Essential Medicine Training – New Initiatives in the South Pacific for Health care worker Training

1. Essential Medicine Training – New Initiatives in the South Pacific for Health care worker Training Andrew Brown Lecturer in Pharmacy

2. Contents • A brief Introduction of Andrew and UC • Explanation of the challenge in PICs. • Human resource issues • 1. Mapping the scope, competencies and workforce needs of heath care workers in PICs. • 2. What are the cultural influences on the learning approaches of South Pacific Students? . • 3. Integrating parallel program training into existing essential medicines training a UNFPA initiative. • Where are we headed? • Strategic Partners.

3. Introducing Andrew Brown • Community Pharmacy • Hospital Pharmacy • Solomon Islands • Managing Pharmacies • Academic Pharmacy - Teaching (Pharmacy Practice, Health Professional Practice) - Research (Equipping healthcare workers for essential Medicines management)

5. The University of Canberra • Faculty of Health: • -Pharmacy (2005) • -Physiotherapy • -Nutrition • -Nursing • Midwifery • Psychology • Sports Science

8. Explanation of the challenge 20 sovereign states. Population of 9.6million dispersed over 1000’s of islands. Lack of consistent supply of Essential Medicines in the clinics of many of these countries. (WHO, AUSAID) Millennium Development Goals not improving. (World Bank, UNPA.)

9. How is Essential Medicine Supply Conducted? The Systems The Staff Pharmacists (If you’re lucky) and pharmacy assistants Pharmacy Assistants/Nurses Nurses • National Medical Stores (Essential Medicines & Equipment) • Regional Centres • Remote Clinics

10. Human Resource Issues • Just over 300 pharmacy staff in the region (Excluding PNG) distributed throughout the public sector of these countries. • 80% of these post filled by pharmacy technicians. • The majority of health care in the region is supplied through the public sector and therefore warrants particular attention. • The Fiji School of Medicine and the University of Papua New Guinea are the only universities in the region providing locally trained pharmacists to a degree level with most of these graduates going to the private sector.

11. Human Resource Issues • There is no formal certificate training available for pharmacy technicians in the region apart from semi structured localised training in the Solomon Islands and Samoa. • Recent WHO systematic review and consultation with chief pharmacists of the region show that health resource issues are a leading factoring hindering essential drug supply.

12. Method • Date of inception to April 2009: • MEDLINE, EMBASE, PubMed, Google Scholar • World Wide Web for grey literature • Others. • Search terms included; Culture, customs, learning approaches, pedagogy, pacific, South Pacific, training, teaching, students and health. • Review Method

13. A Systematic Review Addressing; Competencies, Training and Work force Requirements, for any Health Care Worker in Pacific Island Countries Involved in Essential Medicines Supply Provision,January 1998 to July 2009

14. Method • Review and analysis of WPRO provided papers, consultancy reports and other relevant documents as provided by WPRO through their Fiji Office. • A systematic review of available bibliographic data bases including “INFORMIT” (Containing the Australasian Medical Index), “EMBASE” and the expanded range of “EbscoHost” Data Bases including Medline. • Direct communication with NGO’s active in the region. • Direct communication with the major government donors to the region. • Targeted review of the grey literature (Internet based publications not tracked by bibliographic databases.)

15. Key Words • Health care worker; Includes all levels of pharmacy staff (including pharmacists, pharmacy technicians and pharmacy stores), storeman (not within a pharmacy department but responsible for any aspect of essential medicines supply), nurses, nurses aids or any health care worker,responsible for any aspect of essential medicines supply. • Pacific Island Countries; The 20 independent countries and regions in the South Pacific including; Cook Islands, Federated States of Micronesia, Fiji, Kiribati, Marshall Islands, Niue, Nauru, Palau, Papua New Guinea, Samoa, Solomon Islands, Tonga, Tokelau, Tuvalu and Vanuatu, Guam, Northern Mariana islands, American Samoa, New Caledonia and French Polynesia (Tahiti).

16. WHO/WPRO Reports

18. WHO/WPRO • WHO/WPRO HRH provided individual health workforce plans for 10 PICs prepared in 1998

19. Organisations Contacted and Websites Reviewed • South Pacific Board for Educational Assessment  • Taiwan International Cooperation and Development Fund  • UNFPA in the Pacific  • UNICEF Pacific Islands • United Kingdom AID  • United Nations Education, Scientific and Cultural Organisation  • United States AID  • University of Papua New Guinea • University of the South Pacific • WHO Regional Office for the Western Pacific • WHO Geneva • World Bank • Ausaid  • Australian Nursing and Midwifery Council  • European Union • Fiji School of Medicine • Human Resources for Health Recourse Centre  • International Council of Nurses • International Pharmaceutical Federation (FIP) • Japan International Cooperation Agency  • New Zealand’s International Aid & Development Agency • Pacific Human Resources for Health Alliance • Pacific Islands Development Program • Pacific Islands Forum Secretariat  • Secretariat of the Pacific Community.  • South Pacific Board for Educational Assessment 

20. Limitations • E-mail as a primary mode of communication. • Key organizations were followed up with a phone call if a timely response to e-mail was not received but this was not systematically done for all the organizations. • Individual governments of the countries covered in the review were not contacted. • Very limited material retrieved containing data specifically relating to PICs satisfied the Health Development Agency Evidence Base 2000 standards (Swann 2005).

21. Results - Competencies • There is a scarcity of information documenting the competencies required by health care workers in the region. • Currently available competency documentation is limited to higher domain competencies or only to certain cadres. All the relevant information retrieved for this part of the review was from the grey literature.

22. Results - Competencies • UPNG. • Fiji Review by Griffith University. • The Australian Nursing and Midwifery Council, WSPEAR consultation process resulted in the publication of “Common Competencies for Registered Nurses” in 2006.

23. Observations - Competencies • Very little data. • No detailed competency sets.

24. Results - Workforce • WHO Human Resources for Health provided, individual health workforce plans for 10 PICs. • UNSW detailed review of 15 countries March 2009.

25. Observations - Workforce • Variations in the availability of workforce data • Varied HRH data repositories • Lack of disaggregated workforce data • Limited continuing education and training development • Limited coordination among external partners engaged in HRH support

26. Results - Training • Individual PIC workforce plans from 1998. • In country reviews of the pharmaceutical services of individual PICs 2006 to 2009, • Annual regional workshops where PICs have discussed issues relating to training 2003 to 2009.

27. Observations - Training • Hands on training required. • Flexibility to start and stop training based on workforce requirements. • Preference for training to occur in country. • Strengthening of in country teaching ability. • External support and training should be consistent with health workforce plans. • Training is focused on pharmacists not pharmacy assistants.

28. Observations - Training • External support is needed to provide in-country training. • Pharmacists via UPNG or FSMed. Pharmacy assistants non- certified on the job training. • Nationals trained overseas not returning. • Recognition that nursing staff have a significant role in pharmaceutical services and need to be trained in this. (Pharmacy staff need the skills to be able to do this training) • Modular approach to curriculum design to allow sharing of materials across sectors.

29. Training Observations – Summary • The need for training is clear. • An individual country approach is desired. • A systematic approach to human resources management is desired. • Support from regional institutions requested. • A collaborative regional workforce is ideal. • A collaborative approach to training is ideal. • A review of available training materials is essential. • NGO parallel programs should work to integrate into PIC structures. • The approach to training needs specific features.

30. The approach to training needs specific features. • Flexible in their delivery in relation to time and approach, • Applied to the local environment, • Involve local senior staff where possible, • Be competency/skill based (On the job), • Consider cultural aspects of learning and teaching, • Be conducted in the local country where possible, • Involve the use of local colleges or facilities where available and useful.

31. Potential Recommendations • Conduct comprehensive individual country HRH assessments relating to cadres involved in essential medicines supply provision. • Strengthen and facilitate collaboration of regional pharmacy institutions. • Form and support a Pacific Island Countries HRH pharmacy working group. • Undertake a comprehensive review of available essential medicines training resources in the region. • Strengthen the ability to monitor and plan for HRH.

32. Cultural Influences on Learning Approaches for Students in the South Pacific, with a view to Pharmacy Assistant Training

33. Method • Date of inception to April 2009: • MEDLINE, EMBASE, PubMed, Google Scholar • World Wide Web for grey literature • Others. • Search terms included; Culture, customs, learning approaches, pedagogy, pacific, South Pacific, training, teaching, students and health. • Review Method

34. Results • 52 full text articles and 12 books retrieved. • Reviewed by theme as some overlapping of themes occurred: • 25 papers and 5 books for South Pacific student learning approaches • 21 papers and 4 books for culture, • 11 papers and 4 books for broader educational issues

35. Results –South Pacific student learning approaches • The use and relevance of Western learning style inventories as measurement tools • Other research not involving learning style inventories

36. Results –Culture • Cultural practices which have surrounded and modeled their upbringing from birth • South Pacific indirect style of communication • ‘Pasin bilong Pasifika’ (‘The Pacific Way’) • Health Beliefs • Learning to be and learning to live together

37. Results –Broader educational issues • The effect of Colonial History • Impact of Globalization • Educational Aid • A Pacific Vision for Education

38. Discussion • Limitations • Use of learning approaches. • The Need for more research

39. Conclusions 1. A surface approach to learning is the result of a number of regional, social, historical and cultural contexts and is often a strategic learning method used by students in the South Pacific.

40. Conclusion 2. Students do understand and possess skills for critical thinking and a deep approach to learning. This can be facilitated by integrated, holistic, culturally sensitive & contextualised methods of teaching in accordance with ‘The Pacific Way’, utilising their traditional learning strategies and involving critical reflection.

41. Conclusion 3. We need to be aware that isolation faced by students, is a significant factor requiring the need to utilise technology and multimodal teaching methods to facilitate deep learning.

42. The Development of a Reproductive Health Commodities Security (RHCS) Training Manual for First Level Primary Health Care

43. Brief Overview • Role of UNFPA. • Project Description • Current review of materials. • Desk audit. • Focus group • New materials Development • Trial to be conducted in Vanuatu.

44. Preliminary Analysis

45. Suggested Approach to Training Materials • Students do understand and possess skills for critical thinking and a deep approach to learning. This can be facilitated by integrated, holistic, culturally sensitive & contextualised methods of teaching in accordance with ‘The Pacific Way’, utilising their traditional learning strategies and involving critical reflection. • Wherever possible use student centred leaning methods that challenge passive, rote learning. • Encourage group activities that promote group involvement in learning, and encourage students to take responsibility for their own learning.

46. Suggested Approach to Training Materials • Create a framework within which students are encouraged to think critically. • An individual country approach is desired. • The approach to training needs specific features. • Training should seek to integrate NGO parallel programs into PIC structures. • A Gunning Fog Index of 7-8 is ideal when the intended audience in First Level Primary Health Care Workers.

47. Suggested Approach to Training Materials • Ensure that the content reflects the competencies required for these workers. •  Be consistent with the use of technical jargon and terms. Where necessary explain the various terms used that are equivalent in nature. • Training material layout should be considered for easy of use and easy reference by learners. • Include the use of localizing features including diagrams and examples.

48. Suggested Approach to Training Materials • Include sufficient exercises and working space to allow learners to apply their learning to day to day tasks in their work environment. • Create sufficient flexibility to be inclusive of the different systems that are used across the region. • Current training materials in this area already contain the main components required but the delivery needs to be improved.

49. Trialling a New Methodology • Country chosen based on training need and request from MOH via pharmacy or nursing. • Preliminary country survey of supply procedures. • Training template assembled. • Training materials reviewed by country. • Materials printed. • Work shop conducted. • Follow up support offered.

50. Preliminary Country Survey • Diagrammatic representation of the medicine supply system • Diagrammatic representation of the medical equipment supply system (If different) •  Copy of essential medical equipment list (If available) •  Copy of standard treatment guidelines. •  Does a national medicines policy exist? •  Standard operating procedures for; • ordering stock, • delivery stock • unpacking stock • layout of stock in a clinic • putting away stock Electronic copies of; • bin cards, ordering forms , packing slips, Coat of arms, Country map