Strengthening health services: wealthy countries must meet their workforce needs from within their own resources and not continue to plunder workers from the developing world.

I arrived in Islamabad at 3am on a bleak, wet night. A confusing drive through unlit streets and past armed soldiers and police brought me to the guarded gates of my hotel. After a hot bath I was comfortably tucked up in bed by 6am and soon asleep, after reflecting briefly on the New Zealand Government advisory given to me before I left: "There is extreme risk to your security in Pakistan and travellers ore advised against all travel." However, participation in the World Health Organisation (WHO) Global Consultation on Strengthening Nursing and Midwifery in Islamabad, Pakistan, for three days in early March was too important an opportunity to miss.

Islamabad is a long way from Wellington and an Islamic republic under military rule is very different from a secular state under parliamentary democracy, but people are people the world over. Moreover, the issues facing nurses and midwives differ only by degree and in context. The essentials of nursing are the same, regardless of language, and I found this meeting and sharing about issues central to nursing and midwifery, intensely stimulating and rewarding.

The meeting was hosted by the Pakistan Ministry of Health in co-operation with the WHO, the International Council of Nurses (ICN) and the International Confederation of Midwives (ICM). I was one of 27 nurses and midwives invited to provide strategic direction for strengthening nursing and midwifery around the world in response to resolutions of the 2006 World Health Assembly (WHA). Participants included WHO chief nurse Jean Yan, ICN chief executive Judith Oulton, ICM chief executive Kathy Herschderfer and a number of ICN, ICM and WHO consultants. NZNO president Marion Guy and Te Runanga kaiwhakahaere Brenda Close were members of the New Zealand delegation to the World Health Assembly in 2006 when ways of addressing the global health workforce shortage were debated. Two workforce resolutions resulted. The first recognised that "shortages of these health workers are interfering with efforts to achieve the internationally agreed health-related development goals". (1) The second urged member states to ensure "equitable geographical distribution in sufficient numbers of a balanced skill mix, and a skilled and motivated nursing and midwifery workforce within their health services". (2)

NZNO's extensive experience in working with members to identify and resolve the issues that constrain nurses' abitity to practise in full accordance with professional nursing standards and to make nursing in New Zealand an attractive and rewarding career option, was very relevant to addressing the issues before the Islamabad meeting.

The meeting addressed three issues: determining the appropriate skill mix of health care workers; identifying strategies to scale up health workforce production; and establishing measures to create positive workplace environments, to support recruitment and retention. A set of 13 globally applicable principles for building the capacity of the nursing and midwifery workforces at national and global levels was developed. These were launched by the Pakistan Minister of Health as the Islamabad Declaration on Strengthening Nursing and Midwifery at the conclusion of the meeting. The full text is available on the NZNO website www.nzno.org.nz.

Perhaps the single most significant principle for developed countries like New Zealand is one stating that: "Each country must establish policies and practices to ensure self-sufficiency in workforce production within the limits of its own resources."

New Zealand, like many developed countries, relies heavily on overseas trained nurses. A recent study notes that nursing shortages in the world's wealthiest countries undermine global health initiatives by "pulling" nurses out of the world's poorest nations. (3) We in New Zealand are net users of this scarce resource in a world where health problems are greatest precisely where health workers are most scarce. The professional and industrial work NZNO does to achieve fair pay and safe staffing, thus attracting more New Zealanders into the profession, makes an important contribution to addressing this global inequity. International agreements around ethical recruitment certainly have their place, but the powerful "pull" of wealthy nations will always circumvent such measures, so long as we continue to fail to meet our own net needs for a health workforce from within our own population. Migration of health workers is not bad in itself, but when it means the heavy loss of essential workers from the developing world to wealthy countries, it becomes very damaging. Other fundamental issues addressed in the declaration include the place of unregulated workers in nursing and midwifery, competency-based career frameworks, employment practices, workplace policies and the importance of professional leadership.

The work of the NZNO/district health boards' Safe Staffing and Healthy Workplaces Committee of Inquiry (CoI) informed my participation in this global consultation. The Islamabad Declaration sets out principles that mirror and support the committee's recommendations. NZNO will continue its work with employers and the Government on joint implementation of the recommendations of the CoI. The Islamabad Declaration will provide further impetus to this work. My short time in beautiful but tormented Pakistan reminds me how fortunate we are to be global citizens with our homes in Aotearoa New Zealand. Action upon the Islamabad Declaration by the WHO's member states will help all nations achieve the global health goals.

References

(1) World Health Assembly. (2006) Rapid Scaling up of Health Workforce Production. Resolution WHA 59.23, 2006. Geneva: World Health Organisation.

(2) World Health Assembly. (2006) Strengthening Nursing and Midwifery. Resolution WHA 59.27, 2006. Geneva: World Health Organisation.

(3) Aiken, L.H., Buchan, J., Sochalski, J,, Nichols, B. & Powell, M. (2004) Trends in international migration. Health Affairs: 23: 3, 69-77.

By NZNO chief executive Geoff Annals