National Health Strategic Plan 2016-2020

Solomon Islands National Health Strategic Plan 2016 - 2020 1 National Health Strategic Plan 2016 - 2020 Solomon Islands National Health Strategic Plan 2016 - 20202 Solomon Islands National Health Strategic Plan 2016 - 2020 3 Vision “The People of the Solomon Islands will be Healthy, Happy, and Productive!” This is the strategic plan of the Ministry of Health and Medical Services (MHMS) for the period 2016 to 2020. In keeping with our national motto this plan provides leadership for the health system, in service to our government and the people. In our quest for health we intend to reduce sickness, prevent the loss of young lives and relieve suffering. Our vision for health goes beyond fi ghting disease; we intend to contribute to the wellbeing of all our people. Happiness is more than a smile – it is people who are content, fulfi lled, and have the freedom to live the life they choose. Productivity is more than making money – it is people who are not dependent but self-reliant, who live in a sustainable way, and are able to contribute to our society. Report produced by SynTech Technology Solutions Solomons Email: SolSynTech@gmail.com Ph: +677 773 6833 Solomon Islands National Health Strategic Plan 2016 - 20204 Message from the Minister of Health Hon. Dr Tautai Agikimua Kaitu’u On behalf of the government I endorse this strategic plan for the health sector. It lays out how we intend to improve the health of our people over the next fi ve years. The government has identifi ed a number of priorities in the area of programs, workforce, facility development, and legislation. Our program priorities will ensure that our communities, especially remote areas, have access to safe water and basic sanitation. We intend to improve access to trained health workers and ensuring that area health centres and provincial health systems are adequately resourced. We also intend to improve the health facilities in Honiara and the provinces. We will progress the relocation and building of a new national referral hospital, provincial hospitals such as Kirakira and Kilu’ufi . The government is also intending to bring health legislation up to date and make it more effective. This will include the Health Service Act, legislation for mental health, legislation on tobacco and alcohol to help control noncommunicable disease, and the legislation governing our key health professionals, the Medical Dental Board and the Nursing Council. The government’s underpinning values of accountability, transparency, equity and participation will also be given expression in the work that will be conducted under this plan. Together we will work to support our people to be Healthy, Happy and Productive. Solomon Islands National Health Strategic Plan 2016 - 2020 5 Message from Permanent Secretary for Health Dr Tenneth Dalipanda This strategic plan is a sign post on our road to health. It is an opportunity, after considering what went well in the past and what did not, to refresh our vision and reset our direction for the next fi ve years. Refl ecting on past performance, the MHMS faces a big challenge. We have shown improvement in areas such as malaria control and reducing neonatal deaths, but have plateaued in others. Overall we need to improve the quality of our service delivery. The four Key Result Areas (KRAs) spell out the priorities that we must address; improved program coverage, partnerships, quality, and building a foundation for the future. These priorities apply to the whole organisation, not just one part or program. Take immunisation coverage as an example. Getting full coverage of the population must come fi rst. Never again should we allow our children to be exposed to a widespread measles epidemic. The plan identifi es other areas where we want to improve coverage, access and reach of services. This is what Universal Health Coverage (UHC) is really about. To be effective at improving health we cannot continue to work in isolation, as health is generated by both our work and the impact we make with our partners. The plan will challenge us to work in a coordinated way with partners such as the churches, and with other line ministries in our work across sectors. Improving the quality of services is a key result area that also has relevance to every part of the MHMS. Not only in clinics, in hospitals and in public health programmes but also in internal fi nancing and programming. In preparing for the future, both the skills and the positioning of our workforce feature in the plan. Improving access is directly related to making sure a well trained and appropriately skilled workforce is available and accessible to meet the health needs of our rural and urban populations. The Sustainable Development Goals (SDG) are now on the global agenda and also feature in this plan. The SDGs cover the social determinants, so to achieve them working in partnership is essential, since we are serving the same populations. To meet these strategic challenges, the MHMS is re-organising itself to become more streamlined, more effective and to make each dollar go further. Provinces will have greater sway at the executive table and we will be working to complete the role delineation policy, as it will help drive this strategic plan. We face a challenging fi nancial environment. Aid fl ows are fl uctuating and hard to predict; whilst in some areas we have not fully spent the available resources. The government’s commitment to fi nancing the health sector has been steadily growing. Our challenge is to use it effectively and effi ciently in the service of the people. This plan outlines our approach on the road to health for our nation. I invite all our stakeholders to use it to guide their activities in the health sector through to 2020. This plan is the beginning of the journey. What we do, individually and collectively, over the next fi ve years will make the difference to the health of our people. Solomon Islands National Health Strategic Plan 2016 - 20206 Contents Message from the Minister of Health 4 Message from Permanent Secretary Dr Tenneth Dalipanda 5 Acronyms 7 Current Successes and Challenges 9 Parts of the health system are showing good progress; in other areas we are not progressing. 9 The performance differs between provinces. 10 What hindered service improvement over the last fi ve years? 10 What helped service improvement over the last fi ve years? 10 How will we expand on our achievements and address our weaknesses? 11 Key Result Areas 12 Key Result Area 1: Improve Service Coverage 13 What is happening now? 14 What would we like to see? 15 What needs to change? 17 Key Result Area 2: Build Strong Partnerships 19 What is happening now? 20 What would we like to see? 20 What needs to change? 22 Key Result Area 3: Improve the quality and support of Health Services 23 What is happening now? 25 What would we like to see? 26 What has to change? 26 Key Result Area 4 Lay the Foundations for the Future. 27 What is Happening Now? 28 What would we like to see? 29 What needs to change? 31 The Road Ahead 34 National Outcome Statements and Objectives 36 Solomon Islands National Health Strategic Plan 2016 - 2020 7 Acknowledgements: 43 Appendix: 43 Health Infrastructure and Population in Provinces 43 Indicators: 44 Universal Health Coverage 46 Role Delineation Policy 47 Bottle neck analysis 48 Out-year additional costs of the plan 49 Outline of the Provincial and Program Planning Process 50 How was this strategic plan developed? 50 AHC Area Health Centre AOP Annual Operating Plan CEO Chief Executive Offi cer CHC Community Health Centres (NAP) DP Development Partner FBO Faith Based Organisation GFATM Global Fund Against Aids TB and Malaria HR Human Resources KRA Key Result Areas MDG Millennium Development Goals MHMS Ministry of Health and Medical Services MP Member of Parliament MTEP Mid Term Expenditure Prediction NAP Nurse Aide Post (now called CHCs) NCD Noncommunicable Diseases NGO Non-Governmental Organisations NRH National Referral Hospital NHSP National Health Strategic Plan PEN Package of Essential NCDs RCDF Rural Constituency Development Fund RDP Role Delineation Policy RHC Rural Health Clinic SDG Sustainable Development Goals SIG Solomon Islands Government SINU Solomon Islands National University TB Tuberculosis WHO World Health Organization YLL Years of Life Lost Acronyms Solomon Islands National Health Strategic Plan 2016 - 20208 HE AL TH Y H APPY PRODUCTIVE PEOPLEUN IVE RSA L HEALTH COVERAGE C H IL D RE N WO ME N COMMUNICABLE COM M UN ICA BLE N O N DISEASES DISEA SES p ri or it is e ou tc om es fo r: Focus on the disease causing the most deaths and disab ilitie s Improve Service Coverage Build Strong Partnerships Improve Service Quality Lay the Foundations for the future • Give priority to the most ef fective interventions • Give priority to the most underserved areas and populations • Give priority to the diseases causing the most deaths and illness • With the People through healthy Islands/ Villages/ families/Schools/workplaces • With Provincial Government and MPs • With other government departments • With donors • With Churches, NGOs and Private sector • Within the MHMS • Safety: First do no harm • Effective: Make sure what we do is effective • Effi cient: Make best use of resources – money, people, equipment Make best use of interven tions: Prevention, primary care, secondary care, tertiary care • People Centred: Place the people at the centre of all activities • Timely: Deliver the right in tervention at the right time. • Equity Ensure health is en joyed by all • Build health infrastructure: Train and recruit the health workforce • Develop a sustainable fi nancing mechanism • Build the information system • Prepare for disasters and climate change • Learn from each other We serve the people and their elected government Services are safe and good quality Prevention is the foundation of our approach Health workers are caring, passionate and strive to relieve suffering Resources are distributed fairly and used efficiently The health system is open and accountable to parliament, the provinces, and the people for its performance The manner in which we do our work will build the trust of the people Everyone in the Solomon Islands has access to modern and affordable health care based on their needs VALUES AND PRINCIPLES EQUITY SERVICE Q U A LIT Y PR EV EN TI O N CULTURE/ ATTITUDE HO N ESTY A C C O U N TA B ILIT Y TR US T The National Health Strategic Plan approach. This plan focuses on implementation. Our priority objectives aim to improve child and maternal health outcomes, addressing communicable diseases and responding to noncommunicable diseases. This plan identifi es the approach we will take to improve the health of the people. This involves identifying priority interventions and making sure they reach the whole population especially those most vulnerable and isolated. Solomon Islands National Health Strategic Plan 2016 - 2020 9 Current Successes and Challenges Parts of the health system are showing good progress; in other areas we are not progressing. The malaria and tuberculosis (TB) threat are decreasing. Most women when giving birth are attended by a skilled birth attendant. Also, some support services show improvement. There has been improvement in supplies distribution, audit, fi nancial control and health information systems. Over the last period we also succeeded in increasing the resources available at the provincial level. Considerable challenges remain. We did not achieve the MDG child survival target, we experienced a major measles outbreak because immunisation coverage was too low, and too many children remain malnourished. The contraceptive needs of many women are not met. The number of visits to health facilities is static. 01 02 04 03 05 01 02 04 06 03 05 07 Malaria and TB deaths have reduced by two thirds in ten years 9 out of 10 women have a skilled birth attendant 83% of Health Facilities have working fridges Budget allocations to provinces are increasing 98% of essential medicines are in stock at the National Store but significantly less at Provincial level More children under 5years died last year than in each of the previous three years Family planning, in particular contraceptive use is not increasing and the population is predicted to rise by 60,000 in the period 2016-2020 One in ten children are malnourished We had over 4,000 measles cases last year. Two out of three of our communities do not have safe drinking water The outpatient visits for diabetes and hypertension is not increasing despite rising prevalence NCDs The number of outpatients being seen is not increasing Solomon Islands National Health Strategic Plan 2016 - 202010 The performance differs between provinces. Some provinces have good family planning and high contraceptive use in comparison to other provinces; nearly 100 per cent immunisation and nearly 100 per cent supervised births. This high performance shows what we are currently capable of achieving. This level of performance now needs to be reached in all the provinces, for all priority conditions, and across all Area Health Centres (AHCs) within provinces. The health response needs to be tailored to the needs of specifi c locations. These range from geographically isolated islands such as Rennell and Bellona, to heavily populated areas of Malaita and urban Honiara. In Honiara, for instance, 100 per cent coverage has been attained for immunisation and skilled birth attendance, unlike any other province. Whilst this is good news, failure to provide these services nearer people’s homes is infl ating the fi gure for Honiara. The challenge in the capital is not only the availability of health services, but the need to move towards appropriate use of existing health services. The NRH redevelopment creates this opportunity. At present NRH is being used as a primary health care service, instead of specialising in referred services. Our most skilled clinicians could achieve much more if they were able to focus exclusively on the more diffi cult clinical problems. Part of the solution to the pressure on NRH is to improve service coverage in the provinces. What hindered service improvement over the last fi ve years? A number of reasons for the slow progress have been put forward during this strategic planning process by the MHMS staff and development partners. Most groups identifi ed aspects of leadership and delays in fi nancial and human resource administrative systems as the main problem. • Resources (especially pharmaceuticals and supplies) did not fl ow to the periphery of the system. • Activities were fragmented, with poor coordination, particularly between the public health divisions. • No clear prioritisation meant the agenda was crowded and there was a lack of priority. • Resources were insuffi cient, or resources were available but not spent. • Strategic leadership was primarily focused on donor-led, rather than MHMS led activities. • Social conditions were deteriorating. • Disasters and disease outbreaks interrupted service delivery. • A fraud case crippled core functions such as procurement, and dented confi dence within the sector and with donors. • Some staff showed lack of discipline, including not showing up for work and not carrying out their functions, but were not disciplined. • Decision-makers at provincial and national levels were unable to direct available resources to where needs were greatest. • Operating budgets were tied up in specifi c programme funds, were not fully used, and could not be used to support core functions in the provinces What helped service improvement over the last fi ve years? When resources, staff, information and service interventions were suffi cient and worked in unison. Where leadership at all levels was strong and accountable. Skilled leadership in provinces and programs is closely associated with improved performance. When dedicated staff stayed focused on improving the work in their area of responsibility over a number of years. Where strong partnerships were built both nationally and at the provincial level. Solomon Islands National Health Strategic Plan 2016 - 2020 11 How will we expand on our achievements and address our weaknesses? To start, the MHMS does not function in a vacuum. A number of important changes are being made by other parts of government to improve performance. • The Ministry of Public Service, Solomon Island Government (SIG) has introduced performance requirements to measure investments in public servants against indicators relating to their positions. The indicators in this plan will support performance measurement. • The Ministry of Finance and Treasury has instructed Public Financial Management that all expenditure must be related to the corporate or business plan of each Ministry. • SIG is also moving toward the decentralisation of public service responsibilities making them closer to the community they are servicing. Within the health system there is the realisation that centralised management of services has not resulted in better health outcomes or brought about greater access and broader coverage. The health system has not been utilising the available funds as effi ciently as could have been expected. The weak health outcome results confi rm this. The MHMS has reformed its structure to accommodate several of the above points so there is clearer lines of responsibility and accountability between the various streams and functions. It will give greater prominence to the issues being faced by the provinces, and support a greater focus across the MHMS on what is happening to front line services. Apart from the organisational changes, there is a need to support a high performing culture throughout the MHMS. This involves clarity about everyone’s contribution to the strategic priorities, supporting continuous learning, using performance data at each level, encouraging good communication across the MHMS and celebrating our successes and achievement as they occur. Governance Unit Executive Support Unit Under Secretary Health Care Under Secretary Corporate Services Under Secretary Public Health CEO NRH Permanent Secretary Provincial Health Directors of 10 provinces Manager Internal Audit Director Human Resources Financial Controller Director Supplies, Logistics & Infrastructure Director of Environmental Health Family Health Prevention, Rehabilitation and Community Health Communicable Disease NCDs Strategic Risk Communications Clinical Services Diagnostics and Allied Health Services Corporate Support Solomon Islands National Health Strategic Plan 2016 - 202012 KRA 1: Improve Service Coverage KRA 2: Build Strong Partnerships KRA3: Improve Service Quality KRA4: Lay the Foundation for the Future Key Result Areas This plan has been developed with four KRAs that apply across the health sector. These have a strong implementation focus. All stakeholders, both inside and outside of government, are encouraged to follow these KRAs. The KRAs are designed to encourage working across the organisational siloes. Most parts of the sector have responsibilities across more than one KRA. The four key result areas are: Solomon Islands National Health Strategic Plan 2016 - 2020 13 KRA 1: Improve Service Coverage Solomon Islands National Health Strategic Plan 2016 - 202014 Key Result Area 1: Improve Service Coverage Our overall goal is to achieve Universal Health Coverage. This means that all people can access preventive, curative, rehabilitative and palliative health services they need and which the country can afford, and that they are of suffi cient quality to be effective, while also ensuring that the use of these services does not expose the community to fi nancial hardship. What is happening now? Figure 1 Coverage of basic services is incomplete. We need to make sure all people of the Solomon Islands are getting access to basic health services. This is the highest priority. We are still battling to control communicable diseases and conditions impacting on mothers and children. At the same time, noncommunicable diseases (NCD), consisting of diabetes, heart and respiratory diseases, cancers, mental health conditions and injuries are increasing. Figure 3 shows 12 leading causes of early death in the Solomon Islands. Diabetes and stroke are now the leading cause of death and disability in the Solomon Islands. 35 30 25 20 15 10 5 0 2010 2011 2012 2013 2014* Infant mortality rate Solomon Islands, 2010-2014* Infant mortality rate Three year moving average In fa n t m o rt al it y r at e (p e r 1 ,0 0 0 l iv e b ir th s) 2015 Target Current Coverage Universal Coverage Figure 2 Slow progress on reducing infant mortality Source: MHMS Core Indicator Report 2015 Solomon Islands National Health Strategic Plan 2016 - 2020 15 CONDITION NUMBER OF YEARS OF LIFE LOST (YLL) PER % of Total 2000 4000 6000 8000 10,000 DIABETES STROKE LOWER RESPIRATORY INFECTIONS ISCHEMIC HEART DISEASE TUBERCULOSIS PRETERM BIRTH COMPLICATIONS DIARRHEAL DISEASES MENINGITIS ASTHMA PROTEIN-ENERGY MALNUTRITION NEONATAL ENCEPHALOPATHY SELF-HARM 11,000 YLL (7.0%) 10,000 YLL (6.6.%) 10,000 YLL (6.4%) 8,000 YLL (5.4%) 6,000 YLL (3.6%) 5,000 YLL (3.5%) 5,000 YLL (3.0%) 3,000 YLL (2.1%) 3,000 YLL (2.1%) 4,000 YLL (2.2%) 3,000 YLL (2.1%) 3,000 YLL (2.0%) What would we like to see? Our aim over the next 5 years is to achieve better health outcomes by improving service coverage. Part of the reason for our lacklustre performance has been that we have tried to do too many things without making sure the basics are delivered to the whole population. We don’t have the resources to do everything immediately, so we need to prioritise. Attaining high coverage in these interventions will save lives, save money and reduce future hospitalisations. To improve coverage the sector will focus on: • Strengthening the health response at the local level • Full coverage of priority programs • Improved service access for priority populations • Focus on diseases responsible for most of the deaths and illness Strengthening the health response at the local level: This means ensuring health facilities are open, staffed and equipped. Everyone in the community should be able to access a health facility and see a trained health worker with adequate supplies. The Role Delineation Policy describes this basic level of service. Currently, many provinces have health facilities that are closed. Supplies such as medicines are improving but still only reach 73% of primary care facilities, and often health workers are absent from their posts. Figure 3: Leading Causes of Loss of Life in Solomon Islands showing the increasing NCD burden. Source: Global Burden of Disease Study Solomon Islands National Health Strategic Plan 2016 - 202016 Full coverage of these priority interventions: Listed below are the programs that will be given priority: 1. Immunisation 2. Family Planning 3. WASH 4. Supervised hospital or facility based deliveries and neonatal care 5. Malaria1 Control 6. TB Control Priority to the most underserved provinces and zones: Current service coverage varies in different provinces and between different AHCs within provinces. Priority should be given to identifying the underperforming areas, understanding the reason for the underperformance, and taking appropriate action. Provinces with low levels of service provision across several programs in 2014: 1. Malaita 2. Makira 3. Choiseul 4. Central Due to the large variation in the size of provincial populations, areas of low service coverage at the zone or AHC level will reveal considerable under provision within provinces even when the provincial performance is strong. Hence the importance of focusing on zone coverage to identify weaker performing zones. Provinces will assess performance at the zone level in their annual planning process. Within all populations, priority will be given to: 1. People with disabilities 2. Women exposed to violence and abuse These priority populations are relevant to all programs and provinces. The MHMS has established a gender focal point to act as a resource to assist in the approaches required. Focus on diseases responsible for most of the deaths and illness The disease burden is rapidly shifting to NCDs, so we will build the NCD response in all parts of the health system. This requires much more than a specifi c program – all parts of the health system will be expected to turn their attention to addressing this increasing disease burden. Preventive measures will target the use of tobacco, alcohol, beetle nut, and other addictive drugs. A preventive approach is also required to address the poor diet and lack of physical activity underpinning obesity, diabetes, heart disease and stroke. Some of the most effective approaches involve working with other sectors and the use of legislation and taxation. Treatment for NCDs using the PEN package will be further developed for the Solomon Island context and rolled out to all health facilities. During this period the Healthy Lifestyle Committee and Fund will be established and will play an increasing role in supporting preventive activities. 1 Malaria includes attention to Dengue and other Vector Borne diseases. Solomon Islands National Health Strategic Plan 2016 - 2020 17 What needs to change? Firstly, coverage needs to become the main focus for the sector. This will be refl ected in prioritisation of resources, in reporting of indicators through the HIS and in assessing and rewarding performance at all levels of the system. The specifi c issues to be addressed to improve coverage differ for each province and each programme and zone within a province. Hence the importance of being able to make decisions on the allocation of resources from the provincial and zone levels. Currently, bottlenecks are preventing full coverage. We need to identify these bottlenecks at each level and overcome them. Appendix one contains a description of how bottleneck analysis can be used to improve coverage, even when resources are lacking. It helps identify the specifi c cause of low coverage – which may differ in different zones and provinces. To do this, programs, provinces, and corporate support services need to plan together, identify the bottlenecks, and take appropriate measures to address them. This needs to become part of a regular cycle of improvement. It relies on accurate, timely information and statistics. As a fi rst step, improving the collection of vital information (such as births and deaths) is required. D ru g s a n d S u p p ly H u m a n R e so u rce s Tra in in g E n viro n m e n ta l H e a lth In fo rm a tio n S yste m s F in a n ce sG o ve rn a n a n d N o n co m m u n ica b le D ise a se s Tu b e rcu lo sis V e cto r B o re n D ise a se s M a te rn a l a n d C h ild H e a lth Villages Towns NAPs Area Health Centres, RHC Provinces UN VE RS AL H EA LT H CO VE RA G E Ve rt ica l a nd H or izo nt al W or ki ng T og et he r Figure 4: Bottlenecks preventing universal health coverage. The specifi c cause of the bottleneck differs. Figure 5: All parts of MHMS need to work cooperatively to achieve Universal Health Coverage. Solomon Islands National Health Strategic Plan 2016 - 202018 What does this mean for Programs, Provinces, Hospitals and Support Services? In this plan, programmes will strengthen the role of the Provincial Health Offi ce and AHCs, so that they can focus on improving coverage for the province and the zones. We will also strengthen the oversight role of our national experts in specifi c programme areas and support them to take a more strategic approach to improving both the quality and coverage of their respective programmes. Corporate support services also need to incorporate the priorities into their plans and functions. Hospitals also play a crucial role in coverage. For example, making sure every child who visits a hospital is fully immunised, and that lifesaving secondary care services such as a caesarean section or appendectomy is available when needed. Currently, hospital services are not available to many of the mothers when they give birth. Hospital services are concentrated in Honiara, with decreasing access to populations further away. Strengthening and in some cases establishing general hospitals, outreach secondary care services and transport for those with life threatening conditions plays an important part in improving coverage. Solomon Islands National Health Strategic Plan 2016 - 2020 19 KRA 2: Build Strong Partnerships Solomon Islands National Health Strategic Plan 2016 - 202020 Key Result Area 2: Build Strong Partnerships Health is everybody’s business. Health services make an important contribution to peoples’ health, but so does family and village life, education, agriculture, fi shing, clean water, sanitation and well distributed economic growth. The health services in this plan do not stop at the door of the aid post, rural clinic, AHC or hospital. Instead they are the springboard into the community – where much of health is generated. The health goals of our communities are also our goals. To achieve this, we (health, communities, other sectors and partners) all need to work together. Their success is our success. What is happening now? Two out of three of our communities do not have safe drinking water. Currently our activities and many of those of development partners working at the community level are fragmented. Family planning levels are low, and declining, which has widespread consequences. Over this planning period, if population growth continues at the present rate, the population will increase by 60,000 by 2020, putting more pressure on food, water, education and health services. Within the MHMS there is limited partnerships across programs, between programs and provinces, between NRH and the provincial hospitals. Currently, each service is planned in isolation, leading to gaps and overlaps, and missed opportunities to share and maximise resources. What would we like to see? Partnerships with the people through healthy Islands/ villages/ schools/workplaces In this planning period we intend to make “Healthy Islands” the overarching framework for all health-related activities at the community level. The Pacifi c’s Health Ministers poetically described this historic policy in 1995: Children are nurtured in body and mind Environments invite learning and leisure People work and age with dignity Ecological balance is a source of pride The ocean which sustains us is protected Within this framework there is a focus on healthy villages, healthy families, healthy schools, healthy markets, healthy workplaces, healthy towns and healthy cities. A healthy family is a precursor to a healthy village village where there is safe water supply and sanitation, all children are immunised, women of reproductive age have access to information on family planning and appropriate options for contraception, children are sleeping under insecticide treated mosquito nets, and people with disabilities are able to fully participate in village life. Healthy Islands is also the policy framework we will use for working closely with other sectors. This requires a partnership with provincial government, and MPs. In addition, the multi sectoral approach to NCDs fi ts squarely in a healthy islands approach. The MHMS will take a coordinated approach to this, with different public health programmes working together at the village level, and involving NAP and RHC staff. So too with donor programmes working at this level. They will all be encouraged to work within the healthy village policy. Solomon Islands National Health Strategic Plan 2016 - 2020 21 Partnerships with Provincial Government, MPs, NGOs, Churches, and the Private sector. The decentralisation of resources to the provincial level by the MHMS will require a stronger partnership at that level with other parts of government, churches, businesses, NGOs and local MPs. Provinces will develop a provincial health plan and this will be the opportunity to engage with all the health stakeholders in a province, and develop a coordinated approach to health. The churches play an important role in our communities, and often already have programs and approaches consistent with a healthy settings approach. Where this is the case, building a strong partnerships with the existing church activities is likely to be more effective than starting a separate health program. Mining operations are being established in some provinces, and this offers another opportunity for partnerships to address issues such as health infrastructure, as well as health issues arising secondary to the mining activity such as accidents, increased access to alcohol and tobacco. Partnerships other government departments Health improves through the actions of the health sector, but also when progress is made in other sectors. Tackling issues such as Water and Sanitation, Nutrition, and NCDs requires strong effective partnerships with the other relevant government departments. Partnerships with donors and development partners Development partners have made a major contribution to health in the Solomon Islands and in this period we intend to further strengthen this partnership. The number of donors and partners are increasing, and this calls for increased coordination. These partnerships will be guided by the government’s policy on Aid Effectiveness. Donors and DP activity needs to be “on plan” in support of government priorities, “on budget”, and also supportive of growth and sustainability. In addition, through this partnership we will: • Explore the implications of the current GFATM “results based” funding model, as well as the Joint Performance Assessment incentive programme to derive a consistent approach to performance incentives across the sector • Work with development partners to build confi dence in our delivery systems, and tackle the large infrastructure backlog • Coordinate training and workshops into a structured, prioritised, in-service training Solomon Islands National Health Strategic Plan 2016 - 202022 programme for all health staff • Integrate service delivery across programmes by funding arrangements that incentivise cooperative activity at provincial and zone levels • Work towards a predictable and sustainable funding path for achieving UHC and the SDGs Partnerships with Education and Training Institutions Training institutions play a foundation role in preparing the health workforce of the future. In order to build a strong health sector, there needs to be a close partnership between MHMS and training institutions, such as SINU, to ensure health workers are trained in suffi cient numbers, with the right skills, and with a curriculum that is up to date and able to meet the changing health needs of the community. Within the MHMS Improved coordination is required across programs, provinces and across support services. Corporate plans within the MHMS will describe the joint program of activity with other parts of the MHMS as well as what a specifi c program can do alone. The MHMS will develop and implement an internal communications strategy to facilitate this process. What needs to change? The shared agenda is guided by the National Development Strategy 2010 to 2020, where the government has stated its priorities for this period and identifi ed the partnerships best positioned to action them. The MHMS has been asked to focus on rural infrastructure, water and sanitation, family planning, and support for people with disabilities. These are refl ected in our priorities. Current programmes and actors such as health promotion, RWASH, family planning, NCDs, MCH, local NAPs, and local MPs all need to coordinate their activities. MPs are included in this to acknowledge their role in supporting local development through the RCDP committees. NGOs, development partners, and churches also need to be included in local health partnerships. The change required is to work together under the Healthy Islands framework, to engage with villages and towns in an integrated approach to health improvement with the province taking the lead. Provincial health strategies need strong partnerships with provincial government strategies, to address health infrastructure and coordination of local government development efforts. Cooperative strategies need to be developed at the national level as well. For example: between Health and Education for healthy schools; between Health and Transport for injury reduction; between Health and Finance for sustainable health funding and for health positive, income generating taxation measures (such as tax on tobacco and alcohol); and between Health and Agriculture for improved nutrition. Training programmes for all levels need to be integrated across programmes and prioritised. Underpinning this is the requirement to have and use quality information. Increasing use of indicators to measure progress against agreed indicators will be an important part of this process. These indicators will be shared with the community itself, as well as the local MPs, donors and across the MHMS. Changing indicators for the better will become an important focus, and the yard stick by which the effectiveness of the partnerships are measured. Solomon Islands National Health Strategic Plan 2016 - 2020 23 KRA 3: Improve Service Quality Solomon Islands National Health Strategic Plan 2016 - 202024 Diagram: Daily health service activities info-graph Solomon Islands National Health Strategic Plan 2016 - 2020 25 Key Result Area 3: Improve the quality and support of Health Services This planning period present us with a unique opportunity to re-shape health service delivery to improve the quality of care. We can improve access for all of our people and develop, maintain and use our resources, particularly our skilled health personnel and infrastructure, more effectively and effi ciently. The re-shaping opportunities in this plan include the redevelopment of NRH, the provincial hospitals at Kilu’ufi and Kirakira, as well as the deployment of 130 newly trained medical offi cers. This KRA will assist in guiding these changes to improve the quality of the health system of the future. Quality has a number of dimensions: • Safety - do no harm • Effective - make sure what we do works and is based on evidence • Effi ciency - make best use of resources; money, people, equipment-make best use of interventions; prevention, primary care, secondary care and tertiary care • People centred - place the people at the centre of all activities • Timeliness - deliver the right intervention at the right time • Equity - ensure health is enjoyed by all The quality includes how we nurture a professional workforce and ensure the safety of their practices. It covers the accreditation of each facility’s ability to provide the services and what the community should expect it to be delivering. Maintaining the quality includes ensuring there are adequate buildings, equipment and medical supplies to meet the needs of the communities. The Role Delineation Policy describes what human and other resources are required for facilities to function effectively. There is a considerable gap to be closed between the current state of equipment and facilities and the level required under the RDP – We intend to partially close this gap by 2020 and complete the process over the next 10 years. To strengthen services to achieve better health outcomes with limited public resources requires informed decisions. These decisions need to be based on relevant data that has been appropriately analysed. What is happening now? The info graphic (Day in the life of our health service) shows some of the activities occurring daily in our public health system. Over 3000 people are seen daily, with over one third seen in Rural Health Clinics. 100 people are admitted daily to hospital, with most admissions in NRH. Childbirth is the commonest cause of admission, and we have 49 births a day. Sadly, we lose a baby every four days, and a mother in childbirth every month. Some conditions are expensive to treat: Each TB case costs $45,700, each person admitted with diabetes cost $35,883. A focus on more effi cient and effective ways to treat these patients would save costs as well as patients’ lives. Solomon Islands National Health Strategic Plan 2016 - 202026 No data is available for the private sector activity and this is a gap we intend to fi ll. We have considerable challenges ahead to make the health system safe, effective, effi cient, people centred and equitable. There is an expectation that by building more facilities health will improve. This is not always the case unless the longer term function, funding and staffi ng are carefully considered. The growth of the national economy determines the size of the health budget, forcing diffi cult decisions about what can be funded. The need far outweighs the resources. New drugs and technologies are coming creating additional expenses, people’s understanding and expectations of the health sector is increasing, and both the population and the NCD burden are predicted to grow. What would we like to see? In this period, we want to make progress on all the dimensions of quality. Increased coverage, as well as the scope of services that people have access to within the budgets that are available. We would also like to see a sustainable funding path, with a planned increase in expenditure and less year-to-year variation. This will enable better medium term and operational planning of services and interventions. The challenge for hospital and health centre development is to ensure their services can be accessed by all who need them – not just those who live nearby. We would like to see better access to secondary and tertiary services and more emphasis on keeping people healthy, and treating people early, before they are so sick that they need to seek higher-level treatment. To improve quality and performance requires sound governance and leadership based on appropriate frameworks of law, regulation, strategies and guidelines. What has to change? Planning and decisions around the important developments such as the NRH need to be based on the evidence for improving the health of the population and addressing the different dimensions of quality. We intend to bring health legislation up to date and make it more effective and improve quality. This will include the Health Service Act, legislation for mental health, legislation on tobacco and alcohol to control noncommunicable disease, and the legislation governing our key health professionals, the Medical Dental Board and the Nursing Council. Solomon Islands National Health Strategic Plan 2016 - 2020 27 KRA 4: Lay the Foundations for the Future Solomon Islands National Health Strategic Plan 2016 - 202028 KRA 4 The Foundations for the Future. The global focus on health development has been on the Millennium Development Goals, which conclude as this planning period starts. Replacing them is the Sustainable Development Goals, which sets more stringent targets than the MDGs, and these are to be achieved by 2030. This KRA outlines activities required in the coming fi ve years, which will help build the foundations that will enable us to attain the SDGs. What is Happening Now? The health workforce At present most skilled health workers and resources are in the main centres. Facility National Referral Hospital Provincial and Church Hospitals Area Health Centres Rural Health Clinics Community Health Centre Number 1 11 27 115 190 Average no. of staff 621 58.5 8.3 3.5 1.5 Total number of Staff 621 643 216 402 135 Of the 86 practicing doctors, 73 are at NRH, and the other 13 at provincial hospitals. 0% 20% 40% 60% 80% 100% NRH Hospitals AHC RHC NAP Total 621 58.5 8.5 3.5 1.5 DOCTORS & DENTIST NURSES NURSES AID OTHER CLINICAL STAFF NON CLINICICAL STAFF 80 236 85 96 124 1.7 17.7 11.8 8.2 19 3.9 2 1.3 1.1 1.1 1.3 0.8 0.3 0.1 1.1 0.3 Figure 6 Health worker distribution across the health system shows the concentration of numbers and skills in NRH. Source Health Facility Costing Study, Monash University 2014. Solomon Islands National Health Strategic Plan 2016 - 2020 29 The Health Infrastructure There is a pressing need to improve NRH’s facilities. The situation in many Provincial Hospitals, AHCs, RHCs and NAPs is equally desperate. A survey in three provinces2 in 2014 showed only 15 per cent had an adequate water supply, and 90 per cent did not have an adequate toilet. Of particular concern is the quality of the facilities available for women to give birth. We have 344 health facilities, most of which were built at least 30 years ago. They have not been well maintained so there is now a big backlog of repairs and replacement needed to bring the facilities up to a suitable standard. The total cost of these repairs and replacements has been estimated at SI$2.3 billion, divided equally between NRH, provincial and church hospitals, and AHCs/RHCs/NAPs. Although the resources to fully address this backlog have not been identifi ed, there are commitments by the government and potentially with donors which will see progress over this planning period. Finances: The government is the main funder of health. It allocated approximately 14 per cent of its budget to health over the last fi ve years, and has been increasing its contribution every year. In 2014 and 2015, there was a 4 per cent increase in government funds for health, but a reduction in donor funding from a peak in 2013. The amount of money available each year has to increase by about 7 per cent for the health sector to stay even unless effi ciencies are made, because of the impact of population growth and infl ation. We are not spending all the available money. In 2014, MHMS was unable to spend 13 per cent of its recurrent budget and 94 per cent of its development budget. The provinces spent most of their budgets, as did NRH, pharmaceuticals and NCDs. The under-spending occurred in the budget that supports infrastructure and also in Public Health Divisions. The development budget was almost completely underspent because the purchasing and infrastructure unit was not functioning, a situation that has now been addressed. 2010 2011 2012 2013 2014 2015 600 500 400 300 200 100 0 2 Makira, Temotu and Western Province. MHMS 2014 Figure 7: Total health allocation in $(million) (Includes government and donor funds) Source: World Bank presentation April 2015 Solomon Islands National Health Strategic Plan 2016 - 202030 What would we like to see? Health workforce The health system succeeds or fails on the strength of the health workers. The system is primarily nurse based, and continuing to build the capacity and capability of this workforce is essential. New technologies (such as drugs, vaccines, mobile phones, diagnostic tests) all have the potential to improve the effectiveness and reach of the workforce. For example, misoprostol, a drug that reduces bleeding after childbirth, can save many women’s lives, provided the front line health workers have access to it. Technological advances are also increasing the need for allied health workers to operate specialised equipment. We intend to plan and implement an approach to ensure the right health professionals working in the right places with the right skills, right equipment, right motivation and right supervision. The number of doctors in the Solomon Island health system will more than double in the 2016–2020 period with one hundred and thirty-eight new medical graduates supplementing the 86 current medical graduates. This has the potential to have a profound impact on the health system of the future, if this workforce is trained and equipped to work outside of the main centres and to take both a population health as well as a clinical approach. Health Infrastructure NRH is being developed to improve tertiary service provision. The current approach is strategic, with the main focus in this planning period (2016–2020) on recovery and rehabilitation of the current facility while designing and strengthening primary and secondary healthcare services in Honiara, Guadalcanal and other Solomon Islands. NRH clinical leaders have called for a focus on quality through this reorganisation process. Kilu’ufi and Kirakira are being developed to provide improved secondary care access for the people of Malaita and Makira provinces. Strengthening primary care service provision in Honiara to take on at least 50 per cent of the NRHs current outpatient load, and providing a facility for maternity care for uncomplicated deliveries would substantially reduce both the outpatient and inpatient load at NRH, lower the cost of providing those services, and enable NRH to focus more on its specialities and referred inpatient services. The NCD disease burden will have a big impact on this new development. The NCD burden will increase demand on inpatient facilities; however, it also requires a different response from both primary care and secondary care. It requires a chronic care management approach. The re-developments offer a unique opportunity to develop this different model of care in the urban centres not only for long-term conditions such as NCDs, but also for TB and HIV. This model would primarily be outpatient based, building on the function of existing AHCs, but also using the skills of hospital based specialists as part of the clinical team. Getting the right mix of inpatient, outpatient, and preventive care is an important focus of this development. The developments of secondary and tertiary facilities require oversight by the MHMS executive, which is in the best position to guide the development so the wider system benefi ts are realised. The Role Delineation Policy (RDP) has been developed to deliver on Universal Health Coverage. This policy defi nes the range and level of services – or packages of care – to be delivered to given populations across the Solomon Islands. It answers the question: who does what, where, and for whom? What staffi ng, equipment and drugs are required? What sort of buildings and transport? What will be needed in terms of drugs, energy, water, etc.? What will the cost be to build, and more importantly what will the cost be to run each year and how many health workers are required? Solomon Islands National Health Strategic Plan 2016 - 2020 31 The current RDP policy focuses on RHCs and AHCs, and has already been applied to 18 facilities, to determine the cost of bringing facilities and equipment up to a standard consistent with the policy. This work has identifi ed a considerable gap between current services and those required by the policy. Work is currently underway to apply the policy to the general hospital. Role delineation is not an issue just for AHCs and RHCs. All parts of the system will be included in the policy, with their role and function specifi ed. The role and function of NRH and Kilu’ufi will be defi ned in the master planning process being undertaken prior to the facility rebuilds. Decisions taken for these facilities will have a major impact on the cost and effectiveness of the rest of the health system for years to come. The impact of decisions for these facilities on resources and the workforce in the future is particularly important. Finance: The fi nancial strategy is: • Effectively, effi ciently and accountably spend existing allocations, especially within Infrastructure and Public Health programmes. • Improve information systems and accountability, and relate investments to improved results, so that both government and donors have increased confi dence in the health sector. • Build an evidence-based case for increased investment in health for the out years, and construct an out-year funding path. • Utilise salary negotiations to incentivise universal coverage by developing attractive packages for retaining skilled professional working outside of the main centres. • Work with government and donors to address the infrastructure defi cit. • Make the case for health as an “Investment” rather than a cost. Often, health is seen as an “expense” rather than an investment. This is a limited view, as many health programmes have profound positive impacts on the wider economy and some health programmes can be income-generating for governments. Take Family Planning as an example3. In this planning period if meeting unmet need for contraception meant contraceptive prevalence increased from 28 per cent to 38 per cent. This would result in: • 2,075 less births, slowing population growth from 2.5 per cent to 2.2 per cent • A 50 per cent reduction in abortions. • A reduction of maternal deaths by 12 per cent and infant deaths by 20 per cent • A saving of $180m in public education and health services • A reduction of long-term staff and infrastructure costs for health services by 5 per cent and education by 10 per cent A similar story is seen with other interventions. Each dollar spent on improved sanitation in the region returns $3.60 in social and economic benefi ts4. Health activities, such as tobacco and alcohol taxation, as well as having health benefi ts, generate government income. 3 Mackey-Buckley S, Kennedy E, Subramaniam S. The Case for Investing in Family Planning in Solomon Islands.; 2012. 4 World Health Organisation. Global Costs and Benefi ts of Drinking Water Supply and Sanitation Interventions to Reach MDG Target and Universal Coverage. Geneva; 2012. Solomon Islands National Health Strategic Plan 2016 - 202032 What needs to change? Workforce The number of doctors in the Solomon Island health system will more than double in the 2016–2020 period. One hundred and thirty-eight new medical graduates will be available to health services during this planning period, supplementing the 86 current medical graduates. Up until now, most of the population have not had access to a doctor, unless admitted to hospital. Training and orientation of these new graduates is being undertaken by NRH. The deployment of these graduates also has implications for other parts of the health system. Drugs and supply use will rise, particularly at AHC levels. Demand for housing, in service training, and development of career pathways will increase. Ensuring this infl ux of expertise into the system fl ows through to the more peripheral areas and that it increases system performance overall will be a major management challenge. Resourcing will be a signifi cant issue, as well as insuring that existing staff and systems are strengthened as the new expertise becomes available. Supporting a team approach in these facilities will be important. It will require adequate management, supervision, information, and support. Due to the long lead time between when a health worker starts training and is ready for practice, during this planning period the MHMS needs to work with the Ministry of Education to ensure the health workers required for the 2020s are being trained in suffi cient numbers and with appropriate skills to meet the future challenges. Finances Firstly, we need to effectively spend the money we have been allocated. The biggest part of expenditure is on staff costs and the decisions taken regarding staff costs have the biggest impact on the health budget. Universal coverage will require increasing the incentives for skilled health workers working in remote locations. These incentives can be negotiated when salary levels are set. The Government’s Medium Term Expenditure Pressures identifi es spending pressures for the sector in the years ahead. It is updated annually. For the fi rst part of this planning period, it has identifi ed the additional costs related to the fi rst two blocks of new medical graduates, and seeding costs related to NRH and Kilu’ufi developments. This plan identifi es additional areas of spending that are currently not part of the government’s forward fi nancial planning. The MTEP (Nov 2015) and forward expenditure estimates are in the appendix. The MTEP is updated regularly, and future updates need to include the following: Doctors and nurses from the Eye Care Department. Solomon Islands National Health Strategic Plan 2016 - 2020 33 • the cost of rehabilitating the healthy system infrastructure, estimated at $1.2 billion – spread between NRH (400m), General Hospitals (400m), and rural facilities (AHCs and RHCs) 400m. The current MTEP has identifi ed $684m for infrastructure which, if approved, should go halfway to addressing the infrastructure defi cit in this planning period. At present, the NRH infrastructure planning and potential costs (as refl ected in the MTEP) is in advance of the general hospital and rural facility infrastructure planning and costing. To meet the requirements of this plan, there needs to better balance between NRH and health infrastructure investment in provinces and zones. The current ratio of investment in the MTEP for 2015 and 2016 (NRH: General Hospitals: AHCs and RHCs) is 11:4:1. In other words, 11 dollars will be spent on NRH infrastructure for every four dollars spent on AHCs and every dollar on RHCs. There is an urgent need to progress the RDP’s service delivery package costings so that out year fi nancial forecasts present a better balance between central and peripheral expenditures on infrastructure. • funding new graduate positions post-2018. • increase in staff costs and new positions related to service delivery packages for RHC, AHC, General Hospitals and NRH. The operating costs of new facilities (especially staff costs) are the main expenditure, so these need to be modelled before fi nal decisions around infrastructure are made. • pharmaceuticals/supplies/ medical equipment growth consistent with increased coverage, COD arrangements with the global fund. • contingency for disasters and disease outbreaks. Infrastructure We will change our approach to infrastructure. Facilities in the future will be built with regard to the population needs and how they will be resourced in the medium term. Decisions will be made based on full consideration of the long term impacts of the facility, and the opportunity costs – what else could be achieved for the same amount of money. The RDP service delivery package will provide the guidance. The future MTEP and resulting investments in infrastructure need a better balance of central and provincial expenditure as noted above. (see appendix) Solomon Islands National Health Strategic Plan 2016 - 202034 Build the information system The attainment of the goals in this strategy depends on the continued development of the information system. Vital registration, maternal death reporting and child death reporting are all required. Also the information needs to be analysed and produced in an easily accessible form. This applies to both the public and private sector. Prepare for Disasters and Climate Change For the Solomon Islands there is also the ever-present external and immediate threats of disasters leading to disease outbreaks plus the possibilities of emerging health threats and the need to be able to quickly and effectively detect these and respond. And all the while climate change is insidiously challenging the traditional lifestyles of Solomon Islanders. Preparation is required to respond appropriately to these threats. Climate change effects the social and environmental determinants of health – clean air, safe drinking water, food supplies, secure shelter. Weak infrastructure makes the country more vulnerable. The actions required to respond include: • Increase the understanding of disaster risk • Strengthen the disaster risk governance • Invest in disaster risk reduction for resilience • Enhance disaster preparedness for effective response and “Build Back Better” in recovery, rehabilitation and reconstruction The new MHMS structure has established a section on disaster risk management as well as disease surveillance to progress this work. Learn from the local and global success stories There are high performing programs and provinces within the Solomon Island health sector and other parts of Melanesia. This provides an opportunity to learn from our own examples of best practice and fi nding solutions that work in our own settings. The Planning Process This strategic plan will frame the corporate plans of the MHMS. Currently there are a number of program strategic plans, with differing timeframes. Over this period all planning will be synchronised to the 2016-2020 planning period, and subordinate plans will be referred to as corporate plans. Corporate plans will be developed for each part of the MHMS, including each province, and these will cover the specifi c strategies and intended activities for the period 2016-2020. Every year the Annual Operating Plan (AOP) will be developed on the basis of these corporate plans. See the appendix for an outline of the planning process. Further information and guidance will be described in a planning manual. Indicators Indicators show how we are progressing and will play a much more important role in the way health services in the Solomon Islands are run over the next fi ve years. Each domain will have different information needs to manage their area of responsibility. The indicators in this document are a subset of these wider information needs. Indicators will monitor levels of activity in different parts of the health system. National, Provinces, Zones and Hospitals. Solomon Islands National Health Strategic Plan 2016 - 2020 35 The Monitoring and Evaluation Indicators Framework diagrammatically shows the different levels of indicators that will be utilised. At each level, (i.e. Programme national, provincial, health zone and hospital) will be an agreed set of indicators that will be used by the MHMS to measure the achievements and progress of this plan. Objectives In this plan a number of objectives have been identifi ed. These will be closely monitored by the executive team, using indicators to assess progress every quarter. To achieve the objectives, a number of different parts of the MHMS, and sometimes other parts of government, will need to develop a shared plan and work closely together. The Road Ahead The “road ahead” is summarised in the diagram below. Planning, policies, and indicators will support the KRAs outlined in this document. Targets for some coverage priorities are set: immunisation (90% by end of 2016), safe deliveries (90% by 2018), deployment of doctors at AHCs (60% by 2019). Others will be developed for each of the priority programs in 2016. PROVINCIAL HOSPITAL NATIONAL PROGRAMME ZONE Monitoring and Evaluation Indicators Framework Roadmap Ahead Solomon Islands National Health Strategic Plan 2016 - 202036 Outcome Statement Objectives Lead Department/ Division* Relevant Corporate/ Sub-Strategic Documents** Indicators 1. Improved child survival particularly for disadvantaged, remote, hard to reach 1.1 Reduce under 5 mortality to 15 per 1000 by 2020 Lead: Family Health Hospitals Provinces RMNCAH corporate plan Family Planning 2020 1. Number of Health Stafftrained for RMNCAH competencies 2. Mortality rates for neonatal, infant, and child 1.2 Immunisation coverage 90% for all children under 2 by 2020 Lead: Family Health Provinces 1.3 Number of communities with safe drinking water and sanitation Lead: Environmental Health Provinces WASH strategy Number of ODF Communities 1.4 All health facilities’ open Lead: Provinces, HR, Supplies logistics and infrastructure, FBOs, local health committees RDP SOPs (to be developed) Number of health facilities closed 1.5 All health facility births and deaths are notifi ed Lead: MHMS HIS Ministry of Home Affair – Civil Registration CRVS strategy. 1. Percentage of births and deaths notifi ed by the health system Professional Health Boards Hospitals Provinces, FBOs National Health Strategic Plan Outcomes and Objectives 2016 - 2020 The national outcomes and objectives for 2016-2020 are shaped by the four key result areas and are outlined in the table below; it identifi es the broader outcomes of the plan, the specifi c objectives and the lead department/ division responsible for the overall achievement of an objective(s). The table also lists the relevant corporate plans or sub-strategic documents that explicitly align and describes activities/actions toward achieving of objective; and indicators that help measure the achivevements of those objectives against the plan. Please note: *The Lead Department/division ,leads the coordination of partners (divisions/departments/DPs/other stakeholders) to achieve the objective. The Lead is highlighted in blue. It does not imply they are solely responsible for this objective. Also listed are partners who play a signifi cant role in delivering on the objective. ** As new corporate and provincial plans are developed, they will be shaped according to the four KRAs, and contain joint plans of the relevant lead departments/divisions. They will also identify key objectives for each area. Solomon Islands National Health Strategic Plan 2016 - 2020 37 Outcome Statement Objectives Lead Department/ Division* Relevant Corporate/ Sub-Strategic Documents** Indicators 2. Improved maternal health across all provinces, especially for high risk mothers and those in hard to reach communities 2.1 Reduce Maternal mortality to 7 per year by 2020 Lead: Family Health Hospitals Provinces Reproductive and maternal neonatal child and adolescent health corporate plan 1. Number of maternal deaths per year 2. Percentage of maternal deaths audited 3. Average number of ANC Visits per Mother 2.2 Improve family planning practices and knowledge Lead: Family Health Provinces, FBO’s Communities 1. Family Planning contact rate 2. Contraceptive prevalent rate 3. Number of adolescent births 2.3 100% health facility based deliveries by skilled health workers by 2020 Lead: Family Health Provinces Infrastructure % of births attended by a skilled birth attendant % of births in health facilities 3. Improved health and wellbeing of youth and adolescents 3.1 Develop youth and adolescents health strategy by 2018 Lead: Family Health (Adolescent) Provinces MWYAC Availability of a youth and adolescents health strategy 4. Reduction in non communicable disease impacts 4.1 Reduction of NCD morbidity and mortality Lead: Prevention Health promotion Hospitals Provinces 1. Number of new cases of lung cancerLower limb amputation due to diabetes 2. Availability of essential of NCD medicines 3. Number of new diabetes presentations at outpatients 4.2 Legislative Review and policy Lead: Prevention/ NCD Program Public Health Police Legislation reviewed and developed for: 1. Tobacco 2. Alcohol 3. Betelnut 4. Mental health 4.3 Development of a legislation to address high calorie foods and beverages Lead: Prevention/NCD Program Public Health Police 1. Legislation developed 4.4 Reduce avoidable blindness in Solomon Islands by 25% by 2020 Lead: Eye Care Provinces Eye Corporate Plan Number of cataractsurgeries performed Solomon Islands National Health Strategic Plan 2016 - 202038 Outcome Statement Objectives Lead Department/ Division* Relevant Corporate/ Sub-Strategic Documents** Indicators CONTINUED 4. Reduction in non communicable disease impacts 4.5 Identify and assess dental health needs for Solomon Islands Lead: Family Health Hospitals Provinces Completion of an oral health strategic plan 4.6 Hospitals provide mental health services Lead: Mental Health Correctional Services, USPH Hospitals Provinces 1. Completed MH Act review 2. Number of health facilities delivering mental health services 5. Reduced burden of communicable diseases 5.1 Reduced malaria mortality Lead: Malaria Program, Public Health Provinces Hospitals Malaria Corporate Plan 1. Malaria mortality rate 2. Annual Parasite Index 5.2 Reduce mortality and morbidity from TB Lead: TB Program, Public health Provinces, Hospitals TB Corporate Plan 1. TB treatment success rate 2. TB Case detection rate 3. Development of a DOT Policy 4. Number DOT compliance 5.3 Develop community base DOT (direct observed treatment) policy Lead: TB Program, Public health Provinces, Hospitals TB Corporate Plan 1. TB treatment success rate 2. Case detection rate 3. DOT Policy developed 4. Number DOT compliance 5.4 Reduce number and intensity of food and waterborne outbreaks Lead: Environmental health Surveillance Unit Provinces, Hospitals Reduction of diarrhoeal presentation 6. Reduce environmental health hazards 6.1 Develop environmental hazard exposure policy Lead: Environmental health Public Health Environmental health corporate plan National Strategic plans for Malaria, HIV, TB and Leprosy. National strategic plan for environmental health. 1. Policy developed 2. Act developed Solomon Islands National Health Strategic Plan 2016 - 2020 39 Outcome Statement Objectives Lead Department/ Division* Relevant Corporate/ Sub-Strategic Documents** Indicators 7. Improved health sector responsiveness to gender based violence 7.1 Implementation relevant health related provision of Family Protection Act 2014 Lead: US Public Health NRH Hospitals Province, Police Social Welfare 1. Health compliancy with Act 7.2 Nationalise ‘Seif Ples’ programme across identifi ed health services by 2020 Number of facility with Seif Ples programme 8. All health services and facility are accessible to people with a disability. 8.1 Ratifi ed Disability Convention by 2017 Lead: Planning Rehabilitation Facilities Provinces Malaria Corporate Plan Ratifi cation of Disability Convention by 2017 8.2 Develop Disability Act by 2018 TBdevelopment Lead: Public Health NRH Hospitals Province, Police Social Welfare TB Corporate Plan Development of Disability Act by 2018 9. Strengthen Partnerships 9.1 Improve Partnership Coordination Lead: Executive Support Unit Planning DPs FBOs NGOs MDPAC Provinces National Development Strategy 1. PCU fully established by mid 2016 2. Regularity of partnership meetings held 3. Number of MoU with stakeholders 4. DPs on plan on budget 9.2 Increase multi-sector engagement 1. Policies developed outside health sector where health impact is considered 10. Strengthen Healthy Families and Villages 10.1 Healthy village policy reviewed and implemented in each Province Lead: Health Promotion/ Prevention, Provinces NCD Program, MHMS Executives, Environmental Health Line Ministries Local Government DPs, FBOs, NGOs, CSOs Healthy Village Policy Number of healthy village initiatives per province Solomon Islands National Health Strategic Plan 2016 - 202040 Outcome Statement Objectives Lead Department/ Division* Relevant Corporate/ Sub-Strategic Documents** Indicators 11. Achieve Universal Health Coverage 11.1 Role Delineation Policy implemented in all Provinces (AHC) Lead: Planning /NRH/ Health Care MHMS Executives Public Health Provinces National Medical Store HR Province All Corporate Plans Role Delineation Policy 1. Number of AHCs which are RDP compliant 2. Stock-outs at each health facilities 3. Number of outpatient visits per capita 4. NRH RDP/SDP developed 12. Establish a culture of quality improvement 12.1 Clinical governance established at each hospital Lead: NRH Clinical Governance/ Governance Unit Provinces Hospitals Programmes Community Health 1. Clinical governance group formed 2. Clinical governance policy developed 3. Number of adverse events reporting developed 12.2 Establish patient feedback mechanism at each hospital and health centre 1. Number of Patient satisfaction surveys conducted 2. Established mechanism for community engagement 13. Strenghten health system 13.1 Provincial Corporate plans developed by 2017 Lead: Planning / Corporate Service Provincial Health Directors Provinces, National Programmes Hospitals HIS Provincial Plans (corporate and annual operational) 1. Provincial Corporate plans completed 13.2 Health Information Systems :DHIS2 monthly reporting at 90% for each facility Lead: HIS/ Provinces/ Hospitals National Programmes Hospitals Provinces 2. DHIS monthly reporting status by health facility (90%) 13.3 Identify appropriate integrated hospital patient information system to build on ADT module HIS Strategy 1. Identifi ed integrated patient information managemetn system 2. ADT implemented in Gizo, Kiluufi , NRH hospitals. Solomon Islands National Health Strategic Plan 2016 - 2020 41 Outcome Statement Objectives Lead Department/ Division* Relevant Corporate/ Sub-Strategic Documents** Indicators 13. Strenghten health system CONTINUED 13.4 Implement information system to manage stock from secondary level medical store to health facilities Lead: Supplies Logistics Infrastructure/ Provinces HIS HIS Strategy 1. Number of facility 13.5 HRH workforce and training plan developed by 2019 (US Corporate Services) Lead: Corporate Services - HR HRH plan by 2019 13.6 Medical graduates deployed at Area Health Centres Lead: Corporate services NRH Provinces Number of AHCs with medical doctors (60% across all AHC) 13.7 Provincial budgets are fully expended according to annual operational plans Lead: Provinces/ Corporate Services-Finance Planning Provincial Plans (corporate and annual operational) Percentage of Provincial Budget Expended 13.8 Develop and implement a health services management course for levels 1,2 and 3 to achieve recognised health service management qualifi cation Lead: Corporate Services - HR Percentage of MHMS Management Staff who have completed Health Services Management Course 13.9 Implement national health accounts by 2020 Lead: Corporate Services – Finance/Planning NHA implemented Solomon Islands National Health Strategic Plan 2016 - 202042 Outcome Statement Objectives Lead Department/ Division* Relevant Corporate/ Sub-Strategic Documents** Indicators 14. Relocation and devolvment of hospital and health services 14.1 To progress the reconfi guration of health services in Honiara including the relocation of NRH to ensure primary, secondary and teritary needs of the population for safe effective, effi cient, quality health services are met. Lead: NRH MHMS Executives, Planning Corporate Services Provinces, Hospitals HIS HCC Development Partners NRH Relocation Plan 15. Solomon Island health is prepare for disasters, outbreaks and emerging population health issues 15.1 Improve preparedness and responsiveness for emergency and disaster outbreak Lead: MEOC Environmental Health, Province HEOC NDMO MHMS Emergency and Disaster Response Plans Provincial Corporate Plans Number of outbreaks Number of outbreak deaths Post disaster/ emergency review show improve response 16. Strengthen and maintain health research 16.1 All health research approved via national ethics committee and processes, with abstracts reported to MHMS Executives each quarter and relevant forums Lead: Research and Development/ USPH Planning Public Health Number of research proposals 16.2 Hold annual Health Research Sympossium Health symposium Solomon Islands National Health Strategic Plan 2016 - 2020 43 Acknowledgements: This strategy was developed with the planning division of MHMS under the guidance of the executive. WHO staff in the Honiara offi ce provided excellent technical support. The informatics were designed by Millicent Barty of Honiara and WHO. The statistical information came from the following sources: MHMS Core Indicator report for 2014 (March 2015) Health Facility Costing Study, Monash University 2014 Presentations made by the World Bank at the JAPR meeting March 2015 The Global Burden of Disease Study WHO Pacifi c Country Indicators Appendix: Health Infrastructure and Population in Provinces Solomon Islands National Health Strategic Plan 2016 - 202044 Indicators: General Description of Indicators Many indicators are already being collected in the HIS. What will change is an increased emphasis on monitoring the performance of all health institutions, including AHCs and Hospitals. Where “new” indicators are required, these will be developed and trialled during 2016, before being used nationally from 2017. The list of indicators below will be further developed during 2016, especially with the addition of program indicators. Zone5/ Area Health Centre indicators: • Patients seen • Medicines availability • Immunisation Coverage • Contraceptive contacts • Deliveries by Skilled Birth attendant • Open defecation free communities • Malaria reporting • NCD risk profi les undertaken (new) • Reporting of CRVS (new) Provincial Indicators: • Patients seen • Medicines availability • Staff FTE by cadre by zone (new) • Immunisation coverage • Contraceptive contacts • Deliveries by SBA in a health facility • ODF communities • Presumptive cases of pulmonary TB who underwent bacteriological examination • Malaria Incidence • Tobacco legislation citations (new) • Financial reporting (new) Program Indicators: The current situation is that programs have very large numbers of indicators, often established with the donor partners, and part of contract compliance for funding. In preparing their 2017 AOPs, (during 2016) programs will be required to identify 3-4 indicators that best represent the activity in their area. 5 This indicator covers all the health facilities in an Area Health Centre and their populations. Includes rural health clinics, community health centers. Solomon Islands National Health Strategic Plan 2016 - 2020 45 NRH and General Hospital6 Indicators: • Patients seen (OP and IP) • Medicines and supplies availability (new) • Diabetes and TB admissions and LOS (new) • Clinical reviews, mortality and morbidity meetings, undertaken (new) • Financial reporting (new) • Bed occupancy • Average length of stay • Caesarean section operations (new) Corporate services indicators: • Medicines and supplies availability • Health facilities with safe water and sanitation(new) • Cold chain integrity (new) • HIS reporting completeness • Financial reporting (new) • MTEP identifi ed expenditures ratio on infrastructure (NRH: Gen Hospitals: AHCs and RHCs) • Health trainees by cadre (new) • Staff numbers, cadres, location. • Donor contributions on plan and on budget (new) • Donor funding forecast to 2020 (new) National Indicators: The national indicators to support this are the existing core indicator set. This contains 35 indicators. This has recently been reviewed, and 13 indicators were working well, 15 were working but required improvements, 7 were not working. • Maternal deaths • Infant mortality • Under fi ve mortality • Unmet need for contraception (new) • Access to antenatal care • Acute respiratory infection in children • Infants immunised • Malnourished children • Communities with access to safe drinking water 6 Currently the core indicator set only reports on NRH activity Solomon Islands National Health Strategic Plan 2016 - 202046 • Communities with access to improved sanitation • Basic hygiene practices • Malaria Mortality rate • Annual Parasite Incidence, Malaria • Tuberculosis case notifi cation rate • Tuberculosis treatment success rate • Presentation to a health facility with diabetes (includes IP new) • Presentation to a health facility with hypertension • Sin tax revenue (new) • Access to rehabilitation services • NRH patient discharges • NRH bed occupancy • NRH average length of stay • Nurse to patient ratio • Outpatient consultations per capita • Registered nurses in rural health clinics • Provision of mental health services (new) • Unsupervised deliveries • Stock availability at national medical store and primary health care facilities • Water supply at health facilities • Sanitation at health facilities • Standard medical equipment at health facilities • Recurrent budget allocation to provinces • Financial reporting (new) Universal Health Coverage Our overall goal is to achieve Universal Health Coverage. This means that all people can use the preventive, curative, rehabilitative and palliative health services they need and the country can afford, and that they are of suffi cient quality to be effective, while also ensuring that the use of these services does not expose the community to fi nancial hardship. UHC involves three main objectives: • Equity in access to health services – those who need the services should get them, not only those who can pay for them or those in the main centers. • Quality of health services is high so that it improves the health of those receiving services. • Financial risk protection – ensure that the cost of using care does not put people at risk of fi nancial hardship. Solomon Islands National Health Strategic Plan 2016 - 2020 47 Role Delineation Policy The policy we have developed to deliver Universal Health Coverage is called the Role Delineation Policy (RDP). This policy will operationalise this plan. The policy defi nes the range and level of services – or packages of care – to be delivered to given populations across the Solomon Islands. It answers the question: who does what, where, and for whom? What staffi ng, equipment and drugs are required? What sort of building and transport? The issues of role delineation apply to all parts of the MHMS, and this strategic plan outlines the main shifts in roles that need to be implemented over the planning period. The current RDP policy focuses on RHCs and AHCs, and has already been applied to 18 facilities. This work has identifi ed a considerable gap between current services and those required by the policy. We intend to partially close this gap during this planning period. Role delineation is not an issue just for AHC and RHCs. All parts of the system will need to examine their current role and adjust it to meet the requirements of this strategic plan. As well as describing the services that should be available, in this period we want to focus on the populations who are using the services. It is not enough just to have services available; they must also be used, and used by the whole population. The problem faced by many health facilities is that the number of people requiring immediate attention takes all of the staff time, leaving limited time and resources to do preventive activities and outreach activities. Although this choice to focus on clinical care makes sense in the short term, it is not a good strategy, as the work in the community can in itself lessen the burden in the health facilities. The major health gains are made when services reach everyone in the community. The health services in this plan do not stop at the door of the aid post, clinic, AHC or hospital. Instead they are the springboard into the community – where much of health is generated. What this means is that knowledge of the community becomes important. Our job is to go beyond serving only those that knock on the clinic door, and make sure our services reach everyone in the community. “Universal” means “everyone”. Nurse leaders at the RHC and AHC level have an important role to play in this. They have two roles. They need to run their health centres effectively, but they also need to know their communities well. This includes knowing who is living where, the numbers of people and their ages, and the major health issues they face. They need to know who are the most vulnerable in their communities, and make sure their services reach them. This is also called a population health approach, or, previously, the primary health care approach. Reaching universal health coverage rests on the shoulders of these frontline workers, and the rest of the health system’s role is to support them in their work. The current RDP will require strengthening of its description of functions to encompass the population health approach. This includes identifying population coverage at the AHC level, and positioning public health offi cers at AHCs. The catchment population and subsequent service volumes should be the basis for facility staffi ng and funding. The Master Plans for NRH and Kilu’ufi will help lay the foundation of the RDP for the National and Provincial level functions and facilities. Solomon Islands National Health Strategic Plan 2016 - 202048 Bottle neck analysis7 Bottleneck analysis is an evidence-based method for considering different aspects of delivering health services that may affect coverage and for developing strategies to address these problems. The bottleneck framework assumes six coverage determinants contribute to service delivery for effective health interventions: three on the supply side, two on the demand side and one on quality. When resources are scarce, it is important to identify what particular aspect of the service is causing the bottle neck. For instance, in the example above, the quality of care and patients returning for repeat visits (continued use) and quality are the major bottleneck, and they need to be addressed to improve coverage. In this example, improving the supplies and the number of health workers will have little impact on coverage. If, in the example, quality and repeat visits improved, coverage would increase to 90% with existing resources. Increasing return visits would be addressed with a behavioural change program targeted at this aspect of the program. This analysis can be done by single programmes, or groups of programmes. It can be done at each level. It should involve all the parts of the MHMS as they all contribute to improved coverage. It relies on good information on service coverage, supplies etc. It relies on local knowledge. Some programs within MHMS already use other planning and coverage tools, such as microplanning and the RED (Reach Every District) strategy. Continued use of these approaches is encouraged. 7 Tanahashi T. Health service coverage and its evaluation. Bulletin of the World Health Organization. 1978;56(2):295-303 Solomon Islands National Health Strategic Plan 2016 - 2020 49 Out-year additional costs of the plan 2016 2017 2018 2019 2020 Type of expense New medical graduates 8.2m* 15.4m* 15.4m* xx xx Rec RDP service delivery package xx xx xx xx xx Rec Increments in salaries and condi tions xx xx xx xx xx Rec Training Costs xx xx xx xx xx Rec NRH and Honiara secondary care facilities 128m* 208m* 202m* xx xx Dev Kilu’ufi development 7.7m* 22m* xx xx xx Dev General Facility upgrades 46m* 38m* xx xx xx Dev RHC Upgrades 5.7m* 1.2m* xx xx xx Dev AHC Upgrades 13.6m* 11.5m* xx xx xx Rec Pharms/diagnostics and supplies increases 0.6m* 2.2m* xx xx xx Rec Medical Equipment xx xx xx xx Dev Information / ICT xx xx xx xx xx Rec Population growth xx xx xx xx xx Rec Disasters and Climate Change xx xx xx xx xx Rec/Dev *These are in the current (Nov 2015) MTEP The government makes decisions every year on the actual amounts allocated to the health budgets. The MTEP shows potential future expenditure that will inform this annual government decision making. In order to adequately inform government decision making, accurate potential costing information is required for the items without amounts identifi ed (“xx”). As noted earlier, the SI health system is unbalanced, with most resources and personnel deployed in Honiara, while the bulk of the population requiring services are in the provinces. The current MTEP will perpetrate this imbalance unless potential expenditure (both infrastructure and operating) for General Hospitals, AHCs and RHC are quantifi ed and included in the next MTEP. Quality Effective Coverage Bottlenecks Continued Use First use Physical Access Health Workers Drugs, Surplies, Diagnostics 20% 40% 60% 80% 100% Solomon Islands National Health Strategic Plan 2016 - 202050 Outline of the Provincial and Program Planning Process All parts of the MHMS in the development of their corporate plans will follow a similar process. The key steps: 1. Situation analysis: Form a planning group of key stakeholders to describe the current situation, and identify both good and poor past performance. Gather information on the population, disease patterns, health facilities, health workforce, equipment and supplies, performance information from HIS. Canvas local stakeholders, including patients, views of the health service. 2. Identify priorities based on the NHSP and the situation analysis above a. KRA 1: Strategies and actions to improve coverage of priorities that are relevant for your area. b. KRA 2: Partnerships required and seek their engagement in the planning and delivery process. c. KRA 3: Strategies and actions to address the dimensions of quality. d. KRA 4: Strategies and actions to build solid base for future service provision 3. Undertake a bottleneck analysis to identi fy what needs to be done to increase coverage in priority areas under KRA1. This includes identifying what behavioural change initiatives (demand side) are required to improve coverage. 4. Set Goals for the 5-year period. 5. Identify activities to achieve the goals under the 4 KRAs. 6. Select activities to be carried out, and identify and engage with the responsible part of MHMS and partners to agree on the course of action. 7. Determine resources available, what can be done with existing resources and the resource gaps. 8. Develop activity plans, costs and timelines annually in the AOP. 9. Incorporate indicators to monitor and evaluate with help from HIS. Get Sign off of the Plan and promote it to relevant stakeholders (e.g. MPs, Provincial Offi cials, other parts of government) How was this strategic plan developed? This plan was developed over 2015. The following are the steps undertaken: • A review of the 2011-15 plan was undertaken, and lessons learned identifi ed. • The MHMS executive met and agreed on the overall emphasis of the plan. • Stakeholder consultation workshops were held, often involving a SWAT analysis, with the Executive, NRH senior staff, development partners, national program managers, PM’s department. • Discussions were held with each province on the priorities for the plan in preparation for the 2016 AOP. • The draft plan was discussed in detail at the 2015 National Health Conference, with the conference agenda shaped according to the plan’s KRAs, and café style discussion groups exploring the issues in depth from different perspectives. • The plan was fi nalised after incorporating feedback from the NHC and approved by the MHMS executive in January 2016. Solomon Islands National Health Strategic Plan 2016 - 2020 51 Solomon Islands National Health Strategic Plan 2016 - 202052 Report produced by SynTech Technology Solutions Solomons Email: SolSynTech@gmail.com Ph: +677 773 6833 Ministry of Health and Medical Services Planning and Policy Contact Phone: (+677) 20-830