Achieving Universal Health Care in the Pacific: The need for nursing and midwifery leadership. Review Paper

Summary

The quality of healthcare services and outcomes in the Pacific vary widely, with some countries enjoying some of the world's longest life expectancies, others have high rates of maternal and child mortality and relatively low life expectancy. Nurses and midwives make up more than two thirds of the regional regulated healthcare workforce. This paper argues that if countries are to meet Universal Health Coverage  nursing and midwifery leaders need to be explicitly involved in shaping policy  at the highest levels of government to optimise individual and community health both now and in the future. Using United Nations 2019  declaration towards building a healthier world, this paper provides a rationale for inclusion of these leaders  into national and regional decisionmaking forums related to health policy to provide an informed voice in ministerial deliberations on health policy. We suggest that following several comprehensive regional and global studies, South Pacific Chief Nursing and Midwifery Officer Alliance  and the newly developed Pacific Heads of Nurses and Midwifery provide a vehicle for this to occur. As outlined in the WHO Strategic Directions, it is now time to embed Chief Nurses in national and regional health policy development.

Introduction

Pacific Island Countries (PICs) have been at the forefront of effective leadership in relation to managing the COVID-19 pandemic and their nursing and midwifery leaders, through the South Pacific Chief Nursing and Midwifery Officer Alliance (SPCNMOA), have provided high quality examples on a global stage about the benefits of nursing and midwifery leaders being involved in health policy development.¹⁰ However, given the move towards Universal Health Coverage (UHC)¹² and the need to meet the Sustainable Development Goals (SDGs)¹, the regional research has shown the need for nursing leadership in developing regional health policy has never been greater.^5,13,14

Health outcomes in PICs vary widely, with some countries enjoying some of the world's longest life expectancies and thus ageing populations, whilst others have high rates of maternal and child mortality and relatively low life expectancy.¹⁵ The largest component of the disease burden is non-communicable disease, although control of communicable diseases remains a major challenge.¹⁶ Newer challenges include the health impact of COVID-19, climate change and effective response to disasters, whilst older challenges, such as tuberculosis, remain unresolved.^12,16 The quality of health services varies among the countries and within individual countries, nevertheless nurses and midwives make up more than two thirds of the regional regulated health workforce. Due to the sheer numbers and transformative role of nurses at the frontlines, nurses and midwives need to be involved in shaping health policy to optimise individual and community health both now and in the future.

However, despite making up more 60% of the global health workforce (and 74% in the Pacific region),⁷ to date, nurses have not had a concomitant influence on health policy. Rasheed et al (2020)¹⁷ in their extensive review of nurses’ impact on health policy found that health hierarchies, gender power differentials and lack of confidence and skill all played a role in limiting nurses’ contributions. They found that nurses tended to play the role of policy implementers rather than being drivers of policy change. Indeed, Asuquo et al¹⁸ found that even policies that directly related to nursing were developed without considering a nursing viewpoint or input. An International Council of Nurses (ICN) survey in 2020 showed that although ‘two-thirds (67%) of WHO Member States report having a GCNO ‘focal point’, many of these positions do not have the authority to advice and influence at a strategic level, and that the full range of responsibilities and resources associated with the GCNO role are essential to directly influencing health policy formulation. Some focal points are not even Registered Nurses’.^19,20 Further, results from research in Thailand ²¹ and the Pacific^5,13,22,23 provide evidence of high-quality health policy outcomes such as influencing the Nurses’ Act and improving human resource deployment when nursing leaders are explicitly included and consulted on health policy development. While nurses have long taken their role as patient advocate seriously and sometimes at detriment to their employment²⁴ they have generally not been so vocal or successful at advocacy in government or global forums. There is consensus in the literature however, about the potential benefits for improving health outcomes if nurses were to become more vocal and engaged in developing health policies.

The Pacific is well-placed to leverage the contribution of its nursing and midwifery leaders as there are already well-established leadership groups of Government Chief Nursing and Midwifery Officers (GCNMOs) in the region: The South Pacific Chief Nursing and Midwifery Officers Alliance (SPCNMOA) and the forum of Pacific Heads of Nurses and Midwifery (PHoNM) under the Pacific Community (SPC). The SPCNMOA began in 2004 as an informal group of regional nursing leaders and has developed into a coherent and sophisticated organisation with the capacity to guide and advise on regional and global health policy. It started with members of CNMOs from the South Pacific and now includes the northern Pacific through joint membership of American Pacific Nursing Leadership Council (APNLC). Through regional advocacy by SPCNMOA at meetings with SPC Clinical Directors and Heads of Heath,^3,9, 10, 11^,25, 26, 27 the PHoNM forum was established with a wider membership audience of NGO's, funding bodies, SPC Executive and SPCNMOA. The PHoNM held its inaugural meeting on 11–14 February 2020, Fiji with the aim of providing executive-level oversight of regional nursing functions in the Pacific, including a ‘policy advisory’ and technical role in informing decision-making.¹⁰ The regional GCNMOs have a deep understanding of both the context and needs of their countries and in the region. However, a leadership research carried out in the region,^5,28 a WHO scoping report reviewing quality of education and regulation in the region ⁶ and an ICN survey¹⁹ all suggest that, they are not being fully utilised by their local governments and regional authorities as key sources in relation to health policy development and implementation. This empiric evidence was obtained by prolonged engagement²⁹ and strong informal communication with senior regional nurses at a workshop held at UTS in 2019³, which facilitates information-sharing through forging of partnerships, personal relationships, and trust.³⁰ However, there is a need for rigorous evidence to quantify the extent of engagement and influence of GCNMOs in decision-making.

GCNMOs individually and through the SPCNMOA ³ together play a vital role to in planning, development, and implementation of health policy. To be effective, they must be represented at the highest level of policymaking.^20,31,32 Although some progress has been made in terms of nursing and midwifery leadership in the Western Pacific, there is still a need to assess the extent to which GCNMOs are involved in governmental decision-making in the Region. Frequently, the nursing contribution at national government levels is often non-existent, under-recognised or underutilised, meaning nursing and midwifery leaders are still not able to contribute in a systematic way to central decision-making on health policy.²⁰

This paper provides a rationale for the involvement of regional nursing and midwifery leaders in all health policy decisions, in particular in relation to achieving UHC. This has been outlined as a priority in the WHO Global Strategic Direction for Nursing and Midwifery (SDNM), ‘Policy Priority: Establish and strengthen senior leadership positions for nursing and midwifery workforce governance and management and input into health policy’.⁴ This paper argues for the explicit engagement of the Western Pacific regional GCNMOs and the SPCNMOA in key health policy forums and processes. Using the six key ‘asks’ developed at the United Nations High-level Meeting on Universal Health Coverage ² it provides a rationale and framework for the recommendation of ensuring Government Chief Nursing and Midwifery Officers (GCNMOs) have an explicit place at the table where policy decisions are debated and agreed. This is clearly articulated in the WHO Global Strategic Direction for Nursing and Midwifery⁴ with a series of policy priorities to meet and provide an implementation strategy with ‘broad engagement for robust national data, intersectoral policy dialogue supported by data and analysis, and evidence based decision-making on appropriate policy actions and investments’.⁴

Key Asks in Relation to Meeting Universal Health Coverage

The United Nations High-level Meeting on Universal Health Coverage on 23 September 2019 provided an opportunity for UHC champions and advocates to mobilise high-level political attention at both the global and national levels.² The meeting produced a concise and action-oriented political declaration that strongly committed signatory countries to achieving UHC by 2030 with a view to scaling up the global effort to build a healthier world for all.²

A multi-stakeholder consultation process saw the development of a set of political 'Key Asks' that were presented at the UN High-Level Meeting on UHC. The answers to these key asks were to be fed into the political declaration to provide the foundation for coordinated advocacy efforts. The asks are presented in Table 1.³³

Table 1.

The UHC six asks.

Urinary tract infection

Pressure ulcers

Hospital-acquired pneumonia

Shock or cardiac arrest

In-hospital mortality

Failure to rescue

Upper gastro-intestinal bleeding

Hospital-acquired sepsis (life threatening infection)

Deep vein thrombosis (“DVT”)

Central nervous system complications

Pulmonary failure post-surgery (heart/lung)

Metabolic derangement post-surgery (abnormal biochemical functioning)

Adverse drug events (missed, delayed or incorrect medication)

In-hospital falls.

The following section briefly examines the six asks in relation to nursing and midwifery policy and practice throughout the South Pacific Region and explores why effective nursing and midwifery leadership is crucial if UHC is to be achieved in the Region by 2030.

The UHC six asks

Ensure political leadership beyond health

All health-care providers and associated health-care workers need support from a range of government ministries and organisations outside government to ensure maximum impacts for patients and communities. For nursing and midwifery in the South Pacific, having a GCNMO in every country is central to maximising the impacts of the service across the Region.

The functions of GCNMOs, as set out in detail in the Roles and responsibilities of the government chief nursing and midwifery officer consensus statement,³⁴ are:

… assist the government to achieve the population health goals of the country through nursing and midwifery, by the provision of expert policy and technical advice and recommendations. This advice and subsequent recommendations are based on timely accurate local data and national and international evidence, and through her/his professional collaborations and networks of influence as well as extensive knowledge, experience and understanding of the nursing and midwifery profession.

“Policy activity”, the consensus statement continues, “is the most vital of all roles as it enables nursing and midwifery professionals to be heard at policy level, where the possibilities of health practices are determined.³⁴” WHO SDNM (2021) agrees with the above statement and ‘emphasizes inclusive actions by the national Ministry of Health and key stakeholders in sharing data and nurses and midwives participating in policy dialogue’,⁴ which to date is not occurring systematically or widely.

SPCNMOA worked with the 10^th Pacific Health Ministers meeting in Samoa³⁵ to advocate for a GCNMO in every country of the Pacific. Since that meeting, significant changes in the region in relation to the growth of GCNMO positions have taken place. In 2019, only 27 out of a total of 37 countries in the Western Pacific Region had a chief nurse and midwife, five were making efforts to establish one, and five did not have one or have plans to put one in place.³ However, by 2020, apart from PNG, all countries in the Pacific Region had a GCNMO or equivalent.⁷ This success now needs to be built on to ensure all countries in the Region can benefit from the expertise of a government CNMO.

Outstanding nurse and midwife leaders simultaneously see the big picture and the consequences at micro level.³⁶ They have a unique and integrated perspective of community health that allows them to assess individual, community, and population health; advocate for health equity; and collaborate with legislators and other leaders in the health care system to help address priority health issues.³⁷ However, despite the key roles that policy and politics play in determining health strategies, and nursing and midwifery practice, (with many nurses and midwives carrying out decisions made by others), there is still evidence of nurses and midwives having a weak influence on policy development and participating from a position of relatively low status.^4,16,26 Nursing and midwifery leaders are often neither heard nor heeded in settings where policy decisions are made, such as in parliaments, governments and boardrooms.³⁸ The SDNM highlighted that only 50% of reporting countries (191) indicated the existence of nationally-supported leadership development programmes for nurses.^4,7 This has also been highlighted in other regional studies illustrated that effective leadership programs in the Pacific need to be contextualised.^5,13,25

WHO has been at the forefront of coordinating meetings across the Western Pacific Region to push the case for, and advantages of, having a chief nurse and midwife at government level and this will continue with the WHO SDNM.⁴ As an example, the Collaborating Centre at University of Technology, Sydney hosted a workshop for 18 chief nursing and midwifery officers from the Region in September 2019.³ The workshop focused on health-system strengthening through improved data literacy, data analysis and understanding of the relationship between data, information and knowledge to inform, and translate health expenditure into policy, in line with WHO national health sector accounts methodologies,³⁹ which were used by 18 countries attending to collect the data for the WHO State Worlds Nursing Report. The meeting urged governments to recognise the important role and involvement of chief nursing and midwifery officers in the analysis of high-quality data (population health, quality and safety) for governance and decision-making.³ The data collected from this workshop assisted in the Western Pacific element of the WHO first State of the Worlds Nursing Report (SoWN) 2020⁷ and WHO State of the Worlds Midwifery Report (SoWMy) 2021⁴⁰. This data in turn provided the global evidence for the WHO Global Strategic Direction for Nursing and Midwifery.⁴

Since nurses are on the frontlines of healthcare, their unique perspective of primary health care allows them to identify and appropriately address social determinants of health (SDH).⁴¹ Having nursing and midwifery leaders who actively participate in policy and decision-making could be beneficial in ensuring SDH are taken into consideration in planning processes, policy-making and strategies.

Leave no one behind

Effective nursing and midwifery services are critical to such systems and to expanding effective health coverage in the Region. Investment in building and maintaining a competent nursing and midwifery workforce able to deliver people-centred integrated health services and empowering nurses and midwives in their roles as first responders working with communities to enhance health and reduce harm, is therefore essential.

WHO has emphasised that an adequate, well distributed, motivated and supported health workforce is required to strengthen primary health care, progress towards UHC, detect, prevent and manage health emergencies, promote the health and well-being of the population, and support attainment of the health targets in Sustainable Development Goal (SDG)⁴² (health and well-being). Nurses and midwives are central to this effort.⁴

The approach to nursing and midwifery workforce development in the Western Pacific Region must therefore reflect the recognition that health systems’ effectiveness at country level will be predicated on a primary health care-led model of delivery, which is often nurse or midwifery enabled. This means working with people in their communities, evaluating the impact of policies and programmes on the ground, regularly monitoring and documenting who is being “left behind” to improve equity in access to quality health services, and contributing to data collection to inform national policy development and evaluate performance against, for instance, the SDG Global Indicator Framework.⁴² The ample involvement of nurses and midwives in the delivery and evaluation of primary health care, makes them indispensable actors the process of developing policies that target equitable access to health services.

There is also a clear need to look beyond nursing, midwifery and the broader health and social care workforce when identifying how best to ensure no one is left behind. Whole-of-government action involving various ministries (such as health, education and finance) and other key stakeholders (educators, employers and regulators, for example) is required.

A wider perspective is necessary if health systems are genuinely to ensure no one is excluded and the aspiration of good health becomes a reality for all. Clarity of roles is also needed. Many studies highlight the scope for effective deployment of clinical nurse specialists and nurse practitioners in advanced roles, leading, delivering and evaluating health care interventions for individuals and populations. There is great potential across the Region to enhance the scope of practice for nurses and midwives and utilise more specialist and advanced practice nurses and midwives to work with communities; levelling inequities; providing interventions to manage ill health; and promoting health and well-being.⁶ Policy-makers are beginning to recognise the urgent need for investment and wider implementation of specialist and advanced nursing and midwifery roles to support achievement of the fundamental changes necessary to enable UHC and ensure no one is left behind in communities and populations.

Regulate and legislate

While the nursing and midwifery workforces are well recognised as essential parts of health systems’ service delivery function, they are much less recognised in governance and regulatory functions in health systems.⁴ The nursing and midwifery workforces are therefore potentially underutilised and could be powerful drivers of improved regulation and governance in health systems, particularly in settings with limited resources. The WHO SDNM also provided considerable evidence indicating the value of professional autonomy and impact of nurses and midwives ability to work to their full scope of practice.^4,43, 44, 45, 46, 47, 48

Current nursing and midwifery workforce participation in health-system governance commonly is limited to representation on committees and boards; line accountability through senior positions in relevant institutions; regulation of the nursing workforce and advocacy.¹⁸ Generally, the nursing and midwifery contributions focus only on representing nurses’ and midwives’ perspectives and interests, with very limited influence on overall health-system governance and performance.²⁰

The voices and participation of midwives and nurses in the Region and around the world need to be strengthened. More generally, nursing and midwifery need to have stronger voices in determining the broader issue of how countries more efficiently can regulate health systems to ensure law and policy are implemented and achieve their intended purpose.⁸

Well-designed legislation for the regulation of health professionals:⁴⁹

• •does not create unnecessary burdens for countries (including financial and administrative)
• •is focused on risk to public safety
• •is proportionate to the benefit it brings, and
• •is sufficiently flexible to respond to different health-care needs, approaches and future changes.

Organisational arrangements differ in scope in countries across the Region, but regulation of health practitioners typically involves legislation mandating the maintenance of a register or list of those who are registered; setting and assuring educational standards for entry to practice; investigating and dealing with concerns in relation to the conduct, health or performance of registered practitioners; and, increasingly, assuring continuing competence to practise.⁴⁹ The absence of nurses’ and midwives’ input in the development of educational standards, accreditation and regulation of these professions is reflected in the lack of well-defined regulatory processes and scopes of practice in some countries in the Pacific.²⁶

The Western Pacific Region has amassed considerable experience in health workforce regulation however some weaknesses still exist. Developing more consistent approaches to designing and implementing regulatory frameworks and mechanisms for sharing information, knowledge and expertise about good regulatory practice will build capacity and strengthen regulation across the Region ⁴⁹. Also missing in a number of jurisdictions is the legislative framework required for the accreditation and monitoring of education providers and programmes, essential for facilitating high quality education for health professionals.

Uphold quality of care

Throughout the world, basic population health needs in many lesser-resourced countries remain unmet. Nurses and midwives make critical contributions to meeting population health needs, but increasing the numbers of nurses and midwives on its own is insufficient to address the problem adequately.⁸ Improving the quality of nursing and midwifery education is also needed.²

Special emphasis must be placed on building the capacities of nurses and midwives to work with fellow health professionals and communities to deliver evidence-based, high-quality care across a range of settings and rapidly changing environments.⁵⁰ The UN declaration for UHC went on to state that due to the global concern regarding shortfall of health workers we must recognise need to train, strengthen and retain skilled nurses, midwives and community health workers to maintain a strong resilient health system for UHC.² One specific action mentioned in ‘ask 4’expresses the need to “train a health workforce based on quality and competence, with a special focus on nurses, midwives and community health workers"³³.

In many countries, continuing professional education (CPD) is a requirement. Worldwide, nurses are required to attend an average of 30h per year of CPD in order to maintain professional registration.⁵¹ With a support of a strong leadership and a positive workplace culture, CPD that is relevant to the workplace can improve individual motivation to deliver quality healthcare.^4,52,53 Nurses and midwives who benefit from relevant ongoing professional development opportunities are often in a strong position to drive high-quality care delivery in their teams and communities. But across the region nursing and midwifery education and ongoing professional development organisation, delivery and evaluation is sometimes poor, and accreditation processes are often lacking.

Evidence-based, culturally appropriate strategies are required to educate a new generation of nurses and midwives, particularly those in low-income countries. Participatory approaches for collection of baseline data to best inform the design of effective faculty and professional development programmes are also necessary.

Invest more, invest better

Investing more and investing better in the health-care workforce, including nursing and midwifery, can bring obvious benefits. The aim is to gain the maximum health and well-being outcomes for the population from appropriate and managed investment in the recruitment, deployment, ongoing development and retention of the health-care workforce.⁵⁴

The health sector contributes hugely to supporting and sustaining health and well-being among countries’ populations, and plays a significant part in contributing to countries’ economies, particularly through its employer functions. Youth unemployment throughout the Asia Pacific Region, including the Western Pacific, is high. Before the pandemic youth unemployment was estimated to be around 23 per cent generally, rising to an estimated 40 per cent in Solomon Islands,55, 56, 57 with youth at least three times more likely to be unemployed than adults.⁴⁹ There is a need for far greater innovation and imaginative approaches to selling the attractiveness of careers in nursing, midwifery and other health professions to young people and creating a range of pathways into nursing, midwifery and health service careers. Making nursing attractive to its current practitioners through effective and high-quality and appropriate preparation, ongoing education, career development opportunities, working conditions and remuneration is the best way of making it attractive to future generations of midwives and nurses.

A major challenge for nursing and midwifery, however, is to demonstrate the cost–effectiveness of their services. How far does the cost of an episode of midwifery or nursing service result in benefits in relation to, for instance, improving population health and well-being; reducing health inequality and other forms of inequity; and supporting countries’ economic development and performance? The models and processes for collecting this crucial data have not yet been developed in the Region, pointing to an urgent development need. However, there is a large and convincing body of research conducted by nurses in more developed countries which amply illustrates the benefits of investing wisely in better educated nurses and increasing their numbers.58, 59, 60

Over the past 20 years research has provided an extensive body of research to show a number of common adverse patient events (Table 2) that are significantly related to the number and education level of the nurses who care for those patients.⁶¹ Many of these indicators have been shown to extend the length of stay and increase healthcare costs. The WHO SDNM provided considerable evidence indicating a variety of ‘financial and non-financial incentives that could assist in retaining midwives and nurses in rural, remote and other underserved area’.^4,43, 44, 45, 46, 47, 48

Table 2.

Nurse Sensitive Indicators.

Ask	Goal
ASK 1 - Ensure political leadership beyond health	committing to achieve UHC for healthy lives and well-being for all at all stages as a social contract
ASK 2 - Leave no one behind	pursuing equity in access to quality health services, with financial protection
ASK 3 - Regulate and legislate	create a strong, enabling regulatory and legal environment that is responsive to people's needs
ASK 4 - Uphold quality of care	building quality health systems that people and communities trust
ASK 5 - Invest more, invest better	sustain public financing and harmonize health investments
ASK 6 - Move together	establish multi-stakeholder mechanisms for engaging the whole of society for a healthier world

However, the policy changes required to build safe staffing levels did not occur without nurses being at the table when these policy decisions were made.⁶¹ Initially the Governments who fund healthcare did not appreciate the benefits of increasing staffing numbers and the educational levels of nurses. It took considerable political lobbying and commitment from nurses to persuade Governments and healthcare organisations about both the economic benefits as well as the benefits to individual patients. It is arguable that this major change would not have occurred without nurses being at the table and consistently arguing for the reform.⁶¹

Move together

The UHC key ask of moving together calls on all countries to take active steps to meaningfully engage nongovernmental actors, particularly from unserved, underserved or poorly-served populations, in shaping the UHC agenda.² It goes on to list a specific action agenda that includes:

• •Enabling and introducing processes for structured and meaningful engagement of all government sectors and actors, the private sector and a broad base of civil society, including young people and academia.
• •Empowering individuals, families, communities, local providers and civil society organisations to be at the centre of UHC, especially by strengthening and enhancing community capacity to get involved in decision-making and accountability processes.
• •Empowering communities through a primary health-care approach to, for example, promoting good health, managing disease and mitigating health crises at community level, while also strengthening community participation among all populations.
• •Improving health, legal and systems literacy and capacity for health decision-making by focusing on prevention, appropriate technology and a multisectoral approach at local level, including addressing all determinants of health.
• •Providing financial support for civil society and community groups as key contributors to health systems’ development and critical advocates for vulnerable and marginalized populations.
• •Supporting women as community leaders and change makers, and recognising that their significant unpaid contribution to family care, should be recorded, redistributed and rewarded.
• •Enhancing international coordination and enabling environments at all levels to strengthen national health systems and share knowledge and experience to strengthen the sustainability of UHC.

Ensuring all people have access to this kind of UHC and quality care requires strong and capable leadership.⁶² Nurses and midwives can be at the forefront of providing this; they are the health-care professionals who often are closest to communities, and therefore best understand their needs and wishes and recognise the nature and significance of collectivist societies prevalent in the Region. They act to empower individuals and communities through facilitating self-care and self-management approaches; enhancing health literacy; promoting preventive and health-enhancing behaviours; and supporting individual and joint decision-making.⁶² GCNMOs can provide the professional link between Ministries of Health and the education sectors in relation to nursing and midwifery education and clinical practice.

As predominantly female professions, nurses and midwives understand the gender inequalities that affect women's and girls’ health, education, employment and general life prospects, and can take action to reduce inequities.² Additionally, nurses and midwives are not only acquirers of knowledge and information, but also are conduits for knowledge and information flows to individuals, families, communities and entire populations at local, national, regional and global levels.⁶³

Attention needs to be paid to ensuring that nurses and midwives have the education, mentoring, support and opportunities to enable them to fulfil these much-needed roles for the better health of all.⁶⁴ WHO SDNM highlights this further by prioritising the need to ‘strengthen senior leadership positions for nursing and midwifery workforce governance and management and input into health policy. Government chief nursing officers and chief midwifery officers should work on par with other health professional leadership in making strategic decisions that impact health service planning for meeting population health needs’.

Priorities for Action

Recent research in the Pacific has assessed: leadership,²⁸ faculty development, regulation,⁶⁵ maternal and child health,⁶⁶ health workforce needs during climate related disasters.⁶⁷ A WHO study of online learning in 15 countries in the Pacific found a lack of continuous professional development for nurses.⁵³ Findings across this body of research shows that health workforce education and regulatory systems are weak in many Pacific countries with limited numbers of educators, outdated curricula, education programs that do not match health security needs, and limited continuing professional development opportunities for nurses and midwives.⁵³ Other research also shows that health workers’ skills, competencies, clinical experience, and expectations are often poorly matched to changing population health needs including health security.⁶⁸ This research also highlights the need for leadership training and capacity building.⁶⁸ Further, Pacific Island health ministers have noted the importance of supporting improvements in Human Resources for Health to address UHC and the SDGs.

To advance the status of health professions in line with civil society's changing needs and ensure best practice, the SPCNMOA, PHoNM and GCNMOs who make up its membership need to be part of the development of regional policy in relation to these key areas:

• •Contributing to sound governance. This will ensure issues affecting health populations are taken into consideration by ministerial policy makers. Including the SPCNMOA and through them, the PHoNM, will ensure policies are relevant and communicated to and owned by the nursing and midwifery workforce. Empowered leaders such as GCNMOs are essential to promote policy dialogue across all the health sectors to ensure effective and efficient health governance. An empowered GCNMO can provide effective leadership on different aspects of health system plans and policy, particularly those that have nursing and midwifery implications.²⁰ GCNMOs also have the capacity to assist governments to achieve the health goals of their countries through the effective deployment of the nursing and midwifery workforce.^4,69
• •Accreditation of education programs relevant to nursing and midwifery. Assessing the capabilities of education providers; and the form, content and outcomes of education programs to consistently deliver reliable quality results based on constituent accreditation standards enables consistency in the education of graduates seeking to register as nurses and midwives. Accreditation of education providers and management of conduct are the cornerstones of a well-regulated workforce. Led by the SPCNMOA, nurses and midwives are now moving towards developing regional standards for accreditation and educational outcomes. These standards can form the foundations needed to guide policy development in relation to education of nurses and midwives.^4,69
• •Regulation, through contemporary legislation, ensures the protection of the community by requiring the development, monitoring and maintaining standards to uphold the quality of registrants. Legislation to mandate the establishment of the necessary infrastructure such as systems for creating reliable registration processes (including data); standards, competencies and codes; investigation processes to ensure compliance; and accreditation systems needs to be embedded across the Region. While most countries in the Region now have regulation in relation to the nursing and midwifery, developing a Regional approach will help foster common understanding and trust as well as develop national capacity in terms of governance, accreditation and mutual recognition of qualifications. Until regional standards are achieved, countries and education providers will continue to act independently, experiencing both professional mobility within the region and emigration.^4,68,69 This will lead to shortages of trained staff, national crises due to insufficient production and retention, dealing with identifying equivalencies for course credit transfers, struggling to retain regional academics, duplicating teaching materials and employing professionals from other countries.^4,68,69
• •Quality education requires highly qualified educators, opportunities for CPD, research, regular institutional accreditation, and access to quality curriculums and resources. The SPCNMOA needs to be part of policy discussions in relation to continuing professional education and prioritising its contextualised focus on relevant education for the region.^4,6,69 The WHO SDNM expresses this clearly outlining the.’quality of nursing and midwifery education programmes and the preparation of qualified faculty remain critical challenges’. The WHO SoWN ⁷ and SoWMy reports,⁴⁰ ‘a high proportion of countries reported the existence of education standards and accreditation mechanisms. However, in many countries where accreditation mechanisms exist, the process falls short of identifying quality issues and ensuring education is effective and relevant to meeting local health priorities’.⁴

Conclusion

The COVID-19 pandemic has brought the urgent need for high quality health workers to the fore. The contribution of nurses and midwives has never been more crucial, especially in relation to achieving UHC and the SDGs, as well as enabling an effective response to disasters. Populations continue to grow and age while patterns of disease fluctuate with a variety of factors including social changes brought on by economic and technological expansion. Health workforce shortages affect every corner of the globe while urbanisation draws services and providers into the cities, leaving those on the margins and in remote and isolated settings ever more vulnerable.

United Nations universal health coverage global declaration (2019:23) provides a clear mandate,

“it recognize the need to train, build and retain a skilled health workforce, nurses, midwives and community health workers, who are an important element of strong and resilient health systems, and further recognize that increased investment in a more effective and socially accountable health workforce can unleash significant socio-economic gains and contribute to the eradication of poverty in all its forms and dimensions, empowerment of all women and girls  and reduction of inequality” ²

Nurses and midwives represent between 60% and 80% of the world's health professional workforce.^7,70 For the benefit of both their patients and their professional status, nurses and midwives and nursing and midwifery leaders must step up and engage in health policy planning locally, nationally and globally. Nursing and midwifery leaders need to ‘think globally and act locally’.

Governance, regulation, accreditation and education are the cornerstones of any health system.⁶⁹ It is self-evident that nurses and midwives and nursing and midwifery leaders have integral roles to play in the data revolution that will ensure progress on the path to meeting health-related SDGs and UHC by 2030. Simply recording numbers in relation to population health and workforce requirements is no longer adequate. Policy debates on health matters at the country, regional and global levels must be informed by high-quality, accurate data that is diverse, timely and internationally comparable. The midwifery and nursing professions need new waves of ‘data literate’ nurses, midwives and nursing and midwifery leaders, educated in cutting-edge monitoring and evaluation methods. In order for these nursing leaders to become involved in decision-making in the Pacific, nurses and midwives need to receive contextualised leadership training and capacity building.^5,28,53,67 This will allow policy makers to make better decisions for people-centred care with a primary health care focus in partnership with civil society, nurses, midwives and other health professionals.

In order to improve the quality of health service provision in the Region nursing and midwifery leaders need to be at the heart of policy decision-making. Despite coming from low-resource environments, the SPCNMOA has the structures and relationships to enable it to take a leadership role in achieving UHC. The SPCNMOA works through a model where members are able to collaborate develop and adapt tools, curriculum and standards relevant for their specific contexts. More importantly, the SPCNMOA provides members with a supportive space where they can share challenges, innovations as well as stories of what has not worked well. Their passion for improving the health services for their population ensures that they have persisted despite the organisational and resource constraints they face on a daily basis.

It is self-evident that all countries of the region (and indeed the world) need competent health practitioners, educated by high quality academic staff to ensure that graduates are safe and effective and can support the Healthy Islands Vision, which encourages an emphasis on primary health care and public health to promote the health of island people and communities.⁷¹

There needs to be sustained commitment at ministerial, regional and national level for policy dialogue, investments and implementation of actions if the goals of UHC and SDGs are to be realised. A renewed focus on UHC, and Triple Billion Targets within the SDGs demands a flexible and resilient, highly educated and motivated workforce. The recognition of the nursing and midwifery workforce by WHO and the UN to achieve UHC brings with it both opportunities and challenges. Achieving UHC will only be possible if the full potential of both nurses and midwives is recognised, and their full scopes of practice are utilised. Dominating the frontline of health service delivery, nurses and midwives have a social responsibility to report their experiences and outline their requirements all the way up to the WHA. To do this, appropriate channels of communication and empowered leaders are required. National governments must embed GCNMO into key decision- making forums to ensure that the experience of these workforces are appropriately considered in ministerial deliberations on health policy. Well-briefed ministers, armed with the right information, will enable senior leaders in health to voice their concerns and also empower GCNMOs to communicate with international policymakers at various global forums. The new WHO Global Strategic Directions for Nursing and Midwifery 2021-2025 presents evidence-based practices and an interrelated set of policy priorities that can help countries ensure that midwives and nurses optimally contribute to achieving universal health coverage and other population health goals. Strengthened leadership provided by the GCNMOs of the Pacific and the collective of the SPCNMOA, and through them, the PHoNM would be the conduit for this to occur.

Declaration of interests

None