ABSTRACT

This article describes the human resources for health (HRH) policy and action plan development in Barbados, Grenada, and St. Vincent and the Grenadines, the supporting role of the PAHO/WHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University, and sub-regional action for supporting continuing country-level HRH strengthening. A policy development process, comprising document/literature review and stakeholder consultations, was used to conduct a situational analysis, which informed the HRH policy and action plan. The policies and action plans centered on HRH priority areas of leadership and governance, HRH planning capacity, strengthening primary health care, optimization of pre- and post-licensure education/training, retention and recruitment, deployment and utilization, inter-sectoral and external partnerships for sustainability, health information systems, and HRH research. A cross-sectional analysis of the findings found that HRH challenges and priority areas were consistent across the countries, resulting in similar policy priority actions that are aligned with the regional lines of action for strengthening HRH for universal access to health and universal health coverage. The results support the value-add in collaborating on a regional level to build capacity for needs-based HRH planning within member countries. The Caribbean-Community (CARICOM), with facilitation by Pan American Health Organization (PAHO) Caribbean Subregional Programme, has established the Human Resources for Health Action Task Force for the Caribbean. The expertise of the Dalhousie University PAHO/WHO Collaborating Centre, provided through the technical assistance, supported the three countries in this important initiative and provides for further opportunities to support PAHO, the Task Force, and countries as they work to achieve their HRH strengthening objectives.

Keywords
Policy making; workforce; health

RESUMEN

En este artículo se describe la elaboración de políticas y planes de acción sobre los recursos humanos para la salud en Barbados, Granada y San Vicente y las Granadinas, el apoyo brindado por la Universidad de Dalhousie (centro colaborador de la OPS/OMS para la planificación y la investigación sobre el personal de salud) y las medidas subregionales para apoyar el fortalecimiento continuo de los recursos humanos para la salud a nivel de país. Se llevó a cabo un proceso de elaboración de políticas, que incluyó la revisión de documentos y artículos, así como consultas con las partes interesadas, para realizar un análisis de la situación, que documentó las políticas y los planes de acción sobre recursos humanos para la salud. Las políticas y los planes de acción se centraron en las áreas prioritarias de liderazgo y gobernanza de los recursos humanos para la salud; la capacidad de planificación de los recursos humanos para la salud; el fortalecimiento de la atención primaria de salud; la optimización de la educación y la capacitación previas y posteriores al otorgamiento de licencias, así como la retención y el reclutamiento, el despliegue y la utilización; las asociaciones intersectoriales y externas para la sostenibilidad; los sistemas de información de salud; y la investigación en el ámbito de los recursos humanos para la salud. En un análisis transversal de los resultados se concluyó que los retos y las áreas prioritarias en el ámbito de los recursos humanos para la salud coincidieron en todos los países, por lo que las medidas prioritarias establecidas en las políticas son congruentes con las líneas de acción regionales para fortalecer los recursos humanos respecto del acceso universal a la salud y la cobertura universal de salud. Los resultados respaldan el valor agregado que tiene la colaboración a nivel regional encaminada a crear capacidad para la planificación de los recursos humanos para la salud basada en las necesidades dentro de los Estados Miembros. La Comunidad del Caribe (CARICOM), con la facilitación del Programa Subregional del Caribe de la Organización Panamericana de la Salud (OPS), ha creado el grupo de trabajo de recursos humanos para la salud en el Caribe. La experiencia de la Universidad de Dalhousie como centro colaborador de la OPS/OMS, en forma de la asistencia técnica prestada, brindó apoyo a los tres países en esta importante iniciativa y ofrece nuevas oportunidades para apoyar a la OPS, el grupo de trabajo y los países en su labor para lograr sus objetivos en cuanto al fortalecimiento de los recursos humanos para la salud.

Palabras clave
Formulación de políticas; recursos humanos; salud

RESUMO

Este artigo descreve a política de recursos humanos para a saúde (RHS) e o desenvolvimento de planos de ação em Barbados, Granada e São Vicente e Granadinas, o papel de apoio do Centro Colaborador da OPAS/OMS sobre Planejamento e Pesquisa da Força de Trabalho da Saúde (Universidade Dalhousie) e a ação sub-regional para apoiar o fortalecimento contínuo dos RHS nesses países. Para fazer uma análise da situação visando a subsidiar a política e o plano de ação de recursos humanos para a saúde foi utilizado um processo de desenvolvimento de políticas, incluindo revisão de documentos/literatura e consultas às partes interessadas. As políticas e os planos de ação concentraram-se em áreas prioritárias de liderança e governança de RHS, capacidade de planejamento de RHS, fortalecimento da atenção primária à saúde, otimização da educação/treinamento pré e pós-licenciamento, retenção e recrutamento, implantação e utilização, parcerias intersetoriais e externas para sustentabilidade, sistemas de informação de saúde e pesquisa sobre RHS. Uma análise transversal das conclusões constatou que os desafios e as áreas prioritárias de RHS eram consistentes entre os países, resultando em ações prioritárias de políticas similares que estão alinhadas com as ações regionais de fortalecimento de RHS para o acesso universal e a cobertura universal de saúde. Os resultados apontam a vantagem da colaboração em nível regional para construir capacidade de planejamento de RHS com base nas necessidades dentro dos países-membros. A Comunidade do Caribe (CARICOM), com facilitação do Programa Sub-Regional do Caribe da Organização Pan-Americana da Saúde (OPAS), estabeleceu a Força Tarefa de Ação em Recursos Humanos para a Saúde no Caribe. A experiência da Universidade Dalhousie, um centro colaborador da OPAS/OMS, disponibilizada por meio da assistência técnica, apoiou os três países nesta importante iniciativa e oferece mais oportunidades para apoiar a OPAS, a força tarefa e os países enquanto trabalham para alcançar seus objetivos de fortalecer os RHS.

Palavras-chave
Formulação de Políticas; recursos humanos; saúde

Health care systems in many countries, including the Caribbean, are grappling with issues related to access to care and obstacles to improving health outcomes for their citizens, including issues related to human resources for health (HRH). HRH issues related to recruitment, retention, utilization, and deployment (¹1. Campbell J, Buchan J, Cometto G, David B, Dussault,G, Fogstad H., et al. Human resources for health and universal health coverage: fostering equity and effective coverage. Bull World Health Organ. 2013;91:853–863. Available from: http://dx.doi.org/10.2471/BLT.13.118729. Accessed 6 September 2021.
http://dx.doi.org/10.2471/BLT.13.118729...

2. World Health Organization. Global strategy on human resources for health: workforce 2030. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511131. Accessed 10 May 2022.
https://www.who.int/publications/i/item/...

3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538...

4. Pan American Health Organization. The sustainable health agenda for the Americas 2018-2030. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/49170. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/491... -⁵5. World Health Organization. Retention of the health workforce in rural and remote areas: a systematic review. Geneva: WHO; 2020. Available from: https://www.who.int/publications/i/item/9789240013865. Accessed 29 July 2022.
https://www.who.int/publications/i/item/... ), working conditions (⁶6. International Labour Office. Improving employment and working conditions in health services: report for discussion at the tripartite meeting on improving employment and working conditions in health services (Geneva, 24–28 April 2017). Geneva: ILO; 2017. Available from: https://www.ilo.org/sector/activities/sectoral-meetings/WCMS_548288/lang--en/index.htm. Accessed 2 August 2022.
https://www.ilo.org/sector/activities/se... ), and a lack of robust HRH planning across the health care system (⁷7. Tomblin Murphy G, Birch S, MacKenzie A, Bradish S, Elliott Rose A. A synthesis of recent high-income OECD country analyses of HRH requirements and labor market dynamics. Hum Resour Health. 2016;14(1):59. Available from: https://doi.org/10.1186/s12960-016-0155-2. Accessed 5 October 2016.
https://doi.org/10.1186/s12960-016-0155-... -⁸8. Bourgeault IL, Chamberland-Rowe C, Simkin S. Co-developing an integrated primary care workforce planning approach at a regional level: overarching framework and guiding principles. Hum Resour Health. 2021;19:87. Available at: https://doi.org/10.1186/s12960-021-00578-z. Accessed 28 April 2022.
https://doi.org/10.1186/s12960-021-00578... ) have been relatively constant over the past few decades and highlighted during COVID-19 (⁹9. Llop-Gironés A, Vračar A, Llop-Gironés G, Benach J, Angeli-Silva L, Jaimez L, et al. Employment and working conditions of nurses: where and how health inequalities have increased during the COVID-19 pandemic? Hum Resour Health. 2021;19(1):112. Available from: https://doi.org/10.1186/s12960-021-00651-7. Accessed 28 April 2022.
https://doi.org/10.1186/s12960-021-00651... ). Migration of HRH is also a particular challenge for Caribbean countries (¹⁰10. Rolle Sands S, Ingraham K, Salami B. Caribbean nurse migration—a scoping review. Hum Resour Health. 2020;18(9). Available at: https://doi.org/10.1186/s12960-020-00466-y. Accessed 28 April 2022.
https://doi.org/10.1186/s12960-020-00466... -¹¹11. Drennan VM, Ross F. Global nurse shortages—the facts, the impact and action for change. Brit Med Bull. 2019;130(1):25–37. Available from: https://doi.org/10.1093/bmb/ldz014. Accessed 20 April 2022.
https://doi.org/10.1093/bmb/ldz014... ). The impact of these challenges has been shortages of health professionals (²2. World Health Organization. Global strategy on human resources for health: workforce 2030. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511131. Accessed 10 May 2022.
https://www.who.int/publications/i/item/... , ¹²12. Tomblin Murphy G, MacKenzie A, Waysome B, Guy-Walker J, Palmer R, Elliott Rose A, et al. A mixed-methods study of health worker migration from Jamaica. Hum Resour Health. 2016;14(Suppl):89-103. Available from: https://doi.org/10.1186/s12960-016-0125-8. Accessed 10 July 2016.
https://doi.org/10.1186/s12960-016-0125-... ). Barriers to addressing these challenges include insufficient capacity in HRH leadership and governance, the collection and management of HRH data, and sustainable HRH planning and research (²2. World Health Organization. Global strategy on human resources for health: workforce 2030. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511131. Accessed 10 May 2022.
https://www.who.int/publications/i/item/... , ¹³13. Pan American Health Organization. Plan of action on human resources for universal access to health and universal health coverage 2018-2023: progress report [CD59/INF/16]. 59th Directing Council, 73rd Session of the Regional Committee of WHO for the Americas; 20 - 24 September 2021. Washington, DC: PAHO; 2021. Available at: https://www.observatoriorh.org/sites/default/files/webfiles/fulltext/2021/CD59_8.16_A_en.pdf. Accessed 20 Jul 2022.
https://www.observatoriorh.org/sites/def...

14. World Health Organization. Global strategy on human resources for health: workforce 2030 report by the Director-General [A75/15]. 75th World Health Assembly; 22-28 May 2022. Geneva: WHO, 2022. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_15-en.pdf. Accessed 20 July 2022.
https://apps.who.int/gb/ebwha/pdf_files/... -¹⁵15. Martineau T, Ozano K, Raven J, Mansour W, Bay F, Nkhoma D, et al. Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health. Hum Resour Health. 2022;20:47. Available from: https://doi.org/10.1186/s12960-022-00742-z. Accessed 2 August 2022.
https://doi.org/10.1186/s12960-022-00742... ).

Efforts to address these HRH challenges have been revitalized with the Global Strategy for Human Resources for Health – Workforce 2030, in support of the global commitment to advance the UN Sustainable Development Goals (¹⁶16. United Nations. Goal 3: ensure healthy lives and promote well-being for all at all ages. New York: UN; [date unknown] [cited 24 July 2022]. Available from: http://www.un.org/sustainabledevelopment/health/. Accessed 28 April 2022.
http://www.un.org/sustainabledevelopment... ) and the achievement of universal health coverage. This global strategy is supported in the Americas through the Strategy on Human Resources for Universal Access to Health and Universal Health Coverage (UAC/UHC) and associated Plan of Action (³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... , ¹⁷17. Pan American Health Organization. Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 [CD56/10, Rev.1]. Washington, DC: PAHO; 2018. Available from: https://iris.paho.org/handle/10665.2/49213. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/492... ), the Sustainable Health Agenda for the Americas 2018-2030 (⁴4. Pan American Health Organization. The sustainable health agenda for the Americas 2018-2030. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/49170. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/491... ), and at the sub-regional level, the Caribbean Roadmap on Human Resources for Universal Health, 2018-2022 (¹⁸18. Bengtsson M. How to plan and perform a qualitative study using content analysis. NursingPlus Open. 2016;2:8-14. Available from: https://www.sciencedirect.com/science/article/pii/S2352900816000029. Accessed 2 August 2022.
https://www.sciencedirect.com/science/ar... ). In all these strategies, improving governance and leadership in HRH include having HRH policies adopted and implemented.

The Pan American Health Organization (PAHO) has been working with member countries for over 20 years to strengthen their capacity for HRH strengthening through the Technical Cooperation for Human Resources for Health in the Americas (¹⁹19. Pan American Health Organization. Caribbean roadmap on human resources for universal health 2018-2022. Bridgetown: PAHO; 2018.), including utilizing the expertise of PAHO/WHO Collaborating Centres. Within this Technical Cooperation, the PAHO/WHO Collaborating Centre on Health Workforce Planning and Research at Dalhousie University provided technical assistance for developing HRH policies and action plans to three Caribbean countries – Barbados, Grenada and St. Vincent and the Grenadines. The technical assistance was supported and funded by the PAHO, Barbados/ECC Regional Office and the Sub-regional Program for the Caribbean, PAHO/WHO.

The objectives of this paper are to 1) describe the process of developing HRH policies and action plans within the three countries, 2) highlight the role of the PAHO/WHO Collaborating Centre on Health Workforce Planning and Research, Dalhousie University in supporting PAHO and member country initiatives, and 3) show where further efforts to strengthen HRH can be supported by sub-regional action.

METHODS

The objectives of the Collaborating Centre’s technical assistance were to, in collaboration with the Ministry and PAHO, engage with country-level stakeholders to perform a situational analysis on the current state of HRH and to develop a draft HRH policy and action plan. The deliverables were a draft HRH situational analysis, HRH policy and corresponding action plan for each country. Within each country, a policy development approach was used. Phase one consisted of a situational analysis and phase two involved drafting the HRH policy and action plan, based on key HRH priorities identified in phase one.

Settings

The small Caribbean countries of Barbados, Grenada and St. Vincent and the Grenadines have a public-private health service mix, with most services provided through the public health sector and funded by the government. They are committed to transforming their health systems to achieve UAH/UHC through achieving the goals set out in the PAHO Strategy on Human Resources for UAH/UHC(³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... ) and Plan of Action (¹⁷17. Pan American Health Organization. Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 [CD56/10, Rev.1]. Washington, DC: PAHO; 2018. Available from: https://iris.paho.org/handle/10665.2/49213. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/492... ), and the Sustainable Health Agenda for the Americas 2018-2030 (⁴4. Pan American Health Organization. The sustainable health agenda for the Americas 2018-2030. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/49170. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/491... ). In the context of Barbados and Grenada, there were existing HRH policies, however, they had not been fully implemented and pre-dated the current commitment to UAH/UHC. St. Vincent and the Grenadines did not have a formal HRH policy prior to this work.

Situational analysis

The situational analysis incorporated a document review and stakeholder consultations. The document review included key national documents such as national health strategic plans, health policies, regional and global HRH strategies and relevant peer-reviewed literature.

The Collaborating Centre had an extensive collection of relevant publications, so a directed search of published literature was conducted to capture additional articles. The directed review search terms, developed with a Dalhousie University information scientist, included variations on the following key words, used in combination with various Boolean operators: health manpower, health workforce, health policy, health services, health education, health personnel, delivery of health care, standards [of care], doctors, nurses, midwives, pharmacists, dentists, dental auxiliaries, nurse assistants, community health aides, lab technicians, radiographers, physiotherapists, occupational social workers, nutritionists, primary health care, universal health coverage, integrated health care, community based health care. Documents published in English between 2007 and 2019 were considered for inclusion.

The initial search yielded over 3,000 documents; subsequent searches were narrowed to the key topic of interest – health system and HRH planning. These searches yielded 209 articles, of which 87 were duplicates, yielding 152 remaining articles, whose titles and abstracts were reviewed. The articles meeting the key topics were retrieved for full review. After reviewing the full text of each document, 52 articles were identified as specifically relevant. For non-peer reviewed literature (gray literature), the search strategy included web-based searches using Google Search and targeting specific sites of regional and national governments and organizations, such as PAHO, WHO, Global Health Workforce Alliance, USAID. A literature capture diagram is presented in Figure 1.

Stakeholder Consultations

Key stakeholders were identified within each country by the Ministry, in consultation with PAHO and the Collaborating Centre, based on the recognition that there are many stakeholders which impact HRH planning. Stakeholders within the health system included Ministry staff (Chief Medical Officer, Chief Nursing Officer, Heads of Ministerial departments), District Medical Officers of Health, and health facility leadership. Inter-sectoral stakeholders included Ministries of Education, Cabinet, Public Administration, Finance, and the Public Service Commission. It was also important to include the educational institutions, health regulatory bodies/professional colleges and unions. Stakeholders engaged in the consultations totaled 76 in Barbados, 50 in Grenada and 55 in St. Vincent and the Grenadines.

Stakeholder consultations involved meetings and workshops. Individual meetings were held with senior leaders in Ministries of Health, Education, Cabinet, Public Administration, and the Public Service Commission. Workshops were held with the other key stakeholders within the health sector and external stakeholders described above.

During the workshops, participants were randomly formed into small groups and were asked to provide their perspectives on the leading health conditions, gaps in service delivery and planning and potential strategies to address the gaps; challenges facing the health workforce and potential strategies; and what success would look like and how to measure it. The discussions were captured through MS Power Point presentations, group recorder notes and/or flipcharts. The Collaborating Centre team collated the information and conducted a content analysis (¹⁸18. Bengtsson M. How to plan and perform a qualitative study using content analysis. NursingPlus Open. 2016;2:8-14. Available from: https://www.sciencedirect.com/science/article/pii/S2352900816000029. Accessed 2 August 2022.
https://www.sciencedirect.com/science/ar... ) to categorize the data according to the HRH priority areas drawn from the key global and regional strategies related to strengthening HRH (²2. World Health Organization. Global strategy on human resources for health: workforce 2030. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511131. Accessed 10 May 2022.
https://www.who.int/publications/i/item/...

3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... -⁴4. Pan American Health Organization. The sustainable health agenda for the Americas 2018-2030. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/49170. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/491... , ¹⁷17. Pan American Health Organization. Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 [CD56/10, Rev.1]. Washington, DC: PAHO; 2018. Available from: https://iris.paho.org/handle/10665.2/49213. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/492... , ¹⁹19. Pan American Health Organization. Caribbean roadmap on human resources for universal health 2018-2022. Bridgetown: PAHO; 2018.). The published literature was used to provide context and supportive evidence to potential strategies for addressing the challenges.

Development of HRH policies and action plans

The HRH gaps and strategies from the situational analysis were used to frame the priorities for action within the HRH policy and action plan. For the HRH policy, key priorities were outlined with specific areas of action that could be taken in the short-, medium- and long-term. The HRH action plan outlined specific activities for each area of action, including who would be involved, who had the ultimate responsibility for the action and general costings as well as a monitoring and evaluation framework.

Stakeholders were again invited to provide feedback on the draft policy and action plan during another workshop or individually. Stakeholders were asked to reflect on what they liked about the HRH policy and action plan, what they would like to see improved, if they saw alignment with the country’s health system strategic directions, if there were HRH priorities not reflected in the policy or missing actions in the action plan, if the actions and sub-actions were SMART (specific, measurable, achievable relevant, time-bound), and finally if the evaluation framework would facilitate ongoing monitoring and evaluation. Based on the feedback, revisions were made, and final drafts of all documents were submitted to each Ministry of Health for their ratification.

An additional comparative analysis of the results from the three countries was conducted to determine areas of similarity and overall alignment with the PAHO Strategy for Human Resources for Health for UAH/UHC (³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... ).

RESULTS

Situational context for HRH policy development

A summary of key findings related to health priorities and HRH challenges are provided for each country.

Barbados: Non-communicable diseases (NCDs) and cancer are both being leading causes of death and NCDs are a leading cause of morbidity. Communicable and vector-borne diseases are still of great concern, particularly in light of increasing vaccine hesitancy and the threat of new and re-emerging diseases such as Ebola and Zika. Other health priority areas include mental health and health among specific age-groups such as youth and seniors. Major HRH challenges are related to training, retention, recruitment, deployment and utilization, including the centralized HR processes for public health, the inability to engage private practitioners within the public health system, and a lack of available nurses in the publicly funded health care system as a result of emigration and opportunities within the private health sector. Challenges related to HRH planning and governance/leadership related to succession planning, HRH planning, management mechanisms structures, and evaluation & ongoing monitoring. Health services and system challenges related to resource allocation, procurement, technology/information systems, and working environments. Barbados has a long-standing culture of working in partnerships with other government sectors, organizations and communities, allowing for strong inter-sectoral action (²⁰20. Tomblin Murphy G, Rigby J, MacKenzie A. Barbados National Health Workforce Policy: draft HRH policy prepared for the Ministry of Health and Wellness, Barbados. Halifax, NS: Dalhousie University; 2019. [Unpublished].)

Grenada: While the private sector has a strong presence, most health services are provided through the public health system. NCDs account for four of the top five causes of death. Communicable and vector-borne diseases continue to be important. Identified gaps in the health system included factors related to access (HRH education/training, retention/recruitment, deployment and utilization), health care services and system infrastructure and operations. HRH gap areas included capacity in team delivered care, allocation/distribution/ deployment and flexibility of workers, and supply of workers, particularly medical specialists. Service gap areas included the accessibility of diagnostic services/equipment, referral services, system navigation, wait times, and the prioritization of health promotion and prevention. System gap areas included the utilization of the health information system, communication mechanisms, and facility level leadership and managerial capacity (²¹21. Tomblin Murphy G, Rigby J, Birch S, Gilbert J. National Health Workforce Policy for Grenada: draft policy prepared for the Ministry of Health, Social Security and International Business. Halifax, NS: Dalhousie University; 2017. [Unpublished].).

St. Vincent and the Grenadines: Key health priorities include cancer, NCDs, infectious diseases (primarily HIV/STIs), injuries, vector-borne diseases, nutrition, and mental health and addictions. Key priority population groups were youth and seniors. Identified gaps in the health system included factors related to access (health workforce education/training, retention/ recruitment, deployment and utilization), health care services and system infrastructure and operations. Workforce gap areas included a capacity for team delivered care, allocation/ distribution of workers, and supply of health workers, particularly specialists. Service gap areas included diagnostic services/equipment (including screening programs), referrals, wait times, physical inaccessibility, and prioritization of health promotion and prevention. System gap areas included equipment downtime, challenges in the health information systems, communication mechanisms across the system, leadership and managerial capacity at the facility level, public health emergency response and quality standards (²²22. Tomblin Murphy G, Rigby J, Birch S, Gilbert J. Saint Vincent and the Grenadines National Workforce Policy – “Strengthening Capacity to Meet the Health Needs of Vincentians”: draft policy prepared for the Ministry of Health, Wellness and the Environment. Halifax, NS: Dalhousie University; 2017. [Unpublished].).

The comparative analysis found that the recurring themes related to HRH, health system, and service gaps that emerged individually were also shared across the three countries. The HRH planning challenges, and priority areas were consistent across the countries, such as balancing planning for primary health care and other sectors, building capacity to undertake needs-based integrated planning, and improving their health information systems. All three countries recognized a need for increased capacity in HRH planning.

While each country has their own context, the identified strategies to address many of the challenges and gaps were consistent across countries. The strategies fall within six strategic areas – 1) recruitment and retention, 2) utilization and deployment, 3) governance, 4) leadership, 5) HRH planning, and 6) non-human resource utilization, as presented in Table 1. The literature provided support for many strategies, including strengthening leadership and governance for HRH (¹³13. Pan American Health Organization. Plan of action on human resources for universal access to health and universal health coverage 2018-2023: progress report [CD59/INF/16]. 59th Directing Council, 73rd Session of the Regional Committee of WHO for the Americas; 20 - 24 September 2021. Washington, DC: PAHO; 2021. Available at: https://www.observatoriorh.org/sites/default/files/webfiles/fulltext/2021/CD59_8.16_A_en.pdf. Accessed 20 Jul 2022.
https://www.observatoriorh.org/sites/def...

14. World Health Organization. Global strategy on human resources for health: workforce 2030 report by the Director-General [A75/15]. 75th World Health Assembly; 22-28 May 2022. Geneva: WHO, 2022. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_15-en.pdf. Accessed 20 July 2022.
https://apps.who.int/gb/ebwha/pdf_files/... -¹⁵15. Martineau T, Ozano K, Raven J, Mansour W, Bay F, Nkhoma D, et al. Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health. Hum Resour Health. 2022;20:47. Available from: https://doi.org/10.1186/s12960-022-00742-z. Accessed 2 August 2022.
https://doi.org/10.1186/s12960-022-00742... , ²³23. Cometto G, Nartey E, Zapata T, Kanda M, Md Y, Narayan K, et al. Analysing public sector institutional capacity for health workforce governance in the South-East Asia region of WHO. Hum Resour Health. 2019;17:43. Available from: https://doi.org/10.1186/s12960-019-0385-1. Accessed 28 April 2022.
https://doi.org/10.1186/s12960-019-0385-... -²⁴24. Ahmet A, Okoroafor S, Asamani J, Dovlo D, Millogo J, Illou M, et al. Health workforce policy and plan implementation in the context of universal health coverage in the Africa Region. BMJ Glob Health. 2022;7:e008319. Available from: https://gh.bmj.com/content/7/Suppl_1/e008319. Accessed 2 August 2022.
https://gh.bmj.com/content/7/Suppl_1/e00... ), strengthening HRH for primary health care, as primary health care is critical to universal health coverage (⁹9. Llop-Gironés A, Vračar A, Llop-Gironés G, Benach J, Angeli-Silva L, Jaimez L, et al. Employment and working conditions of nurses: where and how health inequalities have increased during the COVID-19 pandemic? Hum Resour Health. 2021;19(1):112. Available from: https://doi.org/10.1186/s12960-021-00651-7. Accessed 28 April 2022.
https://doi.org/10.1186/s12960-021-00651... , ¹⁴14. World Health Organization. Global strategy on human resources for health: workforce 2030 report by the Director-General [A75/15]. 75th World Health Assembly; 22-28 May 2022. Geneva: WHO, 2022. Available from: https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_15-en.pdf. Accessed 20 July 2022.
https://apps.who.int/gb/ebwha/pdf_files/... , ²⁵25. Pan American Health Organization (PAHO). Working for Health in the Caribbean: PAHO/WHO Subregional Cooperation Strategy 2016-2019. Washington: PAHO; 2016. Available from: https://iris.paho.org/handle/10665.2/52162. Accessed 20 March 2017.
https://iris.paho.org/handle/10665.2/521... , ²⁶26. World Health Organization. Regional Office for South-East Asia. (2021). Implementing a decade of strengthening the health workforce in the WHO South-East Asia Region: achievements and way forward for primary health care. WHO South-East Asia Journal of Public Health, Volume 10, Supplement 1, February 2021, S1–S99, 10 (3), 1 - 11. World Health Organization. Regional Office for South-East Asia. Available from: https://apps.who.int/iris/handle/10665/351490. Accessed 2 August 2022.
https://apps.who.int/iris/handle/10665/3... ), retention and recruitment, particularly for rural areas (⁵5. World Health Organization. Retention of the health workforce in rural and remote areas: a systematic review. Geneva: WHO; 2020. Available from: https://www.who.int/publications/i/item/9789240013865. Accessed 29 July 2022.
https://www.who.int/publications/i/item/... ), training and education of health providers, including interprofessional education (IPE) (²⁷27. Martin P, Pighills A, Burge V, Argus G, Sinclair L. Promoting Interprofessional Education and Collaborative Practice in Rural Health Settings: Learnings from a State-Wide Multi-Methods Study. Int J Environ Res Public Health. 2021;18(10):5162. Available from: https://doi.org/10.3390/ijerph18105162. Accessed 20 April 2022.
https://doi.org/10.3390/ijerph18105162... -²⁸28. Soubra L, Badr SB, Zahran EM, Aboul-Seoud M. Effect of interprofessional education on role clarification and patient care planning by health professions students. Health Prof Educ. 2018;4(4):317-328. Available from: https://doi.org/10.1016/j.hpe.2017.12.005. Accessed 18 April 2022.
https://doi.org/10.1016/j.hpe.2017.12.00... ), and strengthening the health and HRH information systems (²⁹29. Vital Wave, IntraHealth International, Cooper/Smith. Human resources for health: workforce analytics for design and planning. Palo Alto, CA: Vital Wave; 2021. Available from: https://vitalwave.com/wp-content/uploads/2021/06/HRH-Assessment_Final-Report-2021.pdf. Accessed 2 August 2022.
https://vitalwave.com/wp-content/uploads... ).

Development of HRH policies and action plans

For each country, the draft policy and action plan were aligned with the objectives of the country’s health system, the national strategic plan for the health sector, existing policies/strategic plans for health priorities, principles of workforce planning (³⁰30. Tomblin Murphy G. Appendix: Example of A Conceptual Model for HHR Planning In: A Framework for Collaborative Pan-Canadian Health Human Resources Planning. (pp. 29-36). Ottawa: Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources (ACHDHR). September 2005. [Report revised 2007]. Available from: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-human-resources/framework-collaborative-canadian-health-human-resources-planning-health-canada-2007.html. Accessed 10 January 2008.
https://www.canada.ca/en/health-canada/s... ), objectives of UAH/UHC (³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... , ¹³13. Pan American Health Organization. Plan of action on human resources for universal access to health and universal health coverage 2018-2023: progress report [CD59/INF/16]. 59th Directing Council, 73rd Session of the Regional Committee of WHO for the Americas; 20 - 24 September 2021. Washington, DC: PAHO; 2021. Available at: https://www.observatoriorh.org/sites/default/files/webfiles/fulltext/2021/CD59_8.16_A_en.pdf. Accessed 20 Jul 2022.
https://www.observatoriorh.org/sites/def... ), and reaching the sustainable development goals (SDGs) (¹⁶16. United Nations. Goal 3: ensure healthy lives and promote well-being for all at all ages. New York: UN; [date unknown] [cited 24 July 2022]. Available from: http://www.un.org/sustainabledevelopment/health/. Accessed 28 April 2022.
http://www.un.org/sustainabledevelopment... ). Seven core principles, presented in Table 2, guided the policy development for each country.

Priority areas for action centered around the gaps identified during the situational analysis, including leadership and governance, HRH planning capacity, strengthening primary health care, optimization of pre- and post-licensure education/training and continuing education for health providers, retention and recruitment, deployment and utilization, inter-sectoral and external partnerships for sustainability, health information systems, and HRH research. Strategies for addressing HRH gaps were incorporated within the proposed actions.

DISCUSSION

Overall, many of the challenges and gaps identified resonated across the three countries and mirror many of the challenges faced by other countries in the sub-region (³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... ,²⁵25. Pan American Health Organization (PAHO). Working for Health in the Caribbean: PAHO/WHO Subregional Cooperation Strategy 2016-2019. Washington: PAHO; 2016. Available from: https://iris.paho.org/handle/10665.2/52162. Accessed 20 March 2017.
https://iris.paho.org/handle/10665.2/521... ,³¹31. CCH Secretariat. Caribbean Cooperation for Health, Phase IV (CCHIV) - Summary of the Regional Health Framework 2016 – 2025. Georgetown, Guyana: Secretariat; 2017. Available from: https://www.paho.org/en/documents/caribbean-cooperation-health-phase-iv-cch-iv-0. Accessed May 2017.
https://www.paho.org/en/documents/caribb... ) and globally (²2. World Health Organization. Global strategy on human resources for health: workforce 2030. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511131. Accessed 10 May 2022.
https://www.who.int/publications/i/item/... ,¹⁵15. Martineau T, Ozano K, Raven J, Mansour W, Bay F, Nkhoma D, et al. Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health. Hum Resour Health. 2022;20:47. Available from: https://doi.org/10.1186/s12960-022-00742-z. Accessed 2 August 2022.
https://doi.org/10.1186/s12960-022-00742... ). There was an expressed need for ensuring appropriate competencies are in place for efficient and quality team-delivered care (including specialties), safe and motivating working environments (conditions and physical infrastructure), enhanced leadership and managerial capacity, updated and effective legislative, regulatory and accountability processes, and the need for improved HRH planning across the system.

During all consultations, there was a recognition that an HRH planning infrastructure was needed to ensure appropriate mechanisms were utilized to address identified health workforce gaps and to monitor and evaluate the progress in policy/action plan implementation, consistent with the regional strategies (³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... , ²⁵25. Pan American Health Organization (PAHO). Working for Health in the Caribbean: PAHO/WHO Subregional Cooperation Strategy 2016-2019. Washington: PAHO; 2016. Available from: https://iris.paho.org/handle/10665.2/52162. Accessed 20 March 2017.
https://iris.paho.org/handle/10665.2/521... , ³¹31. CCH Secretariat. Caribbean Cooperation for Health, Phase IV (CCHIV) - Summary of the Regional Health Framework 2016 – 2025. Georgetown, Guyana: Secretariat; 2017. Available from: https://www.paho.org/en/documents/caribbean-cooperation-health-phase-iv-cch-iv-0. Accessed May 2017.
https://www.paho.org/en/documents/caribb... ). As HRH planning is a political and technical process (³⁰30. Tomblin Murphy G. Appendix: Example of A Conceptual Model for HHR Planning In: A Framework for Collaborative Pan-Canadian Health Human Resources Planning. (pp. 29-36). Ottawa: Federal/Provincial/Territorial Advisory Committee on Health Delivery and Human Resources (ACHDHR). September 2005. [Report revised 2007]. Available from: https://www.canada.ca/en/health-canada/services/health-care-system/reports-publications/health-human-resources/framework-collaborative-canadian-health-human-resources-planning-health-canada-2007.html. Accessed 10 January 2008.
https://www.canada.ca/en/health-canada/s... ), there is a need for each country to build capacity within both areas. Key to the political process is government commitment to developing the capability for effective planning mechanisms, particularly in terms of the planning infrastructure, guiding principles, and overall governance and accountability. With roles and responsibilities related to HRH being shared by different government sectors, i.e., finance, labour, education and health, as well as external stakeholders, i.e., unions and professional associations and councils, all need to be part of the planning process (¹⁶16. United Nations. Goal 3: ensure healthy lives and promote well-being for all at all ages. New York: UN; [date unknown] [cited 24 July 2022]. Available from: http://www.un.org/sustainabledevelopment/health/. Accessed 28 April 2022.
http://www.un.org/sustainabledevelopment... , ³²32. Kingue S, Rosskam E, Bela AC, Adjidja A, Codjia L. Strengthening human resources for health through multisectoral approaches and leadership: the case of Cameroon. Bull World Health Organ. 2013;91(11):864-867. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3853968/. Accessed 28 April 2022.
https://www.ncbi.nlm.nih.gov/pmc/article... -³³33. Tomblin Murphy G, Birch S, MacKenzie A, Rigby J, Purkis ME. The drive towards sustainable health systems needs an alignment: where are the innovations in health systems planning? Healthc Pap. 2017;16(3):40-46. Available from: https://www.longwoods.com/content/25081/healthcarepapers/the-drive-towards-sustainable-health-systems-needs-an-alignment-where-are-the-innovations-in-health. Accessed 1 February 2017.
https://www.longwoods.com/content/25081/... ). A high-level institutional decision-making body in HRH, supported by an HRH unit embedded within the Ministry, can strengthen the political commitment and process, and integrate other government sectors. As of 2021, seven countries in the Pan-American region have established high-level HRH decision making bodies, with 15 additional countries planning to do so by 2023 (¹³13. Pan American Health Organization. Plan of action on human resources for universal access to health and universal health coverage 2018-2023: progress report [CD59/INF/16]. 59th Directing Council, 73rd Session of the Regional Committee of WHO for the Americas; 20 - 24 September 2021. Washington, DC: PAHO; 2021. Available at: https://www.observatoriorh.org/sites/default/files/webfiles/fulltext/2021/CD59_8.16_A_en.pdf. Accessed 20 Jul 2022.
https://www.observatoriorh.org/sites/def... ). To function effectively, strong stewardship, structured embedded mechanisms for HRH governance and planning, and a solid understanding of HRH planning by both stakeholders and HRH unit staff are needed (¹⁵15. Martineau T, Ozano K, Raven J, Mansour W, Bay F, Nkhoma D, et al. Improving health workforce governance: the role of multi-stakeholder coordination mechanisms and human resources for health units in ministries of health. Hum Resour Health. 2022;20:47. Available from: https://doi.org/10.1186/s12960-022-00742-z. Accessed 2 August 2022.
https://doi.org/10.1186/s12960-022-00742... , ²³23. Cometto G, Nartey E, Zapata T, Kanda M, Md Y, Narayan K, et al. Analysing public sector institutional capacity for health workforce governance in the South-East Asia region of WHO. Hum Resour Health. 2019;17:43. Available from: https://doi.org/10.1186/s12960-019-0385-1. Accessed 28 April 2022.
https://doi.org/10.1186/s12960-019-0385-... ). Key to the technical process is the capacity to undertake planning including the capacity for HRH data collection and management and using iterative and flexible planning tools to identify current and future gaps and assess impacts of different country-relevant strategies (³³33. Tomblin Murphy G, Birch S, MacKenzie A, Rigby J, Purkis ME. The drive towards sustainable health systems needs an alignment: where are the innovations in health systems planning? Healthc Pap. 2017;16(3):40-46. Available from: https://www.longwoods.com/content/25081/healthcarepapers/the-drive-towards-sustainable-health-systems-needs-an-alignment-where-are-the-innovations-in-health. Accessed 1 February 2017.
https://www.longwoods.com/content/25081/... ). Vital to the technical process is the HRH information system. The WHO’s National Health Workforce Accounts provides a framework for HRH monitoring and planning, 78 health workforce indicators across 10 HRH policy domain modules (³⁴34. World Health Organization. National health workforce accounts: a handbook. Geneva: WHO; 2017. Available from: https://apps.who.int/iris/handle/10665/259360. Accessed 10 April 2018.
https://apps.who.int/iris/handle/10665/2... ). This platform offers a good starting point for countries to build their country-specific HRH information systems.

The development of country-specific HRH policies and action plans are an important action to achieve the goals of UAH/UHC (²2. World Health Organization. Global strategy on human resources for health: workforce 2030. Geneva: WHO; 2016. Available from: https://www.who.int/publications/i/item/9789241511131. Accessed 10 May 2022.
https://www.who.int/publications/i/item/... , ¹⁷17. Pan American Health Organization. Plan of Action on Human Resources for Universal Access to Health and Universal Health Coverage 2018-2023 [CD56/10, Rev.1]. Washington, DC: PAHO; 2018. Available from: https://iris.paho.org/handle/10665.2/49213. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/492... ), with regional progress being monitored along the three strategic lines of action from the PAHO’s Strategy on Human Resources for UAH/UHC ( 3) Across the three countries, key HRH policy areas were aligned with these strategic lines of action, as presented in Table 3.

Developing country-specific HRH policies and action plans that are aligned with the regional and sub-regional strategies creates an opportunity for shared learning and support in the policy implementation, particularly in the Caribbean region where there are similar challenges Some strategies may also be implemented at the sub-regional level (e.g., sharing of specialists, training of health workers, common HRH indicators, shared action on migration of health workers).

In recognition of the shared challenges, the Caribbean Community (CARICOM), with facilitation by the PAHO Caribbean Subregional Programme, has established the HRH Action Task Force for the Caribbean (HRH-ATF). The HRH-ATF is a regional technical operational body with representation from 15+ member states with the objectives to 1) provide technical advice to CARICOM in monitoring the progress of HRH development policies at the national and sub-regional level, 2) support execution of the strategic results related to the development of HRH established within the regional and sub-regional strategies (³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... , ⁴4. Pan American Health Organization. The sustainable health agenda for the Americas 2018-2030. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/49170. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/491... , ¹⁹19. Pan American Health Organization. Caribbean roadmap on human resources for universal health 2018-2022. Bridgetown: PAHO; 2018., ³¹31. CCH Secretariat. Caribbean Cooperation for Health, Phase IV (CCHIV) - Summary of the Regional Health Framework 2016 – 2025. Georgetown, Guyana: Secretariat; 2017. Available from: https://www.paho.org/en/documents/caribbean-cooperation-health-phase-iv-cch-iv-0. Accessed May 2017.
https://www.paho.org/en/documents/caribb... ) and CARICOM resolutions and 3) promote actions that allow the linkage of the education sector, health, work, finance and science and technology, as well as coordination with regional authorities (³⁵35. CARICOM, PAHO/WHO. HRH Action Task Force for the Caribbean: Organization and Operation Manual. Barbados: CARICOM; 2021. [Unpublished]., p.3).

In its initial year, the HRH-ATF has created two policy briefs to 1) address COVID-19 vaccine hesitancy among health workers and 2) strengthen the health workforce, including strengthening HRH health information systems. In response to the second brief, the HRH-ATF used the National Health Workforce Accounts (³⁴34. World Health Organization. National health workforce accounts: a handbook. Geneva: WHO; 2017. Available from: https://apps.who.int/iris/handle/10665/259360. Accessed 10 April 2018.
https://apps.who.int/iris/handle/10665/2... ) indicators to identify a draft list of 33 HRH core indicators for the Caribbean. This will provide each country with a core set of indicators for their own planning and also for sub-regional analysis.

As seen through this case study of three Caribbean countries experiences in developing HRH policies and action plans, the opportunities provided through technical assistance from PAHO/WHO Collaborating Centres are valuable resources for supporting actions to achieve HRH strengthening targets. This has been continued through the involvement of Collaborating Centres in the work of the HRH-ATF.

Limitations

The findings from this initiative have some limitations. Firstly, while the process was designed to be as inclusive as possible, some stakeholders' views may have been missed due to their inability to attend the stakeholder workshops. This was mitigated by contact information for comments to be sent back directly to the team and providing a reasonable amount of time for comments on the draft documents to be sent back. Four people provided separate feedback via email. Secondly, the literature searches may have missed key articles that would support the process. The team consulted with an information scientist; however, articles could still have been missed. Finally, other strategies, policies, and actions may have been implemented during the policy development that could change the priority actions, however, using an iterative process ensured that the priority areas were relevant and timely. HRH policies and action plans are ‘living’ documents, and thus should be reviewed and updated as policy directions are adjusted. Reviews of HRH policies and action plans can also be informed by new actions under the Global strategy on HRH: workforce 2030 and the Essential Public Health Functions, and country-level health financing reforms.

Conclusions

The experiences of Barbados, Grenada and St. Vincent and the Grenadines have been showcased in this paper to illustrate efforts within the Caribbean region to achieve the target of strengthening HRH for UAH/UHC (³3. Pan American Health Organization. Strategy on human resources for universal access to health and universal health coverage. Washington, DC: PAHO; 2017. Available from: https://iris.paho.org/handle/10665.2/53838. Accessed 10 May 2022.
https://iris.paho.org/handle/10665.2/538... ). An HRH policy, that is duly implemented through the HRH action plan, is important for achieving this target. The alignment of the HRH policy to other health strategic plans and regional strategies and ensuring the inter-sectoral partnerships (e.g., Health and Education) are formalized in the process allows for the important integration of health workforce, health service and health finance planning. There is also value-add in collaborating on a regional level to address common challenges and collectively build capacity.

Finally, utilizing the experience and expertise of a PAHO/WHO Collaborating Centre in the development of country-level HRH policies and action plans not only provided support for the initial policy development, but also provides an ongoing resource for actions at the country and sub-regional levels.

Recommendations for action

Where existing, country-level HRH policies and action plans should be reviewed and updated to reflect current health and HRH priorities, key actions that have been completed, new actions needed as a result, and updated/new global and regional strategies.

Where non-existent, countries should develop HRH policies, action plans, and HRH planning structures, aligned with the key regional/sub-regional strategies on UAH/UHC and informed by country-specific health strategic plans and health policies, finance, labour markets, and other relevant considerations.

Lessons learned from the toll on HRH brought by the COVID-19 pandemic will be important for future HRH planning. HRH planning approaches must be iterative, flexible, timely and integrated to respond appropriately to emerging surges on the health care system.

Build on existing partnerships with the Education sector at the country and sub-regional level to ensure educational/training actions for strengthening HRH have the appropriate input, support and traction.

Find areas where regional approaches to strengthening the HRH are applicable and develop actions for regional member countries to implement.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or those of the Pan American Health Organization (PAHO).

Acknowledgements.

The authors acknowledge the commitment, dedication and engagement of the Ministry of Health and Wellness, Barbados, the Ministry of Health, Social Security and International Business, Grenada and the Ministry of Health, Wellness and the Environment, Saint Vincent and the Grenadines. In addition, the HRH policies and action plans for these countries would not have been developed without the active participation of all the stakeholders involved in the process.

REFERENCES

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