Guest editorial. Developing human resources for health in the Pacific.

Abstracts from the Pasifika Medical Association Annual Conference – Tonga 2005 266-283s from the Pasifika Medical Association Annual Conference – Tonga 2005 266-283 EDITORIAL ASSISTANCE 284 Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 G U E S T E D IT O R IA L Guest Editorial As we write this introduction, the Hawaiian sailing canoes, Hokule‘a and Alingano Maisu, have just navigated across thousands of miles of the Western Pacific from Hawai‘i through the Republic of the Marshall Islands and on to Pohnpei, Chuuk, Satawal, Ulithi, Yap and Palau. The canoes, sailing without modern navigational aids, carry a message of cultural renewal, pride, and collaboration to accomplish something significant. On several islands, crew members joined clinical teams to highlight how health could be improved if we all work together. This special issue of Pacific Health Dialog examines capacity building through human resource development, sharing those values of cultural awareness, collaboration and creativity to set and reach specific goals. It focuses on our most important resource – people – and how professional development across the diverse health workforce can lead to improved outcomes. The timing of this special issue is critical as health leaders in United States-Affiliated Pacific Island (USAPI) jurisdictions embark on a strategic plan to improve human resources for health. Human resource development (HRD) in health requires a broad perspective and implementation of a number of careful strategic steps, beginning with a thoughtful needs assessment, which recognizes the critical role of all health workers (not just doctors and nurses) in both formal and informal health systems. It must include collection and analysis of data even when those data are not readily available or reliable. Development of training programs and curricula must grow out of local needs and conditions, and employ technology appropriate to the setting. Human resource development must effectively link continuing education to professional degree programs and work toward establishing both professional standards, as well as professional associations that maintain those standards in the various disciplines. Additionally, HRD must include provision of those tools needed by professionals to maintain current standards of quality medical care, while also facilitating improved health of community members. Sometimes this involves the latest technological advances, while other times it entails incorporating cognitive tools, such as evidence-based medicine or problem-based learning. This broad approach must be built upon recognition of the value of traditional healing systems, even as those systems are evolving, and also the value of local degrees and education, rather than focusing solely on imported credentials. Finally, HRD programs must incorporate an ongoing, critical evaluation of both process and outcomes, and allow feedback to drive improvement. As we begin to explore these issues, taking an historical perspective may be instructive. The original systems of health in the Pacific were indigenous, traditional, and tied closely to fitting with the ecosystem. Rapid westernization over the past 100 years linked to periods of colonization by Spain, Germany, Japan and, most recently, the United Lee E. Buenconsejo-Lum, MD, Assistant Professor, PACT Project Director, PHD Guest Co-Editor Allen L. Hixon, MD, Associate Professor, PHD Guest Co-Editor Neal A. Palafox, MD, MPH, Professor and Chair, PHD Guest Co-Editor Susan Matsuko Shinagawa, Past Chair, Intercultural Cancer Council, PHD Guest Co-Editor and Copy Editor Department of Family Medicine and Community Health, John A. Burns School of Medicine, University of Hawai‘i at Manoa, 95-390 Kuahelani Ave, Mililani, Hawai‘i 96789-1192. Development of training programs and curricula must grow out of local needs and conditions, and employ technology appropriate to the setting. Photograph of Micronesian canoe. Photo Credit: Na‘alehu Anthony, Polynesian Voyaging Society Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 States (U.S.), led to the introduction of secondary and tertiary hospital-based health systems, which tend to be centralized and particularly poorly aligned with the critical need to deliver healthcare to outlying areas. With hospitals staffed by U.S.-trained physicians and nurses under military and civilian contracts, a medical education system that roughly mimicked that found in the U.S. was variably developed. Beginning in the 1950s and well into the 1960s, recognition of the need for locally trained staff resulted in initial waves of trainees – often hand picked by the trusteeship governments – being sent to complete formal training in Hawai‘i and Guam. Graduating as nurses or medical officers, these pioneer trainees returned to their home islands and became the backbone of the healthcare system in the USAPI. From an HRD perspective, these groups imparted on-the-job training for other local doctors, nurses and allied health workers. This informal training system was unable to keep up with increasing demands to improve health conditions in these resource-poor areas. Lacking appropriate curricula and programs necessary to adequately prepare students for careers in health, local public school graduates often found it difficult to succeed at universities and professional schools in the U.S., Fiji, and elsewhere. As the initial waves of trainees approached retirement age, the need for a new cadre of well trained health workers became apparent. One early effort, led by Richard Smith of the University of Hawai‘i, was the MEDEX training program in Chuuk, which trained a cadre of indigenous health care professionals, known as Medical Extenders, some of whom remain active today. From 1986 to 1997, a collaborative effort between the University of Hawai‘i and the W.K. Kellogg Foundation helped to fill the void by establishing the Pacific Basin Medical Officer Training Program (PBMOTP) based in Pohnpei State, Federated States of Micronesia (FSM). During the decade of its operation, PBMOTP produced a number of indigenous doctors who were deployed to hospitals and clinics, as well as USAPI government posts throughout the region. In 1998, the Institute of Medicine’s Committee on Health Care Services in the U.S.-Associated Pacific released, “Pacific Partnerships for Health: Charting a Course for the 21 Century”. In its landmark report, the Committee concluded that the paucity of local professionals in the Pacific across all health disciplines resulted in the lack of available personnel to provide both formal training and continuing education sufficient to maintain currency of knowledge and skills among the existing healthcare workforce. At present (2007), some areas of the Pacific remain dependent on expatriate health workers from the U.S. and other countries. Over the past six years there have been a number of initiatives to increase the training of health workers within the region. Some of these efforts have attempted to move away from the traditional U.S. training model in favor of modular curricula, problem-based learning, adult learning methods, and building the infrastructure for continuing education. Efforts have also focused on developing a health workforce pipeline by implementing higher learning standards beginning in primary school, as well as strengthening the relevance of educational content and methods. In addition, by changing the focus of learning away from a purely curative model, public and community health approaches have been infused. Management and organizational issues are increasingly being scrutinized and identified as areas for improvement. Recognizing the importance of these changes, this special issue of Pacific Health Dialog focuses on ensuring sustainable cadres of high quality, indigenous health professionals who are closely aligned with the health needs of local communities. To address these broad issues, the articles in this special edition have been selected from among numerous submissions from many areas across the Pacific. Articles were submitted by clinicians, nurses, public health officials, academic physicians, community outreach workers, and voyaging sailors. The manuscripts span educational innovation and the testing of new learning modalities, presenting strategies that work well, and some that do not. Three major HRD themes are explored: (1) needs assessment, (2) novel methodology and approaches, and (3) community health. The first theme is addressed up front in the initial series of Original Articles, in which health leaders from nine Pacific jurisdictions (the Territory of American Samoa, Commonwealth of the Northern Mariana Islands, Territory of Guam, the FSM states of Chuuk, Kosrae, Pohnpei and Yap, Republic of Palau, and the Republic of the Marshall Islands) report on their respective needs assessments for establishing a continuing professional development program. These nine articles are preceded by an By changing the focus of learning away from a purely curative model, public and community health approaches have been infused. Management and organizational issues are increasingly being scrutinized and identified as areas for improvement. Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 overall Summary and followed by a report on the elearning telecommunications assessment of the Pacific Association for Clinical Training (PACT) by Higa. In each of the needs assessment articles, authors examine currently existing healthcare infrastructure and resources in the respective jurisdictions, and articulate strategies required to bridge existing gaps. While each jurisdiction reports its unique needs assessment, they all share the common challenge of adequately training their healthcare workforce to deliver quality and timely care across a vast expanse of the globe. A summary report on the PACT project – lessons learned (Buenconsejo-Lum et al), a Pacific Health Institutions article — describes successes and challenges and potential next steps for HRD in the region. Contributing authors whose articles pertain to the second theme explore new approaches and report on their experiences with novel HRD methodologies. In the lead article, authors Chen and colleagues review the PACT pilot project (“A Pilot Evaluation of Distance Education Modalities for Health Workers in the U.S.—Affiliated Pacific Islands”), and evaluate a variety of methods to deliver continuing education to health workers. Other authors discuss the utility of evidence-based medicine (e.g., Rarick), problem-based learning techniques (e.g., Yamada et al.), and distance education methods (e.g., Withy et al.). A second article by Higa presents challenges and opportunities for developing skilled information technology specialists who are needed to assist with distance learning opportunities in the USAPI. Articles on the final theme highlight disease-specific approaches to HRD in the community, focusing on clinical issues, such as obesity (e.g., Durand), cancer (Tanjasiri et al.; Cuaresma et al.), oral health (Tut et al.), and the human immunodeficiency virus (HIV) (Vezina et al.; Patrick et al.). Other community health-related articles underscore the social determinants of health in the Pacific by examining homelessness (e.g., Omori et al.; Lee et al.), poverty (e.g., book review by Hixon), and a variety of public health initiatives (e.g., Mitschke et al.; Duerler et al.). Finally, issues of structural violence – in Paul Farmer’s sense of the ways that social status, history, and economics conspire to constrain individual agency – are revealed through a discussion of militarization (Niheu et al.) and the unfortunate legacy of nuclear testing in the Pacific (Palafox et al.). It is imperative that HRD programs aimed at improving health across the Pacific be conducted in full recognition of the region’s existing historic and cultural patterns, as well as the changing paradigms of healthcare delivery. Innovative community-based training programs that are culturally relevant, technologically appropriate, and designed to leverage resources must both anticipate and lead that change. Recognition of the importance of HRD in health is evidenced by the array of federal grants and other funding sources supporting the research and activities reported in this special issue. A complete listing of grant support by article and funding agency follows. Like the Hokule‘a, this special issue of Pacific Health Dialog is a voyage of sorts – an exploration of the human potential to share ideas, techniques and resources in a collaborative and focused effort towards improving the health of populations. Our hope is that these articles will serve as “navigational aids” for all those concerned with improving healthcare and health outcomes in the Pacific. Bringing this special issue of Pacific Health Dialog to its successful fruition would not have been possible without the assistance of many individuals. We thank all those who submitted manuscripts for consideration of publication, and we are especially appreciative for the generosity and responsiveness of all our contributing authors and peer reviewers. Their interest, dedication and collaborative efforts within and across the myriad of disciplines comprising human resource development bode well for the future of the healthcare workforce in the Pacific, as well as the health of Pacificans, both in and beyond the region. We also acknowledge Mr. YuSharn Wang and Mr. Richard Yutaka Okubo for their assistance with electronic files conversion, and especially Ms. Nikki Baraquio for her assistance in copy-editing many of the articles in this issue; their efforts were invaluable to its successful completion. We hope you enjoy this special issue of PHD on "Developing Human Resources for Health in the Pacific”. We encourage you to disseminate and discuss the information and strategies described in these articles with your colleagues, and invite you to share with us your reactions and comments. We look forward to working closely with many of you in the future as we all Like the Hokule‘a, this special issue of Pacific Health Dialog is a voyage of sorts – an exploration of the human potential to share ideas, techniques and resources in a collaborative and focused effort towards improving the health of populations . Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 Developing Human ResouRces FoR HealtH in tHe paciFic vol 14. no 1. 2007 strive to strengthen the healthcare workforce, enhance healthcare delivery, and better the health of individuals and communities throughout the Pacific.