regional approach to leadership development in the health sector has merit.
Maximizing the benefits of capacity contributions to the Pacific region is even more essential in the face of constrained budgets. Approaches which recognise that most countries in the region are not likely to be able to sustain their own high quality in-service training for nurses and midwives are essential.
In summary, the nurses and midwives leadership program run by WHO CC UTS over the last 5 years needs to be sustained, in ways which continue to maximize alignment with global, regional and local policy priorities, cultural relevance, and capacity development lessons.
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