Tonga Millennium Development Goals, Final Report September 2015

2.1. Country Profile Location and Geography1 It is said that the Tongans, known for their sea faring skills, migrated from Asia and populated the islands more than 3,000 years ago. Tonga is located in the South Pacific, almost 3,600 km northeast of Sydney, Australia and 2,000 km north of Auckland, New Zealand. It is 8,600 kilometers from Los Angeles, California in the West Coast of the United States. These cities are also the centres for the Tongan diaspora. It is estimated that more than 120,000 Tongans are living in Australia, New Zealand and the United States. A lesser number of Tongans live in Europe, United Kingdom and Japan. Tonga consists of 172 islands with a land area of 747 square kilometers, as well as a total land/ocean surface area of approximately 720,000 square kilometers. There are four major island groups with Tongatapu being 35% of the total land area and ‘Eua which covers 12% of the land area in the South. Ha’apai is in the middle which is 15% of the land area and Vava’u is to the North and is 16% of land area. The north-most islands, the Niuas, cover only 10%. The islands are both coral and volcanic, where the coral islands like Tongatapu and Ha’apai are low lying, water sources are underground and vegetation cover is mostly of grassland and savanna. The volcanic islands which are ‘Eua, Vava’u and the Niuas are hilly with thick vegetation in the sloping areas with surface water runoff, mainly in ‘Eua. The climate is tropical with the rainy season from November to April, which is also the hurricane season and the dry season from May to October, which is also the cold weather season. Around 65% of rainfall occur during the wet season and 35% during the dry season. Mean temperature varies between 24°C and 27°C. The El Nino phenomenon affects Tonga’s climate pattern, which causes drought in Tonga almost every 7 to 8 years. However, about every year a cyclone affects Tonga and intermittenly a number of them have caused very serious damage to infrastructure, domestic properties and agriculture requiring emergency relief. Sea level rise has been on the increase with a magnitude of 6.4mm per year. Population Distribution The population of Tonga, is a total of 103,252, according to the 2011 census, a growth of 0.2% from the last census and only 37 of its 172 islands are inhabited. There are 51,979 males and 51,273 females showing a ratio of 100 female to 101 males. The population density is 144 persons per sq kilometers but varies between islands (SD, 2011). Tongatapu, the largest island, is where 73% of the total population live with 34% of this living at Nuku’alofa, the capital and its peri-urban areas. Vava’u, which is 309 kilometers away from 1 For general discussions – see ADB (2013); SOPAC (2007); DOE (2005; 2010) 4 Tongatapu, popular for tourist marine based activities, holds 15% of the total population. It is served by both sea and air transportation services. The Ha’apai group consists of numerous dotted islands with 10% of the population, and is 176 kilometers away from Nuku’alofa. The Niuas are two volcanic islands and are the furthest to the north of Tongatapu. The overall population growth for Tonga between 2006 and 2011 was 0.2%. This relatively low growth is due to outward migration. Over the decades the population of the outer islands have showed negative growth while the population of Tongatapu showed positive growth. This is the impact of internal rural-urban migration. The Economy2 The Gross Domestic Product (GDP) stood at TOP$880.4million (USD$434.4 million) in 2014/2015, a GDP growth of 2.1% from 2013/2014 (ABD Outlook, 2015). This growth is due to economic activities mainly in the productive sectors and construction and manufacturing. The primary sector – agriculture, forestry and fisheries – accounts for 18% of total GDP. It had strong growth in 2013/14, especially in the agricultural sector, but is expected to slow down in 2015 due to a drought in the second half of 2014. The agricultural sector in 2013/2014 accounts for 15% of GDP and grew by 4.7%, of which 1.5% came from export and 3.2% from local production. Agricultural exports was valued at $12 million, a growth of 11% in earnings and a growth of 6% in volume of export. It is expected that growth will decline during the 2014/2015 period, with export declining by 15% due to the drought and local production to decline by 10%. However, recovery in outer years will be gradual. It should be noted that a large share of agricultural production is for subsistence and engages around 60% of the labour force. Climatic conditions, concern for food security, availability of labour and technology, innovative practices and market access are all the issues affecting agricultural production. An Agricultural Sector Growth Committee is dealing with the issues using the Agricultural Marketing Fund to encourage production and export. The forestry sector’s performance has been very volatile in recent years due to changes in the structure of the industry but this does not affect the overall growth and its contribution is also minimal, only 0.4%. The challenge is increasing production capacity and accelerate replanting of trees for future production. The performance of the fisheries sector has been weak although its contribution is minimal as well, only 3%. The fisheries sector has been fluctuating over time due to the boom and bust cycles which is affected by the migration of the tuna species, market access, prices and Government policy. Growth is expected for 2014/2015 due to expected higher yield of tuna and live corals and other species for export. The secondary sector accounts for 17% of GDP including construction and manufacturing. While construction also fluctuates over time contributing 7%, because of the volatility of the sector, manufacturing added 6% to GDP and is focusing on value adding export products. However, its scope for export diversification and import substitution is limited due to geographical isolation 2 See 2015/2016 Budget Statement (Ministry of Finance and National Planning) for further details and discussion on this section 5 and the narrow base of resources. The rest comes from mining of 1% and electricity and water supply with 3%. In the tertiary sector, the tourism sector has not experienced a major growth in the last 10 years but contributes about 15% of GDP. Its major markets are New Zealand, Australia and the West Coast of the United States. Tourist air arrivals and cruiseship arrivals account for about half of total arrivals and the rest are Tongans visiting friends and relatives. The average spending by tourists is about $1,200 per head for more than 46,000 visitors per year. The rest of the contribution to GDP come from wholesale and retail trade (10%), hotels and restaurants (3%), transport and communication (4%), financial intermediation (6%), public services (12%), ownership of dwellings (9%), education, health and social work (5%), and recreation, cultural and sporting activities (1%). The Tongan Society Tonga enjoys reasonable standards of education and health services, although a large number of people experience hardship due to high levels of unemployment and lack of opportunities for income generation because of low growth. While the economy is dependent on a narrow base of primary level activities and tourism, remittances from overseas - Australia, New Zealand and the United States - have helped to relieve economic hardship. Tonga is largely homogeneous with 98% of the population as Tongans. It is predominantly Christian and there is freedom of religion and freedom of speech guaranteed by the Constitution. Tonga cherishes the values of peace, love, respect, working together, patriotic zeal, keeping relationship, honour, consideration, willingness, steadfastness and justice. They translate these values into the work they do and the goals they pursue. Tongans live in tightly knit extended families which belong to the confederation of extended families – the kainga which belong to the ha’a – the confederation of kaingas – that make up the Tongan society. At its apex is the monarchy who unifies the Tongan ha’as. At the next level are the – ‘eikis – those of superior social status which can be traced to ancient times – and who are in modern terms the nobility and their talking chiefs. The talking chiefs are the guardians of the Tongan values and are responsible for order and cohesion. In recent times, the church has played a large role in ensuring peace and harmony in society and socialising them into internalising the Christian values. All Tongans are a part of an extended family that belongs to one of the kaingas and hence the ha’as that make up the Tongan society. The extended families and the kaingas are headed by paternal males who collectively make the decisions for the welfare and social obligations of the extended families, or the kainga or the ha’a. The extended family networks encourage sharing and working together to achieve goals. While the predominant role of the church is spiritual development, the church denominations have become networks that also protect the Tongan society and help to maintain order and cohesion. Forces of globalisation and international development have put to the test the strengths of the social networks that protect the Tongan society. 6 Tonga is a ‘rank conscious’ society and age, sex and social status determine a person’s rank. Women enjoy their status in society and play a significant role in managing family affairs and community level work. Women are socially superior to men, and sisters are socially superior to the brothers, and older females are socially superior to younger females. Older males are superior to younger males and the children of the sisters are socially superior to the children of the brothers. The children of the older females are socially superior to the children of younger females and so on. Rank determination is an endless business in the Tongan society and it binds together everyone so that the same person, who is socially inferior to one would be socially superior to another. It makes everyone equal. In times of crisis, the extended family networks act to protect people and protect their communities from harm. Paternal males of extended families make decisions and females take the management roles of organising the families and communities for action. More Western values, institutions and social technologies have now permeated the Tongan society and the economy. These values may complement or may be in conflict with the values of the Tongan society. The administration of Government, politics and economic activities, as outlined below, are played out against such a backdrop of a society whose important values are in tack but changing and an economy and environment that are vulnerable to forces beyond the control of Tonga.

2.2. The Economic and Social Development Agenda The Government has now declared that the priority agenda of Government for 2015-2025, under its Tonga Strategic Development Framework (TSDF) II are: Good Governance: focusing on building efficient and effective public services upholding the principles of honesty, transparency, accountability and trust Inclusive and Sustainable Growth: building macro level stability, strong partnership for growth Poverty Alleviation: building value added employment, a healthy and educated workforce Safer and Better Public Infrastructure: building infrastructure resilient to disasters and climate change Since the 1990s, the Government national plans have put emphasis on key areas relating to social and economic development for Tonga. These plans and their focus are outlined below, as they are the appropriate tools that could have been used to mainstream and achieve the MDGs. It provides an opportunity to see how far the MDGs have been mainstreamed into the planning and development process in Tonga.

2.2.1. Economic Development The Tonga National Strategic Development Plan (TNSDP) 7 - 2001-2004 was clear in its expectations that Tonga would pursue the following goals: 7 - Increase GDP per capita from TOP$2257 in 1998/1999 to TOP$8906 by 2024-2025 at constant price - Elevate Tonga to the Upper Middle Income class before the end of 2025 - Build a dynamic, higher competitive economy driven mainly by the private sector During this period, a number of significant programs, with an economic focus, were put in place. These included the Economic and Public Sector Reform Program for reforming the public sector including public enterprises and the Public Sector Investment Program for investment in the infrastructure. Improvement was made to the legislative and policy environment to facilitate private sector growth, trade and investment. Projects in tourism, agriculture and fisheries as the priority growth sectors, were initiated. Environmental protection and improving public services, especially in rural areas, also gained the attention of the development partners. However, the implementation of reforms were slow although significant improvements were noted in health and education. Growth was modest and there was still heavy reliance on remittances and foreign aid. The next TNSDP 8 - 2006-2009, was subjected to a very wide public consultation process. As such, its coverage of pressing issues brought forth attention to hardship caused by widespread unemployment, inequalities in income distribution, environmental degradation and vulnerability. The goals to be pursued under this plan period were: - Create a better governance environment - Ensure macro-economic stability - Promote sustained private sector led economic growth - Ensure equitable distribution of the benefits of growth - Improve education standards - Improve health standards - Ensure environmental sustainability and disaster risk reduction - Maintain social cohesion and cultural identity There was then a need to further extend the social services to the rural areas as a matter of priority. Investment in the infrastructure (roads and sea transportation and facilities) was important to allow people in rural and remote areas to access services and markets. The focus had also now begun to centre on solid waste management, environmental conservation, disaster management and renewable energy. Agriculture, fisheries and tourism continued as the priority sectors for promoting economic growth and creating employment and income generating opportunities for a large majority. Improvement to the infrastructure and the utilities that facilitated economic activities was therefore important. At the same time, the business environment and efficient and effective government administration were improved through regulatory and policy reforms. The Tonga Strategic Development Framework (TSDF) 1 - 2011-2014, which replaced the previous TNSDPs stated the following goals. - Strong inclusive communities, by engaging them 8 - Dynamic public and private sector partnership as the engine of growth - Appropriate, well planned and maintained infrastructure - Sound education standards - Appropriately skilled workforce to meet the available opportunities in Tonga and overseas - Improved health of the people - Cultural awareness, environmental sustainability, disaster risk management and climate change adaptation - Better governance - Safe, secure and stable society, by maintaining law and order On the economic front, doing business need a skilled workforce and doing business successfully relies on partnership between the public sector and private sector. The National Economic Development Committee was set up to reform business services and create a conducive business environment. Fostering technological development, promoting trade and improving the performance of the productive sector were again the priorities – tourism, agriculture and fisheries. Seabed mining and improving returns from seasonal work in Australia and New Zealand were new emphasis. The infrastructure continued to be important and covered widely the important aspects of Tonga’s development. Apart from improving roads and sea transport, air transport and safety, effective telecommunication, affordable power supply, proper management of solid and liquid waste and safe water and sanitation were identified as top priority. Reducing Tonga’s vulnerability to natural disasters and risks were incorporated into joint national action plans between Tonga and the development partners.

2.2.2. Social Development In 2013, Tonga’s Human Development Index (HDI) value was 0.705 (compared to 0.631 in 1990), which ranks Tonga 100th among 187 countries and territories. This is placing Tonga in the High Human Development Category. Although it is below the average for this category it is well above the average for small developing islands with 0.665 and slightly ahead of the average for East Asian and the Pacific with 0.703. However, it is expected that a revision of the 2013 HDI value, would indicate that it would fall to 0.065 due to changes in life expectancy (UNDP, 2014). The TNSDP 7 – 2001-2004, also state the following social goals: - Elevate Tonga to the Higher Human Development Category of the UNDP Global Human Development Index before 2010 - Full employment and high incomes for both men and women in the labour force It seems that the elevation to the High Human Development Category has been achieved. Health and education have always been the cornerstone of social development in Tonga. During the TNSDP 7 period, the Tonga Education Sector Study (TESS) was undertaken. The ground work for the reform in the health sector also commenced and later became the basis for the Tonga 9 Health Sector Support Project (THSSP). This TNSDP 7 also initiated dialogue on poverty alleviation and vulnerability that led to the development of long term plans to address the needs of vulnerable groups, and including the formulation of a national gender policy and a retirement benefit scheme. Again, education and health continued to feature strongly during the plan period for the next TNSDP 8 - 2006-2009. A Tonga Education Sector Program (TESP) was implemented, based on TESS, to improve access and quality and the administration and management of education in Tonga. The THSSP also commenced, with emphasis on the non-communicable diseases (NCDs) and primary health care. Renovation of the main hospital was also undertaken to improve curative health services. The new Tonga Strategic Development Framework (TSDF) I - 2010-2014 was rather different from the previous plans, as the ‘people’ was now emphasised. Governance at the community level through councils were encouraged and development plans were drawn up focusing on developing the livelihoods of people in the rural and remote areas. Now there was a focus on women in business and women in the informal sector as well as the ‘vulnerable groups’ and how they could become productive. It also saw the start of the work to set up a national retirement fund scheme, envisaged by the previous TNSDP, to encourage savings by the ordinary workers. A new Ministry of Training, Employment, Youth and Sports (MOTEYS), now the MIA, was created in 2006 to reform the training sector and national employment, and focus on youth development (through training, micro-enterprise development and health education) and sports development. The development of the informal sector so that it can contribute to generating incomes was part of its work. It was also the beginning of a working relationship between the Government and the CSOs sector to deliver services to those who are vulnerable. While the focus on quality and access to primary and secondary education continued in this plan, new emphasis were placed on technical and vocational training, which was part of the responsibilities of the MOTEYS, to improve access and quality as well as productivity and participation in the local and international labour markets. The health focus continued with improving the delivery of health services across the country and especially preventative health care and NCDs.

2.2.3. Political Development Tonga’ economic and social development in the last two decades have been undertaken within a changing political landscape, which may have also influenced the outcomes of the MDGs. Traditionally, Tonga had unique political institutions that evolved over time. Its Constitution was enacted in 1875 which effectively set up the structure and processes of Government. It provided for a Parliament whose function was to enact the laws, and whose members were chiefly nobles only and whose titles were bestowed by the King. In the beginning there could be up to 30 nobles sitting in Parliament. 10 The highest executive authority was vested in the Privy Council, chaired by the King, and which adviced the King in Council in his important functions. The members of the Privy Council were the Ministers of Cabinet. The Prime Minister and the Ministers, who were also nobles, were appointed to Cabinet by the King (until the 1970s that commoners were appointed to Cabinet). Cabinet was responsible for the day to day administration of Government. It was not until 1910s that representatives of the people were elected to parliament by the people. Men only were allowed to vote until 1950s that women were allowed the same right. The Parliament then consisted of nine representatives of the people, nine representatives of the nobles and the appointed Cabinet ministers, which at one time, there were 14. Political reform was stated as part of the TNSDP 8 - 2006-2009. During the period a National Committee, established in early 2000s, was already consulting on the parameters of political reform. A program for reforming the public service and the public sector was also formulated. In 2010, amendments to the Constitution and the laws of Tonga were made to allow the increase in the number of people’s representatives from 9 to a majority of 17 in Parliament, with the noble’s retaining their 9 seats. It marked the apex of a decade long focus on promoting good governance. The Prime Minister is now appointed by the King from among the elected members of Parliament, after he had been nominated by Parliament by secret ballot. He will then recommend the appointment of other Ministers from the elected members of Parliament. The executive powers of Privy Council have been given to Cabinet for the conduct of Government affairs. The Constitution also allows the Prime Minister to recommend the appointment of up to four from outside Parliament to be members of Cabinet. By virtue of this appointment they also sit in Parliament.

2.3. The Economic and Social Implications of the MDGs The records show a gradual embrace of the MDGs at the beginning. The TNSDP 7 - 2001-2004 did not have an explicit focus on the MDGs. The focus had been on macro level policy adjustments and economic growth. However, at the time, development partners continued to provide funding for projects on improving sanitation, health, education, and developing the productive sectors and rural development. The link between Tonga’s economic and social development and the MDGs was stronger in TNSDP 8 than in the previous one. Wider consultation for the TNSDP 8 - 2006-2009 - recognised the importance of the issues implicated in the MDGs. These included reducing hardship through infrastructural development so that income generation is facilitated, so that the poor can reach the market and so that the quality of life is improved for communities. Increased investment by the private sector was required to create more opportunities. Employment and income generation opportunities for the poor were expected to be realised through growth in the productive sectors. While education and health were seen by the TNSDP 8 as the pro-poor policies, there was no exclusive policy on poverty and hardship, as yet. However, there were no significant emphasis on women, youth and children but the TNSDP 8 identified them clearly as being vulnerable. Youth and children would be vulnerable to dropping 11 out of school and involvement in crime and abuse of substances. Unemployment was high among young people as well as women, especially single mothers, prostitutes, victims of abuse, school drop outs and single women. The disabled and the elderly would suffer hardship most because of the absence of a welfare system in Tonga. The implementation of the strategies for TNSDP 8 saw the mainstreaming of some of the MDGs into the development agenda, although implicitly. However, monitoring and evaluation was lacking and therefore the impact of TNSDP 8 on the MDGs were largely unknown. The next plan - TSDF 1 - 2010-2014 was best in mainstreaming the MDGs into the framework for social and economic development. There was now more focus on the informal sector and the community, skills training, employment and social protection. Overall, the MDGs had resulted in bringing into sharper focus some of the significant issues that needed urgent attention. The economic difficulties of the late 2000s, highlighted the need to deal with ‘hardship’ and ‘poverty’ at the policy level as well as at the ground level for the delivery of services. In health, significant attention was given to the fact that NCDs was becoming an epidemic in Tonga. For education, the biggest concern was quality and access, with gender equity in the education sector. The work on the environment continued to be important, especially climate change and environmental protection. This report will examine how far Tonga has achieved the targets set for the MDGs. 12 3. The Methodology for Completing the Report The methodology used in compiling and writing this 3rd report is described below. It is multi- level where the data and information in the report were vetted at all levels (as described below) before it was finally tabled. Firstly, the previous two MDGs reports were reviewed so that what they had covered were made clear. Quantitative data were then collected from Ministries and Government agencies and also from reports and surveys. Qualitative data were also extracted from reports and documents made available by Ministries, development partners and CSOs. The data were verified at all levels, firstly at the Ministry level, and then at the sector ‘cluster’ level before it was vetted by the Technical Committee, which is under the National MDGs Taskforce set up by Government. The report was lastly vetted by the National MDGs Taskforce before it was finally submitted.

3.1. Review of the 1st and 2nd MDGs Reports The 1st MDGs Report – Tonga’s 1st National Status Report – Millennium Goals Today and Tomorrow – 2005 (National MDGs Taskforce) was reviewed. It was understood that the task for this report was to establish the baselines for the future assessment of progress and final determination of the achievement or otherwise of the MDGs. This report was prepared by the Central Planning Department under the direction of the National MDGs Taskforce and the Development Coordination Committee chaired by the Deputy Prime Minister. The purpose of reviewing this report is to verify the baseline figures for the 19 targets and 54 performance indicators for Tonga. This is important for Tonga’s 3rd and final report on the MDGs because progress and the end results would be measured from these baseline figures. The 2nd MDGs report – 2nd National Millennium Development Goals Report – Tonga – 2010 - was also reviewed. It was understood that the focus of this report was on progress after 10 years of the MDGs. Therefore, the purpose of reviewing it is to see what progress were identified. Furthermore, the Addendum to the 2nd Guidance Notes issued by the UNDG required more in- depth analysis of issues affecting the progress of countries including Tonga towards the end of the MDGs. This is considered important as the 2nd MDGs report provides a background for writing the 3rd MDGs report. It appeared from the review that the following were issues with regards to the 1st and 2nd MDGs reports: 1. The 1st and 2nd MDGs report differed on some of the figures 2. Some goals and targets were adapted and contextualised to reflect the local situation 3. New indicators were added in 2010 when the 2nd MDGs report was written 4. Some indicators were analysed in 2005 for the 1st MDGs report but to in 2010 when the 2nd MDGs report was written 5. Some indicators were not analysed in 2005 when the 1st MDGs report was written but were analysed in 2010 when the 2nd MDGs report was written 13 6. The 1st and 2nd MDGs reports differ on some of the figures for a particular year 7. Some of the figures used were for different years rather than the year of reporting 8. There are no data for some of the indicators These issues were tabled with the Technical Committee for confirmation and for a resolution, so that the indicators are properly aligned. This is important so that the achievement of the targets could be properly ascertained.

3.2. Collection of Data and Information The collection of data was undertaken at two levels. At the policy level, qualitative and quantitative data were extracted from reports and official documents and at the technical level, technical quantitative data for the targets were confirmed and submitted by the relevant Ministries. In the event that the Ministries did not have the data, then national level data were used. In the absence of both, international level sources of data were used.

3.2.1. Policy Level Data and Information The policy level data and information were extracted from reports and official documents held by the relevant Ministries and Government agencies: - annual reports - corporate plans - project reports - reports of international level organisations - reports on surveys and interviews Some of the documents were downloaded from their websites or websites of regional and international development organisations. Reports on Tonga by bilateral development partners and international multilateral development partners were also used to extract policy level data, which were obtained from their local offices or from their websites.

3.2.2. Technical Level Data The technical level data were collected from Ministries which kept them in databases and conducted periodic surveys or collect them from primary sources regularly. The Ministries were asked to produce and verify the data for discussion in various meetings organised. In the end, the data were confirmed and submitted by the Ministries as final official data. The following Ministries were the sources of the technical quantitative data: Ministry of Finance and National Planning (MFNP) MET, MOH, MEIDECC and SD. The sources of international level data were the Asian Development Bank (ADB), the World Bank (WB) and the Secretariat of the Pacific Community (SPC), if the Ministries or the SD did have the data for some of the targets. 14

3.3. Consultations

3.3.1. Ministry Level Consultation The Chief Executive Officers of the key Ministries (MOH, MET, MEIDECC, SD, MIA, MAFFF, SD and Ministry of Commerce and Labour (MCTL) were initially and then subsequently consulted on the collection of data and assistance required from their staff. They were kept informed of the progress in the data collection which involved consulting their staff. The data collected from the Ministries were initially discussed and further verified with them in a series of organised meetings. Other meetings were also organised with the Ministries to discuss the issues emanating from the data and the documents used to extract policy level data and how they will be dealt with by the report.

3.3.2. Sector Cluster Groups The sectors implicated in the MDGs were divided into 5 groups. They were consulted on the policy level data and technical level data collected for writing the report as well as the issues identified during the Ministry level consultation, for their inputs. They were as follows: - poverty alleviation - education - health - environment and climate change - development partners The consultation for the MDG Goal 1 – Eradicate Extreme Poverty and Hunger – called on the MIA, MAFFF, MCTL, Church Leaders Forum (CLF), Tonga National Youth Congress (TNYC), the Civil Society Forum of Tonga (CSFT) and the development partners. MDG Goal 2 – Achieve Universal Primary Education – the MET led the discussion with inputs from the development partners and the church-based education systems. For MDG Goal 3 – Promote Gender Equality and Empower Women – the consultation included the MIA, MAFFF, Women and Children Crisis Centre (WCCC) and the National Centre for Women and Children (NCWC). The health sector is the focus of the MDG Goal 4 – on Maternal Health, MDG Goal 5 – on Child Mortality and MDG Goal 6 – Combat HIV/AIDs and NCDs. The consultation brought together service providers – Tonga Health Promotion Foundation (THPF), Tonga Family Health Association (TFHA) and the CLF. MDG Goal 7 – Environment – involved the MEIDECC, Ministry of Lands and Natural Resources (MLNR), Tonga Waste Authority (TWAL) and the Tonga Water Board (TWB). 15 For MDG Goal 8 – on Development Partners – the UNDP, European Union (EU), World Health Organisation (WHO), ADB, WB, AusAID and NZAID participated in the sector consultation.

3.3.3. Key Informants Some of the key informants were interviewed because of their close association with the MDGs. Their names are in the list in Annex 1.

3.3.4. Technical Committee The Technical Committee met four times to vet the data, discuss issues and look at specific areas covered by the report. The intention was to use the Technical Committee as a platform for consolidating the report before it was submitted to the National MDGs Taskforce ensuring that its contents had been given due consideration.

3.3.5. The National MDGs Taskforce The National MDGs Taskforce then met twice to consider the content of the report before it was submitted for public consultation and then re-considered it after the public consultation. After amendments were made based on comments from the public consultation, the report was endorsed for submission to Cabinet.

3.3.6. Public Consultation and Peer Review The public consultation was organised with the purpose of opening up the content of the report for comments from the members of the public, stakeholders as well as a final opportunity for comments by the Government Ministries and agencies, development partners and CSOs. After the public consultation, the comments were used to amend the report. The report was then returned to the National MDGs Taskforce for final consideration. At the end of this process, the report was then finalised for tabling with Cabinet. At the same time, the draft report was then divided into chapters and sent to the Ministries and Government agencies for final review of the content and comments. Their comments were also incorporated into the report.

3.4. Notes on Data Collection Because there was no monitoring and evaluation framework for the MDGs, the mainstreaming of the MDGs into the national policy and strategy frameworks may have been weak. The regular tracking of the data and progress of work on the MDGs was therefore largely absent as there was no national platform for doing so. As such, data presented in this report may still be incomplete and hence the trends may not be clearly delineated. During the data collection, the Ministries and Government agencies were willing to review the figures quoted for the MDGs targets in the 1st and 2nd MDGs report. The reason for doing so is that some of the figures submitted for these reports were tentative only, and now their databases and information systems have matured to provide data that are correct and verified for the years since 2000. As such, the figures quoted in some of the Target Tables are the latest. The review of the 1st and 2nd MDGs report in the next section may be quoting figures that have been updated for the 3rd MDGs report. 16 4. Review of the 1st and 2nd MDG Reports3 The 1st MDGs report was written and tabled in March of 2005. It dealt with two tasks which was not only to report on progress since 2000, but also to establish some of the baselines against which the achievement of the targets would be measured.4 However, it was expected to be concise and reporting not only on an assessment of the current situation but also on emerging challenges and the policy response to deal with them. The 2nd MDGs report was tabled in 2010, which outlined the progress since 2000. Eradication of Extreme Poverty and Hunger – Goal 1 Reducing the Proportion of Population Living Under the Poverty Line – Target 1 Living Below US$1 Per Day The 1st MDGs report provided some discussions on the difficulty in applying the international standardised measure for ‘absolute poverty’, which was US$1 per day (and revised in 2009 to US$1.25 per day). The cultural context and values is a strong influence on the understanding of what poverty means in Tonga. It referred to the fact that it is not ‘absolute poverty’ but ‘relative poverty’ and ‘hardship’. The ADB study in 2004 on hardship in Tonga was a milestone in contributing to the understanding of ‘poverty’ - destitution, hunger and homelessness, and the more relevant phenomena of ‘hardship’ in Tonga - the difficulty in meeting basic needs, high cost of living, lack of access to basic services and inability to gain opportunities. The 2nd MDGs report re-emphasised the same points and the added difficulties experienced by those migrating internally to the urban centres, especially to Nuku’alofa looking for opportunities. The hardship experienced by people are often made worse by external shocks because of a vulnerable economy. The hardship is cushioned by the social safety net of sharing, including the inflow of in-kind and cash remittances from overseas Tongans. The poverty line for Tonga was established by the 1st MDGs report as T$1.42 per day, the equivalent of the purchasing power parity (PPP) of US$1 per day in 2001 prices. This was translated to TOPT$2840 per household per annum or TOP$28.20 per person per week. The Household Income and Expenditure (HIES) of 2001 established that 4.0% of household were below this level, which is the baseline for the MDGs. In 2009, a new cut off point for the international poverty line was re-established at US$1.25. However, the 2nd MDGs report shifted the focus to the more relevant measures of Food Poverty Line and Basic Needs Poverty Line and presented detailed data on the proportion of households and of population below the poverty line and disaggregated by rural versus urban.5 3 Some of the figures in the 2nd MDGs report were updated by the responsible Government agencies and these appear in this 3rd MDGs report. 4 The baseline year for the MDGs is 1990 for some of the Goals 5 The discussion in this report will focus on the Food Poverty Line and the Basic Needs Poverty Line, which are more relevant to Tonga’s relative poverty and hardship status. 17 The Poverty Gap Ratio The ADB study in 2004 estimated that around 23% of households were living in hardship. The poverty gap ratio, which measures the severity and depth of poverty for those below the poverty line, was calculated at 7.7%, indicating neither deep nor severe poverty. The share of the poorest quintile in national consumption was calculated at 7.7%. Both of these percentages would be the baseline for the indicators. Full Employment and Decent Work for All The 1st MDGs report did not discuss ‘full employment’ and ‘decent work for all, including women and young people’ and their indicators. This was left for the 2nd MDGs report. However, there was analysis of the proportion of people who suffer from hunger focusing on the underweight children under five and dietary energy consumption. The 1986 National Nutrition Survey indicated that 1.6% of children under 5 were underweight, a baseline for this indicator. There was no data available at the time on the proportion of the population below the minimum level of dietary consumption. The earliest data available was for 2001 and this will be used as the baseline for the indicators, except for the 1986 data for underweight children under five. Achieving Universal Primary Education – Goal 2 The 1st MDGs report examined the net enrolment ratio in primary level education, the proportion of students starting grade one (class 1) and completing grade six (class 6) and the literacy rate for the 15-24 age group. Data was found for 1990 as the baseline year, for net enrolment ratio which was 91.6% and for 2000, 89.4%. The 2nd MDGs report quoted 88.4% for 2006 and 93% for 2008 as the latest figures available at the time. Hence, there had been some consistency in the reporting of the data, which shows near universal access. The proportion of students starting form 1 and completing form 5, was 84% for 1996 (to be the baseline year) rather than 1990, and 93% for 2001. The 2nd MDGs report found 88.9% for 2006 and 90% for 2007. While the variation is small, the figures show the number of students dropping out, which was more marked for boys. The report quoted a 15% drop out rate for boys at 16 in 2007 and a contributing factor is lack of access to secondary schooling in rural areas, the highly academic nature of the education system and inability to pay for the cost of education. The literacy rate for 15-24 age category was 98.8% for 1986 and 99.3% for 1996. The 2nd MDGs report stated 99.4% for 2006. As such, the literacy rate is maintained at a very high universal level reflecting good access to basic education. The figures for the earliest years would be used as the baseline. The claim by the 1st MDGs report was that the compulsory education policy of age six to age fourteen (proposed to 18) and placement of primary schools within a two-mile radius of populated villages as part of making primary education accessible, has made positive effects on enrolment 18 at the primary school level. This policy does not apply to secondary education, therefore there are problems with access to secondary schooling, a point also picked up by the 2nd MDGs report. The 2nd MDGs report noted some of the pertinent issues including a better focus on student achievement, technical and vocational training, and making early childhood education available and accessible. While the level of enrolment and literacy rate are high, the quality of education is a concern and is of high priority. To help meet the standards, the community and ex-students bear the cost, although the Government provides a budget to cover teaching staff and operation. The 2nd MDGs report mentioned the efforts to improve quality of education through quality assurance and minimum standards. Promoting Gender Equality and Empowering Women – Goal 3 The ratio of girls to boys in enrolment in primary school was placed at 87 girls for every 100 boys, for 1997, the earliest available and baseline, and improved to 89 in 2001, as outlined in the 1st MDGs report. In 2008, it was 88, according to the 2nd MDGs report. For the ratio of girls to boys in enrolment in secondary school, the figures were 97 for 1997 and 99 for 2001, and 99 for 2005. The ratios are high but at the same time, the report found that more boys than girls were likely to drop out of school. The enrolment ratio was 67 girls for every 100 boys for 1997, the baseline year. It was 69 for 2001 for tertiary level, showing under-representation for girls. This means that more boys than girls were continuing to the tertiary level, including those that had scholarships to study overseas. The ratio was 99 for 2006, and 97 for 2008, according to the 2nd MDGs report, showing improvement in enrolment. The literacy rate was high for the 15-24 age category. It was 94 females for every 100 males for the census year 1986 and 95 for the census year 1996. A similar trend was shown in the share of women in wage employment, which was 33.3% for census year 1986. It was 35.7% in the census year 1996, although 50.4% of the working age population were women. At the same time, the participation of women in the workforce, improved from 18% in 1986 to 42% in 1996. This was due to their participation in the informal sector economic activities and household work. This was estimated to be at 43.5% in 2006 by the 2nd MDGs report. The share of women in wage employment in the non-agricultural sector was 39.2% in 2006. The earliest years would be the baseline years. Political participation by women as in the number of seats they hold in parliament is very low: – 1 seat in 2003 but none in 2004, as quoted in 1st MDGs report. There was 1 in 2005 and 1 in 2010. There is cultural perception and sanction given to the role of women, says the 2nd MDGs report, where decision making is reserved to men with women playing a subordinate role. 19 Reducing Infant Mortality, Improving Maternal Health and Combating HIV/AIDS and NCDs – Goal 4 – Goal 6 Infant Mortality The under-five mortality rate was stated by the 1st MDGs report as 27 for every 1000 in 1990, the baseline, and 20 in 2001. It was 16.4 in 2006 and 26 in 2008. The rate is lower than other Pacific island countries, although the data is not disaggregated to find any inequalities. The infant mortality rate was put at 12.2 for every 1000 live birth in 1991, the baseline, 14.4 for 1995, 13 for 2002, 11.8 for 2005 and 16.4 for 2008. There is an average of 30 infant deaths per years for the same period. The leading cause of death for under five are diarrhea and pneumonia. With the baseline of 27 in 1990, and 12.2 in 2001, the 2nd MDGs report stated that it would be unlikely that it could be reduced further as it is already low. The 1st MDGs report also raised attention to child morbidity and childhood obesity.6 There is also indication of child malnutrition in the poorer sections of the community. The proportion of one year old children immunised against measles were 94% in 1999 and 96% in 2002, with 95% immunised against other infectious diseases. The 1st MDGs report quoted that Tonga’s performance in infant mortality is relatively high with high quality accessible primary health care. The MOH had been developing policies and programs to support immunisation. Maternal Health The maternal mortality ratio per 100,000 live births was set by the 1st MDGs report at 196 for 1995, as baseline, and 78.2 for 2002, the earliest data available. The 1st MDGs report mentioned the shortage of data at the time in order to establish a trend. The mortality rate was considered low by the 1st MDGs report and attributed to the ‘good’ health standards in Tonga, only that in very remote areas that this would be a concern. However, the 2nd MDGs report quoted a ratio of 204.7 for 1995, 81.4 for 2000, 227 for 2005 and 76.1 for 2008, showing a discrepancy for the data for 1995. It is also pointed out that the ratio is an indicator of how well the health system handles obstetric risks. Hence, Tonga is doing remarkably well. Furthermore, a trend analysis is problematic because the population of Tonga is equivalent to the denominator. Given the denominator, one maternal death translates to around 40 and the leading cause of death is post- partum hemorrhage. The proportion of births attended by skilled health professionals was set for baseline year 1999 at 96 and for 2001 at 95. The 1st MDGs report considered this high and at the same time, the low level of contraceptive use and prohibition by law of abortion. This means that there would be restricted choices in unwanted pregnancy, especially teenage pregnancy, where the health of the mother is at risk. The 2nd MDGs report established 96% for 2005 and 98 for 2007. Tonga is performing relatively well, because pregnant women have access to skilled attendants in hospitals and clinics across Tonga, although there is a shortage. However, the challenge is the increase in gestational diabetes and pregnancy induced hypertension and complications such as obstructed labour and puerperal sepsis. 6 This aspect will be further discussed in this report as part of the issues and concerns with NCDs. 20 The calculations for both infant mortality and maternal mortality suffer from statistical weaknesses. The 2nd MDGs report pointed out the commitment by the MOH to accurately report the data. Universal Access to Reproductive Health The prevalence rate for contraceptive use was established by the 2nd MDGs report at 33 for 1990, the baseline. HIV/AIDS and NCDs The prevalence of HIV/AIDs among the 15-24 years old pregnant women, were 0 for 1990 and 0 for 2002. The contraceptive prevalence rate among women aged 15-49 were 33 per 1000 women for 1999 and 23 for 2002. The number of children orphaned by HIV/AIDS were 0 for 1990 and 3 for 2003. Diabetes and tuberculosis were outlined in the 1st MDGs report. The prevalence rate for diabetes was 280 per 100,000 population for 1998 and 277 for 2003. The death rate was 11 per 100,000 population for 1998 and 9 for 2003. The prevalence of NCDs were identified by the 1st MDGs report as a challenge while communicable diseases have been brought under control. While the proportion of deaths caused by the infectious diseases has fallen from 32% in the 1950s to 6% in the 1990s, the proportion of death from NCDs related diseases rose from 5.6% to 38% for the same period. The focus was particularly on issues related to diabetes. The prevalence of type II diabetes rose from 7% to 16.5% from the 1980s. However, many cases are undetected. For tuberculosis the prevalence was a baseline of 24 per 100,000 for 1990 population and 29 for 2002. The death rate per 100,000 population was 2 for 2004 and 4 for 2002. Over a 20 year period, from 1984 to 2004, only 13 cases have been indicated and 12 have died from full-blown AIDS by 2005. The DOTS detection rate for tuberculosis was 74% for 1977 and 98% for 2002. The DOTS treatment success was 82% for 1999 and 93% for 2002. More than 95% of the population in 2002 had access to affordable essential drugs on a sustainable basis. Environmental Sustainability – Goal 7 It was stated in the first report that the proportion of land area covered by forest in 1990 was 5.5%, the baseline and 11% in 1994. The ratio of area protected to maintain biodiversity to surface area was 6.7% in 1998 and 5.4% in 1996. Large commercial farming practices have stripped off forest covers in land areas. Environmental conservation continued to be a major concern. For carbon dioxide emission metric tons per capita, it was 0.8 in 1990, to be used as the baseline and 3.0 in 1994 and for consumption of ozone depleting CFCs (ODP tons), it was 0.71 for 1991, the baseline year, and 0.32 in 2003. The use of bio-mass fuels was stated at 75.42% of the population in 1986 and 73.7% in 1996. However, there has been increasing reliance on consumption of fossil fuels making Tonga vulnerable to oil price shocks. 21 For sustainable access to improved water sources, it was 91.5% in 1986 but was 98.19% in 1996. For urban areas it rose from 96.57% of households in 1986 to 98.34% in 1996 for urban areas, and for rural areas, the improvement was from 90.18% in 1986 to 98.14% in 1996. There was also dramatic improvement in access to improved sanitation in urban areas from 54.82% in 1986 of the population to 99% in 1996. Still, poor management of solid wastes poses severe environmental and health concerns. The earliest years would be the baseline. Global Partnership for Development – Goal 8 In dealing with special needs of small island states, in the 1st MDGs report, the proportion of total developed country imports from less developed countries admitted free of duty rose from 3.5% in 1996 to 8% in 2000 for Tonga. The agricultural support estimate for Organisation for Economic Cooperation and Development (OECD) countries as a percentage of Tonga’s GDP was 1.21% in 2002/2003. The proportion of debt service as a percentage of exports was 2.9% in 1996 but 45% in 2002/2003. The total assistance by OECD countries as a percentage of Gross National Income (GNI), fell to an all-time low at .22 in 2000/2001 but expected to increase to .26 in the next 5 years. The overall Overseas Development Assistance (ODA) to Pacific Islands fell, and for Tonga from 5.5% from 1980s to 2.0% in 2001/2002. The ODA for Tonga in 2002/2003 was 8.9% of Tonga’s GNI, which is high. The unemployment rate for youth, age 15-24, was 25.27% in 1986 and 30.28% in 1996, according to the 2nd MDGs report. The unemployment rate for females of the same age group was higher than males, in 1986 with 48.19% for females and 17.11% for males. However, the figures were lower in 1996, with 26.95% for females and 32.01% for males. Tonga had a youthful population and opportunities were scarce. Programs were put in place to address youth concerns including skill training and micro enterprise development. Other needs such as access to telecommunication and computers was discussed by the 1st MDGs report. In 2003/2004 there were 274 telephone line subscribers per 1000 population. Internet users per 1000 population was 1.8 in 2003/2004. There was no data on cellular subscribers and personal computer use. 22 5. MDGs Acceleration Framework After the 2nd MDGs report was submitted, it was recommended that Tonga needs to accelerate the achievement of the targets under Goal 1 – Eradicate Extreme Poverty and Hunger, Goal 3: Promote Gender Equality and Empower Women and Goal 6: Combat NCDs. A framework was then designed and approved by the Government of Tonga as the MGDs Acceleration Framework (MAF) in early 2013 as the basis for undertaking the required tasks. Work began in early 2014 after the appointment of the MAF Coordinator. 7 Annex 2 provides an outline of the work undertaken during 2014 under the MAF. Other activities undertaken by Government agencies and stakeholders relating to these Goals, are described in this report. 7 The MAF Coordinator left in late 2014. At the same time, the responsible Government agencies continued work related to the Goals identified for acceleration. These are described under the relevant sections of this report. 23 PART 2 THE MILLENNIUM DEVELOPMENT GOALS The Tongan Flag 24 6. Tonga’s Final Status at a Glance Tonga’s final status on the MDGs is summarised in the Final Status Matrix for the MDGs and Targets below. For the status of each of the individual indicators, this is outlined in the Final Status Matrix for the MDGs Indicators in Annex 3. The status of the MDGs is assessed on the progress of work over the past 15 years, from 2000 to 2015. The assessment is based on the following three measures: 1. State of progress towards the target – is graded: - Very Good - most or all the appropriate plans and policies were implemented and activities completed or ongoing - Good - a substantial part of the plans and policies were implemented and a majority of the activities were completed or ongoing - Satisfactory – no further action was undertaken to progress the implementation of the plans and policies and the work required was only partially done - Poor - only minimal work was done on both the implementation of plans and policies and completion of the required activities 2. Degree of achievement – is graded: - On Target - most or all of the set targets and the indicators were achieved, at least 80% - Near Target - substantial part of the targets and indicators were achieved, at least 60% to 80% - Below Target - only around 50% to 60% of the targets and indicators were achieved - Off Target - below 50% of the targets and indicators were achieve 3. Degree of state and stakeholder support – is graded: - Strong - widespread support by Government, stakeholders and the public - Moderate - substantial support by Government, stakeholders and the public - Weak - limited support by Government, stakeholders and the public - Absent - minimal or no support at all 4. Colour coding The gradings are represented in the colour-coded Key at the bottom of the Matrix: 25 TONGA’S FINAL STATUS ON THE MDGs AND TARGETS AT A GLANCE State of Degree of Degree of State Progress Achievement and Stakeholder Support Goal 1: Eradicate extreme poverty and hunger Target 1A: Halve between 1990 and 2015 the proportion of people whose income is less than one ** M dollar a day Target 1B: Achieve full and productive employment and decent work for all, including women and young ** M people Target 1C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger **** S Goal 2: Achieve universal primary education Target 2A: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full **** S course of primary schooling Goal 3: Promote gender equality and empower women Target 3A: Eliminate gender disparity in primary and secondary education preferably by 2005, and at all **** S levels by 2015 Goal 4: Reduce child mortality Target 4A: Reduce by two thirds between 1990 and **** S 2015 the under-five mortality rate Goal 5: Improve maternal health Target 5A: Reduce by three quarters between 1990 **** S and 2015 the maternal mortality ratio Target 5B: Achieve by 2015, universal access to ** S reproductive health Goal 6: Combat HIV/AIDS and NCDs Target 6A: Have halted by 2015 and begun to reverse **** S the spread of HV/AID Target 6B: Achieve, by 2010, universal access to **** S treatment for HIV/AIDS for all those who need it 26 Target 6C: Have halted by 2015 and begun to reverse the incidence of TB and reduced the prevalence of **** S NCDs Target 6D: Have halted by 2015 and begun to reduce the prevalence of NCDs ** S Goal 7: Ensure environmental sustainability Target 7A: Integrate the principles of sustainable development into country policies and programs to *** S reverse the loss of environmental resources Target 7B: Reduce bio-diversity loss, achieving, by 2010, a significant reduction in the rate of loss *** S Target 7C: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and *** S basic sanitation Goal 8: Develop a global partnership for development Target 8A: Develop further an open, rule-based, predictable, non-discriminatory trading and financial **** S system. Target 8C: Address the special needs of small island **** S developing states Target 8E: In cooperation with pharmaceutical companies, provide access to affordable essential **** S drugs in developing countries Target 8F: In cooperation with the private sector, make available the benefits of new technologies, **** S especially information and communication Final Performance Status: State of Progress Towards Degree of Achievement Degree of State and Stakeholder the Target Support Very Good **** On Target S Strong Good *** Near Target M Moderate Satisfactory ** Below Target W Weak Poor * Off Target A Absent 27 Goal 1: Eradicate extreme poverty and hunger Courtesy: MORDI Tonga 28 Target Table 1: Target 1A: Halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day Indicators 1990 1995 2000 2005 2010 2015* Target Status

1.1 Proportion of population - - 4.0% 4.0% - - 2.0% - below $1 (PPP) per day (2001) (2006) 1.1A Proportion of people - - 16.2% - 22.5% 22.1% 8.1% Below living below National (2001) (2009) (2015) target Poverty Line %

1.2 Poverty gap ratio - - 7.7% - 6.3% 6.1% 3.8% Below (2001) (2009 target

1.3 Share of poorest quintile - - 7.7% - 10% - 20% Below in national consumption (2001) (2009) target Source: HIES 2001, HIES 2009, Statistics Department 2015 *estimated 1. Progress and Achievement of Targets Target Table 1 provides the final figures on ‘poverty eradication’. The proportion of the Tongan population below US$1 (revised to US$1.25 in 2009) (purchasing power parity)(PPP) per day was 4% in 2001 and 4% in 2006. There is no further data available as it was agreed that this indicator will be replaced by the ‘Proportion of people living below the National Poverty Line’.8 The proportion of people living below the National Poverty Line or the Basic Needs Poverty Line9 increased from 16.2% in 2001 to 22.5% in 2009. It decreased marginally to an estimated 22.1% only in 2015, which indicates that the proportion of people who experienced hardship in 2009 has not been reduced. They are essentially in the same situation today because of high cost of living and difficulty in meeting basic needs and obligations. They also lack access to the appropriate basic infrastructures, basic services and utilities and inability to gain employment or income generating opportunities. The poverty gap ratio, measures the depth of poverty and its incidence, in terms of the mean shortfall of the total population from the National Poverty Line, which is a percentage of the poverty line. It stood at 7.7% in both 2001 and 2004%. The latest figure for 2015, is estimated at 6.1%, an improvement of 1.6%. This percentage means that they are not too far below the Line and therefore, hardship is neither severe nor deep. Hence, those living below the National Poverty Line and in hardship, do not experience severe deprivation and destitution. The share of the poorest quintile or 20% of the population in the national consumption or income was 7.7% in 2000 but 10% in 2010, an improvement of 2.3%. There is no data available after 2010 but the best estimate is that the share of the poorest quintile has essentially remained 8 The definition of the indicators quoted throughout the report were taken from the UNDP website of the MDGs. The definitions are quoted directly from the website for ease of reference by the reader. 9 For the rest of the discussion in this section, the reference will be made to Basic Needs Poverty Line rather than the National Poverty Line. 29 the same. It is a measure of inequality in the distribution of income. The value is between 0 and 20%, the lesser the number the more the inequality, hence the inequality in the distribution of income is moderate. Final Assessment: Dialogue over the last 15 years on ‘poverty’ became clearer after a number of reports were produced, notably by ADB on poverty and hardship in Tonga released in 2004 (noted earlier) and the HIES of 2001 and 2009. It was clear that there is no ‘absolute poverty in Tonga’ but ‘hardship’, defined. The measurement which was accepted then (as it is now) was to calculate a Food Poverty Line and a Basic Needs Poverty Line which were more relevant to the ‘hardship’ situation in Tonga. Both Lines were established in 2010 after the HIES of 2009, and the results are repeated here because of its relevance to the Tongan situation, as follows in Table 1: Table 1: Food Poverty Line and Basic Needs Poverty Line 2001-2015 Measurement Poverty Line Proportion Below the Line TOP$ Household Population 2001 2009 2015* 2001 2009 2015 2001 2009 2015* Food Poverty Line 1.7% 2.0% 2.4% 2.8% 3.1% 3.8% Per head per week 13.52 24.12 29.74 Per head per year 703 1254 1546 Basic Needs Poverty Line 12.2% 16.4% 15.8% 16.2% 22.5% 22.1% Per head per week 28.20 49.73 56.71 Per head per year 1466 2586 2949 Source: HIES 2001, HIES 2009, SD 2015 *=Estimated As in Table 1, the proportion of households living under the Food Poverty Line is estimated at 2.4%, a marginal increase of 0.4% from 2009. Similarly, at the population level, it increased from 3.1% in 2009 to an estimated 3.8% in 2015. As such, the proportion of households and proportion of people living under the Food Poverty Line, has not been substantially reduced. Households and people in the general population would still be able to feed themselves from subsistence farming and fishing. During the research for this report, there was no evidence or data attributed to any person dying of hunger or living in destitution. The social system in villages and communities act as safety nets. The Basic Needs Poverty Line (combining food and non-food basic needs) is important because it indicates the number of people who face hardship in meeting their basic needs. The proportion of households living under this Line, decreased marginally from 16.4% in 2009 to an estimated 15.8% in 2015, and the proportion of people living under the same Line also decreased slightly from 22.5% in 2009 to 22.1% in 2015. These numbers indicate that there has not been any real change to the situation in 2009. 30 Therefore, the targets have not been achieved in the sense that there has been no real change to the situation between 2009 and 2015. Progress towards the target is satisfactory only given the limited amount of work completed or ongoing during the last 15 years. Tonga is ‘below target’ with all the indicators under Target 1A (see Target Table 1 above). Only a number of activities were undertaken by some of the Government agencies, in the absence of a clear policy framework to alleviate poverty. The support from stakeholders was not strong. Final Performance Status: For proportion below National Poverty Line: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate For poverty gap ratio: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate For share of poorest quintile in national consumption: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate Overall: For halve the proportion of people below income of less than one dollar a day: State of Progress Towards Degree of Achievement of Degree of State and the Target Target Stakeholder Support Satisfactory Below Target Moderate 31 Target Table 2: Target 1B: Achieve full and productive employment and decent work for all, including women and young people Indicators 1990 1995 2000 2005 2010 2015 Target Status

1.4. Growth rate of 10.1% 0.7% 6.7% 8.3% 7.4% 3.2% - Below GDP per person (2014) target employed

1.5. Employment-to- 38.4% 49.4% - 37.2% 36.7% - 100 Below population ratio (1986) (1996) (2006) (2011) target

1.6. Proportion of No No No No No No - - employed people Data Data data Data Data data living below $1 (PPP) per day

1.7. Proportion of 35.3% 31.1% - 59.7% 55.3% - - Below own-account and (1986) (1996) (2006) (2011) target contributing family workers in total employment Source: Statistics Department 2015 2. Progress and Achievement of Targets Target Table 2 outlines the figures for ‘employment’. ‘The ‘growth rate of GDP per person employed’ is the growth rate of output per unit of labour input and therefore showing labour productivity. Labour productivity can be used to assess the likelihood of a country’s economic environment to create and sustain decent employment opportunities with fair and equitable remuneration. While increases in productivity do not guarantee progress toward full and productive employment and decent work for all, improvements in conditions of work and employment opportunities are less likely to occur without productive improvements.’ ‘There is empirical evidence that the link between productivity growth and poverty reduction is strong when productivity growth and employment growth go hand in hand. However, labour productivity growth is not always associated with employment growth. However, labour productivity growth is not always associated with employment growth. Consequently, measuring both growth in employment (see employment-to-population ratio, Indicator 1.5) and labour productivity is required to assess whether GDP growth is likely to reduce poverty.’ ‘The employment- to-population ratio, is a measure of the proportion of the working age population currently working, both in the formal and informal sector. This is a reflection of the ability of the economy to generate jobs and employment opportunities that are decent for all in terms of ‘fair and equitable’ wages. Therefore, efforts for reduction of poverty through employment and decent work will be minimal if the ratios are declining over time, as in this case.’ For Tonga, the GDP growth per person had been fluctuating and on a declining trend over time since 2005. From 1990 it declined from 10.1% to 6.7% in 2000. Hence, the ability of the economy 32 to create further employment opportunities has been weak. The employment to population ratio has also been declining over time. Therefore, it is less likely that reducing poverty and hardship through employment has been minimal. The ‘proportion of own-account and contributing family workers in total employment’ has increased from 31.1% since the census year 1996 to 59.7% in census year 2006 and remained at 55.3% in census year 2011. There is no further data available but it is estimated that probably more and more people are engaged in this type of work. This is ‘the proportion of workers who are self-employed and perform unpaid work – regarded as ‘family workers’ and ‘own account workers’. They are in the informal sector without any formal work arrangements and work in precarious circumstances, no access to benefits and unable to save to protect their families.’ Those living in hardship and poverty are vulnerable in times of economic down turn. The reports collected during the writing of this report have indicated increasing efforts to provide social protection measures and initiate income generating activities in the informal sector. These may have had a positive effect in relieving the hardship faced by such vulnerable workers. Final Assessment: The indicators for Target 1B have implied that the effort to create full and productive employment and decent work for all has not been achieved. The data shows that labour productivity has been on a fluctuating and declining trend and the proportion of those in productive employment has not increased over the years. The ability of the economy to generate decent work for all is low. Given the work in the informal sector to engage people in income generation and participation in unskilled seasonal work overseas, it is considered that the progress towards the target is only satisfactory. Such efforts should be appreciated, as in the discussion in the sections below. While the national development plans have made statements on national employment, targeting specific sectors and programs to encourage investments in industries and in areas that would generate employment opportunities, both locally and internationally, the progress has been slow. The achievement of the target has been ‘below’ the expectation in terms of full and productive employment for all. ‘Satisfactory progress’ was made in sustaining the current status so that people living in hardship would not be worse off than their situation in 2009. The degree of support by the stakeholders in employment creation was ‘moderate’ and this is reflected in the discussions below. Final Performance Status: For growth rate of GDP per person employed: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate 33 For employment to population ratio: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate For proportion of own account and family workers in total employment: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate Overall: For achieve full and productive employment and decent work for all: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate Target Table 3: Target 1C: Halve, between 1990 and 2015 the proportion of people who suffer from hunger Indicators 1990 1995 2000 2005 2010 2015 Target Status

1.8. Prevalence of 1.6% 2.0% - - 1.9% 0.8% On underweight children (1986) (1999) (2012) Target under-five years of age

1.9. Proportion of - - - 4% - 2.9% 2.0% On population below (2004) (2012) Target minimum level of dietary energy consumption Source: Statistics Department and SPC PRISM for data for 1990-2010 columns; DHS 2012 for the 2015 column 3. Progress and Achievement of Targets Target Table 3 provides the figures on ‘hunger’. Underweight children under five-years old ‘are children who are 59 months old and whose weight is less than 2 standard deviations below the median weight of children. The prevalence of 34 underweight children under five are the percentage of children who are two standards deviation below the median weight for ‘age group in the reference population’, and is an indication of the low level of access to health services, low level of education and poverty.’ The indicators in Target Table 3 show that in 2012 less than 1.9% of children are underweight, a marginal increase from 1.6% in 1986. This is still low prevalence according to the standard WHO guide. This is compared to the 9.9% of children under-five years old, who are 2-standard deviations above and hence are obese for their age. The prevalence of underweight children is slightly higher in the outer islands than in Tongatapu, while the inverse is true for overweight children. The prevalence of overweight children increases with wealth quintiles (DHS, 2012).10 The proportion of the population below minimum level of dietary energy consumption or ‘undernourished people’ is the proportion in a population suffering from hunger and food deprivation. According to the Demographic and Health Survey (DHS) of 2012, approximately 2.9% of adult from age 18-59, were 2-standard deviations below the median weight for adults. This is low prevalence. However, the prevalence rate for adults is comparable to the proportion of people under the Food Poverty Line (2%), discussed in the previous sections. The progress towards the target has been ‘very good’ and is on target. The prevalence of under- five year olds who are underweight has been kept very low and is contained at this level of prevalence, while still meeting the World Health Organisation (WHO) standard. Therefore it can be said that it is ‘on target’. The indicators suggest that people have sufficient food supply and the work of key Government agencies, development partners and CSOs should be noted in ensuring that people are able to meet their food security needs. Therefore, the support by stakeholders has been ‘strong’. The research and consultation for writing this report did not find evidence of widespread malnutrition due to deprivation of food to eat. The incidences of underweight children dying is very low, but these were due to neglect. Final Performance Status: For prevalence of underweight children: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong For proportion of population below minimum dietary energy consumption: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong 10 The MET has declared a ‘food policy in schools’ where the sale of poor quality processed food items within the school compound are prohibited and children are discouraged from bringing the same to school. 35 Overall: For halve the proportion of people who suffer from hunger: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong 4. The Challenges

4.1. Technical Considerations Hardship – Incidence and Prevalence The report by ADB in 2004 and the two HIES of 2001 and 2009 provide a basis for understanding relative poverty11 and hardship in the Tongan context. Because there is no ‘absolute’ or ‘extreme’ poverty, the measurement using US$1 per day in PPP cannot be accurately estimated for Tonga as the PPP indices were not available (although it was estimated then that 1-2% of the population would be at this level in 2001). The more relevant measures would be to establish a minimum level of food and basic needs poverty lines to accurately capture relative poverty and hardship (MOFNP, 2011). Table 1 above was discussed in the 2nd MDGs report of 2010 and it is discussed again shortly here. According to the data, the proportion of people and households were worse off in 2009 than in 2001. The Food Poverty Line and the Basic Needs Poverty Line, are used for measuring the relative level of hardship experienced by households and persons in meeting their basic needs for food and other non-food items. This suggests that the incidences of poverty in total were around 21,300 people, estimated to be living below the Basic Needs Poverty Line in 2009. This is compared to around 14,800 estimated in 2001, which is a 44% increase. Around 50% were in rural Tongatapu, 30% in the outer islands and 20% in Nuku’alofa (MOFNP, 2011). The situation in 2015 is already explained in page 30. Poverty and hardship is worse in rural areas and outer islands largely due to remoteness and high cost of transportation, lack of employment opportunities, and poor quality of social services and infrastructures. As stated in the 2009 HIES, incidence of hardship had increased between 2001 and 2009 from 12.2% to 16.4% of households, and the biggest gap is in the outer islands where the incidence of hardship increased from 9% to 17% (also Herbert, 2013). The DHS 2012 shows that women and children are affected. Approximately 20.4% of households with children in Nuku’alofa fall below the Basic Need Poverty Line, 21.6% in rural Tongatapu and 22.2% in the outer islands. Around 25.8% of children in Nuku’alofa live in households which are below the Basic Needs Poverty Line, 29.4% in rural Tongatapu and 29.9% in the outer islands. 11 A reference to ‘poverty’ in this report is a reference to ‘relative poverty’ rather than ‘absolute poverty’ 36 It also shows that female headed households, accounts for 24.6% of households falling below the Basic Needs Poverty Line. Female headed household in rural Tongatapu represents 27.8% of households living below the Basic Needs Poverty Line and in the outer islands, 23.9%. About 29.5% of children living in female headed households are living in households which are below the Basic Needs Poverty Line. Therefore, children living in these female headed households have a higher chance of living in poverty compared to those living in other households. Economically Disadvantaged The foregoing discussions show the magnitude of poverty and hardship across Tonga and the implications on households and women and children. The proportion of people identified as living in relative poverty and hardship, are already economically disadvantaged, as the evidence suggests that they are also in the lowest quintile in income distribution. The increase in the number of people under hardship, between 2001 and 2009, (and remaining at the 2009 level in 2015) is due to a number of factors. The demand for cash to meet non-food needs and obligations had been increasing. At the same time, remittances from Tongans who live abroad, especially the United States, Australia and New Zealand, had been declining substantially as a result of the global economic and financial crises in the late 1990s. The remittances are used to meet family needs and obligations. It has been estimated that during the period remittance declined from 30% of GDP in 2001 to 20% of GDP in 2009 (MOFNP, 2015/2016). The level of remittance recovered to 24.6% in 2012 and now at 20%, but still below the record level of 40%- 50% in 1990s-2000s (WB, 2015; MOFNP, 2014/15). This is also a reflection of the economic situation in the sending countries. Food and fuel prices increases affected many rural households while real incomes were declining. The cost of living had been increasing over the years, by 89.9% between 2001 and 2009, and between 2009 and 2015, it has risen by 14.8%. It has been fueled by inflation, especially basic need items and basic services due to increases in imported oil and food prices. At the same time, real incomes for households have been declining, by 47% between 2001 and 2009. Between 2009 and 2015, it has been declining by 13% (MOFNP, 2011; SD, 2015). The proportion of people living under the Basic Needs Poverty Line decreased marginally by 0.4% only in 2015, as outlined in Table 1. Hardship is aggravated by lack of employment opportunities. The data under Target 1B shows a decline in the growth rate of GDP per person employed and employment to population ratio. These indicate that the ability of the economy to generate employment is low and that more and more may be depending on their own efforts and on ‘unsecured employment, unpaid work and work in precarious circumstances.’ Natural Disasters12 The impact of being economically disadvantaged on hardship is compounded by the indiscriminate destruction caused by natural disasters. They have often stripped off the livelihoods of people including their personal properties and critical infrastructures. Tonga is vulnerable to natural disasters and its climate pattern is very much affected by the El Nino. The 12 See SOPAC (20007), DOE (2005), DOE (2010), for example for this section. 37 El Nino has been the cause of major drought, during the last 15 years, in 1998 and 2006 and recently a mild drought in 2014. The reduced rainfall severely affects soil moisture and fertility. This impacts on the total yield from primary produce, especially root crops and thereby the livelihoods and food security of people, especially in the rural areas. Increased rainfall has caused flooding of low lying areas. Prolonged ponding of water has been posing health risks with potential for the outbreak of water borne and vector diseases. It has also caused damage to residential areas and infrastructures such as schools and roads. Sea level rise has resulted in coastal erosion claiming roadways and coastal town and tax allotments, which have displaced a lot of those people already experiencing hardship. The warm sea temperatures brought by the El Nino has also affected the fisheries activities and livelihoods of those who depend on fishing for food and for incomes. Coral bleaching appearing in the reefs in Tonga has resulted in coral mortality, destruction of reef habitat and reduction in the diversity of reef species. The evidence shows that the intensity of cyclones is increasing since 1980s and Tonga has been affected by 6 very severe cycles since 1960s. They have caused total damage to crops and food supplies and emergency relief had to intervene and the services to rural and remote areas had to be provided for a prolonged period of time. The challenge has been the way in which Tonga responds to natural disasters and relieve the hardship experienced by those affected. The development partners have been quite active in disaster recovery and rehabilitation efforts in recent years, working closely with the CSOs to deal with those whose livelihoods have been destroyed by cyclones and tsunamis. Dependency on Traditional Industries Those experiencing poverty and hardship depend on traditional industries – agriculture, fisheries, handicrafts and tourism - for their livelihoods. These traditional industries are susceptible to destruction by natural disasters and could make people in hardship worse off. According to the Agriculture Census of 2001, a large number of households in Tonga are engaged in agricultural activity – 64.2%, as in Table 2. Tongatapu has the largest proportion of non- agricultural households – 38.6%, while the outer islands were very highly dependent on agriculture. For the agriculturally active households, those which were engaging in agriculture for subsistence and home consumption only, were 59% and those who occasionally sell part of their produce were 38.6%. Those who were commercial producers were only 2.4%. A large number of agriculturally active households in Tongatapu (67.7%) and Ha’apai (77.8%) were in agricultural production for consumption only while Vava’u (55.4%). ‘Eua (72%) and the Niuas (60.5%) were producing for consumption and occasionally sell what they produce. The proportion of commercial producers were also low in ‘Eua (4.4%), Vava’u (1.8%) and Tongatapu (2.8). 38 Table 2: Agriculturally Active Households 2001 ____________________________________________________________________________ Proportion of Households (%) by Level of Agricultural Activity Location Total Household Non-agricultural Minor Agricultural Agriculturally Of Household Active ___________________________________________________________________________________ Tonga 15,738 30.4 5.3 64.2 Tongatapu 10,583 38.6 7.3 54.2 Vava’u 2,625 15.4 1.4 83.2 Ha’apai 1,298 15.6 1.5 82.9 ‘Eua 863 9.0 1.3 89.7 Niuas 369 8.9 0.5 90.5 ___________________________________________________________________________________ Source: Agriculture Census 2001 The MAFFF is currently finalising its 2015 Agriculture Census. The data and preliminary results show that the number of households which are agriculturally active is increasing. This is indicating that new households are now participating in agricultural activities as the alternative option for those who cannot find work elsewhere. The data also suggest that households are in need of improving their levels of income. Around 83.8% of agriculturally active households in 2001 derived their main source of income from agriculture. Such a proportion may increase further as more households become dependent on agriculture for their incomes, according to MAFFF. About 57.4% of the agriculturally active households also engage themselves in handicraft making, and 98% were females. About 54% of those who produce handicrafts, sold them. Presently, handicrafts incomes is of high value not only in local but in overseas markets. According to the data from the 2015 Agriculture Census, more households are now moving into the handicraft sector, especially women, as means of income generation to supplement incomes (MAFFF, 2001). In 2001, about one third of households in Tonga were engaged in fishing. Out of this, approximately 46.7% were residing in Tongatapu, 26.1% in Vava’u, 18.3% in Ha’apai, 4.1% in ‘Eua and 4.9% in the Niuas. Approximately 72% of the households in Ha’apai were engaged in fishing, 68% in the Niuas, 50% in Vava’u, and only 22.6% in Tongatapu and 24.4% in ‘Eua. About 75% of the households engaged in fishing for consumption and 20% were occasionally fishing for sale. This situation is not expected to change substantially since 2001, according to the preliminary data from the Agriculture Census of 2015. These statistics show that those who live in poverty and hardship, are highly dependent on agriculture, fisheries and handicrafts for their livelihood and subsistence. The heavy reliance on agriculture and recently on handicraft making by a substantial proportion of the population indicates the inability of the economy in recent years to create employment and opportunities for households to generate incomes. 39 Tourism development had provided some opportunities for community participation and income generation.13 In 2000-2005, eco-tourism projects were implemented by the Ministry of Tourism (MOT) to allow communities to manage tourism activities which are based on culture and traditions and the use of the natural environment. Eco-tourism did not receive much funding and remained a small component of the work of the MOT in later years. The cost of entry into the tourism sector and complying with the standards is relatively high. Although it is currently generating more than TOP$50million for the Tongan economy, the growth has been rather stable. It is estimated that it employs around 2,000 workers in tourism related services and because of slow growth, it has not generated additional jobs. Despite the forecasting of growth and prediction that tourism would be a major development opportunity generating broad-based employment and income generation, this has not been happening fast enough. Tonga is a high cost destination and suffers from small scale development, which generate low mass level and not the critical mass that is required for large scale investment, transport operation and support services. The small scale development leads to limited availability of private sector funds and investment by hotel brands, and hence low market awareness and recognition and low confidence by the tourist market. In the absence of a clear set of strategies, the participation by those who are vulnerable and living in hardship in tourism related activities will continue to remain low. Lack of Training and Employment Opportunities14 Various reports have indicated issues with access to opportunities by those facing poverty and hardship, especially in education and training, employment and markets. Approximately 80% of secondary schools are run by church education systems. The discussion in the next chapters shows that around 50% of the secondary schools are located in urban and peri-urban areas, making them inaccessible for those in rural areas. At the post-secondary school level, more than 50% of the technical and vocational training institutes are run by church education systems and are highly urbanised. The efforts during the late 2000s, by the then MOTEYS and the Taskforce for Alternative Pathways (TAP) to introduce vocational and technical training into the secondary schools should be noted. Groundwork undertaken in 2007 and 2008, showed that the academic nature of the curriculum affects the level of commitment of students to complete secondary schooling. The TAP was then established to look into introducing vocational training as alternative pathways for students from Form 4 to Form 6 at the secondary schools. In this way, young people will have an early opportunity to learn skills that would enable them to go into a trade or a vocation. The rationale had been that more young students would be able to access such training opportunities through the secondary school system which is more spread out into the outer islands than the post- secondary school system, which concentrates in Nuku’alofa. The work of the TAP was short- 13 Full discussion can be found in the Tonga Tourism Roadmap 2013-2018 (MCTL, 2013). 14 This section is based on discussions with key informants 40 lived as the restructuring of the Public Service in 2011, meant that the MOTEYS was no longer responsible for vocational and technical training. Therefore, the funding to undertake the work of ensuring that the secondary schools meet the training standards were no longer available. Funding for short-term skill training was reduced over time and training were outsourced to an independent training organisation for the delivery of the courses. There are no vocational and technical training centres in the outer islands and rural areas to cater for the training of those in need of skills to be able to engage themselves in income generation activities and value-added processing. If the hardship experienced by those living under the poverty line is to be relieved, the best option is to skill them for work. The large number of males and females participating in the seasonal work in Australia and New Zealand15 indicates that a greater number of people in the community are unskilled. The technical and vocational training institutes providing skills training could only provide around 1,600 places whereas around 12,000 – 13,000 students with secondary qualifications can leave the secondary school system in any year. The rest of the students would either find low paid jobs, or are effectively unemployed. Some may find subsistence farming and handicraft making an option, but it is more likely they will be married at a young age and bear children early or become single mothers. Marketing and financial literacy are areas that must be strengthened if those under hardship are to be able to sustain their livelihoods. Large commercial farmers, which is a small percentage of all those engaged in agriculture (around 2.4%) have been able to organise larger markets whereas there is a need to source niche markets for small farmers. Accessing niche markets would be facilitated through better transportation networks that link the small farmers and their markets, both land and sea. Far greater attention is given to the development of large infrastructures, whereas the need for small infrastructure development is of significance to income generation and development needs of the majority of the population. The ability of the Tongan economy to create jobs for all is low as the size of the private sector is small and the rate of investment is slow. Rising unemployment was noted by the ADB in its Country Partnership Agreement 2007-2012. Between 1995 and 2005, 22% of households migrated from the outer islands into Nuku’alofa and by 2003, unemployment was estimated at 5.2% with youth unemployment running at 43% for those at the age group 15-24. Unemployment was higher among women (7.4%) than among men (3.6%). In order to create more employment opportunities, the informal sector should be developed. During the first half of 2000s, the MOTEYS conducted a survey of the informal sector, and found that there is a need for skilling through vocational training so that people are able to engage themselves in income generation. The skills most in need are in product development, product design, value added processing, financial literacy, marketing and customer service. This report did not find evidence that the training needs of the informal sector had been fully catered for. 15 Seasonal work available in Australia and New Zealand in the horticulture industry, is an arrangement between the Pacific Islands Countries and Australia and New Zealand, facilitated by World Bank, where unskilled workers would be sent during the season to work in farms in these countries. 41

4.2. Policy Considerations The Attention to Poverty Eradication The foregoing discussions show that in the absence of sound policy, the challenges would be more difficult to overcome. Action would be more successful if they are guided by good policy. The report by the ADB in 2004 has been the benchmark and comprehensive look at poverty and hardship in Tonga and provided a basis for focus in Tonga’s development agenda. The ADB in its 2003-2005 Tonga Country Strategy indicated work with the Tonga Government on a poverty partnership agreement, signed in 2002, which would see Government examining poverty, design strategies and incorporate them into the national strategic plans. Looking at the national plans, for Tonga since 1990s, none had any firm and explicit statement on poverty alleviation and poverty eradication. Their focus was, inter alia, on rural development and outer islands development assuming that promoting social and economic development in rural areas and outer islands would resolve the problems that underlie poverty and hardship. The first national plan to recognise the significance of reducing the incidence of poverty and hardship was TNSDP 8 – 2006-2009, which was a product of wide community consultation. The focus of this national plan on poverty and hardship was on the ‘vulnerable groups’ in society and the establishment of a pro-poor policy environment. The plan recognised that unemployment and lack of income-earning opportunities were the major contributors to hardship for those regarded as vulnerable including the disabled, the elderly, persons without families, women, the landless and the jobless (see ADB, 2004a). Food Security As stated earlier, a large proportion of the population still rely on agriculture, fishing and production of handicrafts for their livelihoods. Food security and the availability of secured sources of food supply and substitutes is an important issue for them. The MAFFF works with District Agriculture Committees (DAC) and community groups to ensure that sufficient acres of crops and vegetables are grown by farmers (MAFFF:2002, 2005, 2010). The data from MAFFF for the last 10 years indicate that Tonga is a net exporter of root crops, produce and exotic plant and marine products (especially taro varieties, yams).16 At the same time, it is a net importer of meat products (especially beef, mutton, chicken), wheat-based processed foods, vegetables and fruits. In this regard, MAFFF considered import substitution as a measure to reduce the import of meat products, by encouraging households to raise domestically their own meat supply from chicken, goat, pig and lamb. Quarterly market surveys are undertaken by MAFFF and are used to monitor food supply in the local markets. Such data would indicate excess or critical low levels of supply. Over the decades, MAFFF had been working with farmers on promoting export of agricultural produce by providing advice, assistance in marketing and training in land preparation, fertilizer application and pest 16 Data on exports and imports were provided by the Quarantine Division of MAFFF 42 control. The data from its Quarantine Division as well have indicated reliance and dependence on imports of specific basic food items. A local food security benchmark for Tongatapu (where 73% of the population live) was established by MAFFF in the year 2000 – with 1,386 metric tons. Between 2000 and 2004 food crops supply for Tongatapu declined by 48% and fruit supply by 75%, because of the focus by farmers on growing high value crops for export, especially of squash to Japan and Korea. During the last 10 years, the supply of food crops, fluctuated because of drought and the increase in the export of root crops to markets in New Zealand and Australia. There are a total of more than 18,000 households in Tonga, and many would rely on the availability of food supply in the local market. However, there was no severe shortage of food crops recorded by MAFFF during the last 15 years (MAFFF: 2000, 2005, 2010). The issue then is how families could continue to secure food supply, especially the ‘landless and the jobless’, when the cost of food items keep rising and in times of natural disasters and food shortages. The extension work of the MAFFF advising local farmers and monitoring the food supply should be recognised. The work of the churches and CSOs, with tight budgets, in taking care of the needs of those who are most vulnerable should be brought into a formal structure of partnering with Government in providing social protection. The ‘landless and the jobless’ are the most vulnerable as far as food security is concerned. They are the displaced through rural-urban migration. The landless will find it difficult to secure food supply and may have to rent plots in return for part of the produce. There are no data available on those who are landless but the 2001 Agriculture Census is the earliest report on land availability. It indicated that only 41% of the agriculturally active households owned tax allotments. It is notable that Tongatapu was lowest in ownership of tax allotment with only 36% of the agriculturally active households, with ‘Eua being the highest with 56%, the rest were around 48%- 50%. Civil Society Organisations (CSOs)17 The CSOs have been working in areas relating to poverty alleviation and social protection for the vulnerable. They also work in the informal sector which is largely rural and engages around 60% of the working age population. In some cases there is no formal recognition or oversight by Government, although an informal working relationship existed. While their work may be under- reported the working relationship with the relevant Government Ministries needs to be strengthened. It will make the commitment by both parties predictable in providing services that are adequately funded, meet the required quality and widely cover those in need. There is a need for a clear demarcation of the division of responsibility where the Government Ministries would be responsible for policy and oversight and the CSOs are responsible for the delivery of the services. For the working relationship to function effectively and efficiently, a partnership should be defined under a policy framework to ensure sustainability and accountability. It should also allow sharing of information and participation by CSOs in decision making to represent the views of the community. A forward rolling plan, defining the programs, 17 The discussion in this section is based on cluster meetings held with the CSOs. 43 work relationship, funding and division of responsibility needs to be formulated to guide the delivery of services. Gaps in the Strategic Approach The TNSDP 8 – 2006-2009 – is the first official policy document to define who is likely to be vulnerable and therefore susceptible to living in hardship. They include large families with children living in poor conditions with no access to land or earning an income, children who are dis-parented, youth who drop out of school without qualifications, women who are single and widowed, young single mothers, the disabled, the elderly without children or income and the deportees. The policy response under TNSDP 8, was to focus on education, health and regional and rural development, but they were not easily translated into programs and projects that actually address the specific needs of the poor. While the work in education and health were to improve the outreach of the services, rural and regional development focused more on the transport infrastructure to allow production and market access and further development of agriculture and fisheries and youth enterprises. These were emphasised further in the next plan – TSDF I - 2010- 2014. The challenge then is the translation of the policy statements in these plans into projects and programs that targeted poverty and hardship and those who are vulnerable. In 1990s to early 2000s the development partners (such as the EU, Japan, Australia and New Zealand) were providing funding for community projects to improve water and sanitation, women in development, and small income generating micro-projects. However, there was still a need for a coordinated approach for meeting the needs of those who are vulnerable and living in hardship. While there was no consistent set of policy or strategy for dealing with poverty and hardship, the recognition in development policy of the informal sector and its potential to create wealth is still low. This is important because of the large number of the working age population including youth whose livelihoods depend on the informal sector. The HIES of 2009 indicated that the total income from subsistence activities in agriculture, fisheries, livestock, home-made products and handicraft was TOP$66.8 million and about 40% come from handicraft, 27% from agriculture and 21% from livestock. Only 11% of household incomes were from fisheries. Around 82% of subsistence incomes were generated in the rural areas. The Tonga Handicraft Market Survey (CF, 2015) on handicraft production indicated that its economic value is understated in terms of contributing to household incomes. Since the 1990s, the handicraft products are in demand widely, not only in Tonga but in overseas countries where the Tongans live. Anecdotal evidence suggests that more women are now entering microenterprise activities such as paid domestic work, sewing, food vending, food processing and so on. The World Bank (2014) states that active communication of data is important to increasing understanding of poverty and hardship. Representative household surveys are not undertaken regularly, which means that there is lack of data and timely information for policy makers and 44 development partners. Investment in data collection and in fielding of regular household surveys is worthwhile. The data should also be made available to policy makers and practitioners for planning and strategy making. 5. Enabling Factors

5.1. Technical Consideration While there are challenges in trying to reduce poverty and hardship, the Government and development partners and CSOs have undertaken initiatives to benefit the poor, apart from the remittances. The role of remittances from families and relatives who live overseas has been played an important role in alleviating poverty and hardship in Tonga. The HIES 2009 stated that remittances make up 21% of the total income of households. The proportion of people below the Basic Needs Poverty Line would have been at 62%, rather than 23%, without the remittances. It had reduced the incidence of poverty by 31%. The remittances perform a function similar to safety nets and social protection and insulate families from negative income shocks, although the level of remittances has fluctuated over time. However, in times of economic down turn in countries where Tongan migrants live, the flow of remittances is expected to decline. In 2009 remittances was reduced by 30%. In 2008, during the global economic downturn, the Australian and New Zealand Governments provided the opportunity, based on earlier WB studies, for Tonga and other Pacific Island countries to send workers to work on a temporary basis in the farms in the horticulture industry in both countries. This opportunity was provided, as seasonal workers schemes, on the basis that it will help to alleviate poverty in Pacific island countries. Currently, Tonga has been sending more than 3,000 workers to both Australia and New Zealand as seasonal workers. The seasonal workers have been remitting to Tonga a net of TOP$27million a year, an average of TOP$9,000 per head. 18 The new TSDF II has focus on the potential for Tongans to participate in the international labour market and encouraging foreign investment in Tonga to create wealth and employment. The development of the traditional industries is an important part of the informal sector. The Government is now providing soft loan schemes through the Tonga Development Bank (TDB) to encourage those in the informal sector and small enterprises to engage in product development, marketing, export, processing and services in the sectors, which are more likely to benefit the poor and the vulnerable – agriculture, fisheries, tourism, handicrafts and small and micro- enterprises. Assistance has been provided by the development partners towards training that provide those who operate in the informal sector and traditional industries with the appropriate skills. However, there is a need to ensure that the services are user-friendly and affordable. Government also takes note, in the TSDF II 2015 – 2025, of the need and importance of developing the private sector by embarking upon creating a strengthened business-enabling 18 Information provided by the MIA 45 environment. The legislative and regulatory frameworks for doing business and the efficiency of services provided by Government to the private sector business will be improved. There will also be focus on the small and informal business sector, to encourage engagement with the larger private sector. The Tonga Chamber of Commerce and Industries (TCCI), the umbrella organisation for the private sector businesses, delivers business advice and training through the Tonga Business Enterprise Centre (TBEC). The private sector would still be the mainstay of the economy and it is important that the policy environment is conducive. The TCCI provides a forum for dialogue on policy issues including support for export-ready enterprises, the development of small and medium enterprises, availability of Government funding and incentives for the business community, unfair competition and tax incentives. The members have been in consultation with Government on the Employment Bill, Income Tax Act, business licensing reform, income tax reforms and small business tax and their likely impact on businesses. The TCCI is active in promoting women in business and youth in business encouraging entry into the small business and micro-enterprise sectors (TCCI, 2013; 2014). The TCCI could work together with the CSOs on projects and activities in the private sector and informal sector to encourage income generation and employment creation. The work by CSOs should be commended in delivering services at the grass-root levels to people who are vulnerable and experiencing hardship. 19 The CSOs areas of work range from youth development, family planning and health to women, disability and rural development. While their areas of work spread across many areas, the CSOs stated that the following have become the enabling factors in their work: - the passion of volunteers to deliver the services - government providing support, both in kind and in cash although not sufficient - regional and international obligations of CSOs to provide services to the poor - support from the development partners both technical advice and funding projects - good working relationship with stakeholders and clients - community-wide support for the work of CSOs - recognition given to the work of CSOs - relationship with their stakeholders and clients - working together towards common goals

5.2. Policy Considerations20 In 2008, a youth micro-enterpise development project was implemented by MOTEYS to encourage young people to engage in micro-enterprise activities to generate incomes. This project was based on a Tonga National Youth Strategy produced to guide youth work in Tonga in areas of skill training, employment creation, health education, community service and advocacy. In 2015, the Strategy was reviewed and a new one is now in place with specific focus on skills development and employment creation. 19 Information provided during cluster meetings with CSOs. 20 The discussion in this section is based on consultations with MIA 46 Further restructuring in 2011, brought women’s affairs, culture, local government and social protection under MOTEYS. Now social protection and seasonal work have become the main functional areas for partnering with communities and CSOs to deliver services for those who are vulnerable. Seasonal work in Australia and New Zealand in the horticulture industry have provided temporary employment. The seasonal work schemes are likely to be extended to semi- skilled and skilled areas in hospitality, aquaculture, aged care and the trades in the near future. In 2012, the Government introduced the Social Assistance Payment and administered by the National Retirement Scheme. Tongans who are 70 and who are no longer working or paid a pension are eligible to be paid a monthly allowance. In 2013/2014 there were 2,383 beneficiaries. The National Retirement Scheme, with assistance from the Australian Government and International Labour Organisation (ILO), has also been set up to encourage workers to make savings in a retirement account, with contribution from the employers (MIA, 2015). The Tonga National Policy on Disability Inclusive Development 2014-2018 has been approved to be implemented by the Social Protection and Disability Office in MIA. A regulatory and monitoring and evaluation frameworks to guide implementation is in place. These are important steps towards ratifying the UN Convention on the Rights of Persons with Disability (MIA, 2015a). Social protection is important in ensuring food security, income security and health care for those who are most disadvantaged and vulnerable and is an effective tool for combating poverty and inequality. The Social Protection and Disability Office estimates that there are more than 2,000 disability clients out in the community that need the assistance. According to the 2011 Census there are 13,980 people with disabilities with 52% of all disabilities in the age group 60 or over. The WB estimates that between 11%-18% of the population in most countries have a disability (MIA, 2015b). In 2013 the Social Service Pilot Project was launched and funded by ADB, Japanese Government and the Tonga Government. The aim is to target ‘the vulnerable’ with MIA providing a focal point for the Project through its Social Protection and Disability Office. The Office works with the CSOs to deliver the appropriate social protection services for the elderly and the disabled. The projects involve care giving to the elderly most disadvantaged such as elderly without families, transition of the disabled babies to early childhood education and inclusive classes (Early Intervention Program), skill training for adult disabled and transition from skills training to independent living (Innovative Social Enterprise) (MIA, 2015, 2015a). 6. MDG Milestones and Consequences One of the milestones in trying to eradicate poverty and hunger is the fact there is now a very clear understanding of ‘poverty’ and ‘hardship’ in Tonga. It has also been clear that Tonga is vulnerable to external economic crises and natural disasters. The lack of opportunities to participate in the economy and formal employment, will move a majority of the population to depend on the traditional industries for their livelihoods. The Government, development partners and CSOs respond to protect those who are most vulnerable and ensure food security, but at the 47 same time, there are recognised gaps in policy and in coordination of efforts. These must be addressed to reduce the number of people facing hardship and who are vulnerable. The work on poverty and hardship will continue beyond the end of the MDGs but out of this new understanding comes several issues to be addressed and therefore should result in the design of an integrated policy framework for poverty eradication for implementation after 2015. This will allow better coordination of action and addressing the issues of inequality, vulnerability, equity, equality of opportunity and access and creating a conducive environment for concerted efforts. There should be some focus on the informal sector for the purposes of generating wealth and incomes for those who face hardship. It should be developed side by side with the private sector as the twin engines of economic growth. Developing the informal sector, require a policy framework which will also take into account the need to create employment and income generation, explore and link with markets and skilling people for product development and quality assurance. The work of CSOs in the development of the informal sector should be formalised and sharing of responsibilities with the public sector clearly defined. The issue of internal migration should be addressed at the policy level as it is part of the rural- urban drift. The negative impact on households can be severe because those affected may be jobless and landless. Internal migration contributes to the hardship faced by people, but especially the impact on women and children. Hardship contributes to the escalation of social problems. It should be addressed together with the concern in the health sector for population planning. 48 Goal 2: Achieve Universal Primary Education Photos: ‘Eva Tu’uholoaki 49 Target Table 4: Target 2A: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling Indicators 1990 1995 2000 2005 2010 2015 Target Status

2.1 Net enrolment ratio in 91.6 - 89.4 88.4 93 97 100 On primary education (2006) (2008) (2013) target

2.2 Proportion of pupils - 84 93 88.9 90 91.8 100 On starting grade 1 who (1996) (2001) (2006) (2007) (2013) target reach last grade of primary

2.3 Literacy rate of 15-24 98.8 99.3 - 99.4 99.5 - 100 On year-olds, women and (1996) (2006) (2011) target men Source: Ministry of Education and Training 2015, Statistics Department 2015 1. Progress and Achievement of Targets Target Table 4 shows the figures on ‘primary education’. ‘The number of children who are of official age for primary education and who are enrolled in primary education, as a percentage of the total number of children who are also of primary school age in a population is the net enrolment ratio.’ Tonga has a relatively very high ratio of net enrolment in primary education. ‘The proportion of pupils starting grade 1 who reach the last grade of primary education is the percentage of pupils who are enrolled in a given school year, and are expected to reach the last grade.’ For Tonga, the proportion is maintained at a high level over the last 15 years. The literacy rate, derived from the Census, is maintained also at a very high rate over time.21 Since the last MDGs Report in 2010, the MET had been working to ensure consistent reporting of progress in the implementation of projects and activities that support Target 2A. Information are also disseminated to stakeholders and decision makers. The TESP provides the means for developing an education management information system that generates data and information on education in Tonga. Data are gathered from across the education sector on a regular basis through surveys and field reports. They are analysed and used as the basis for policy decisions made by the MET. The net enrolment ratio has been steady over the 25 year period varying slightly between 88% and 97%. This is considered high and an excellent performance. The figure for 2013 (97%) is the result of a trial in moving the cut off birthdate for enrolment in grade 1 from 30 April to 30 May. This allowed the enrolment of children who should have been enrolling in 2014, rather than in 2013. 21 In accordance with the international standard definition – “read and write a simple sentence” (Statistics Department, 2015) 50 The proportion of pupils who reach the last grade or class 6 at primary school level is also high, varying between 84% and 91.8%. This is also considered a very good performance in sustaining the number of pupils enrolling and completing primary school education. The rest of the children who do not enroll in primary education are accounted for by those who are severely disabled, migrating, too sick to attend school or are repeating the last grade in primary school. The progress towards the target has been consistent and very good and therefore the target is achieved. This is due to the strong support by all the stakeholders (schools, communities, parents- teachers association). The discussion below provides further details. Final Performance Status: For net enrolment in primary education: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong For proportion of pupils reaching last grade: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong For literacy rate for 15-24 year olds: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong Overall: For children everywhere completing primary schooling: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong 51 2. The Challenges While the net enrolment and proportion of pupils completing primary schooling are high, the MET still has to overcome the challenges relating to the increase in its scope of responsibility in the education sector as a result of the review of the Education Act and maintain accessibility, equity, quality and relevance of primary education. These challenges, both at the technical and policy levels, can undermine the efforts to maintain the high track records that are already established.

2.1. Technical Considerations22 Early Childhood Education (ECE) The ECE is preparatory for moving into primary level education. It was introduced into Tonga in the 1970s and by the early 1980s it expanded very slowly under the churches and private organisations. By 2000s, there were more than 40 ECE centres and now there are more than 70 registered with the MET, as in Table 3. The figures do not include those that are not yet registered. Table 3: Distribution of ECE Centres in Tonga Year No ECE Centres Tongatapu Outer Islands 2000 42 23 19 2005 49 26 23 2010 56 30 26 2013 71 45 26 Source: Ministry of Education and Training Annual Reports The ECE is now formalised into the structure and educational policy responsibilities of the MET, as required by the Education Act. This will effectively include ECE as part of the new policy to extend the compulsory education age to start from age 4 until age 18. However, the ECE centres are concentrated in the main island, Tongatapu and in the urban areas. Access to ECE is severely limited in the rural and remote areas and in most of these locations the technology is not available to assist in the delivery of the programs. At the same time, it is still misunderstood by many in these communities that the children who most deserve to go to ECE, are not enrolled with an ECE centre by their parents. The quality of the programs the ECE centres deliver and the teaching and learning materials have been below the appropriate standards and the teachers lack proper training. There has not been any stable source of financial resources to support their operation, although the MET only started to provide a TOP$50 per head grant in 2011/2012. For the time being, the MET can only help to establish the ECE centres, provide this grant and begin to train the ECE teachers. 22 The discussions in this section is based on cluster consultation with the stakeholders in the education sector and annual reports of the MET, reports on TESP, Corporate Plans and the Lakalaka Education Policy Framework 52 Tonga has been slow to adopt ECE as it was Sunday school-based and home-based where the mothers and grandmothers become the teachers focusing mainly on imparting moral values to young children (lehilehi’i). This was considered to be important in educating Tongan children. This form of ECE began to disappear gradually as the traditional extended family networks break down, especially in urban areas. The mothers and the grandmothers were no longer living together or both were working, leaving the children with caregivers. This led to the gradual emergence and spread of ECE centres in urban areas, in its early stages. Primary School Education Table 4 shows the total number of primary schools across Tonga and student enrolment. At the primary school level, equity and quality in provision in remote areas are the greatest challenge, especially in small remote islands. On an equity basis, the mandate given by the Education Act is to provide national coverage so that every child has access to a primary school. Provision of teachers willing to serve in such remote areas and serviced by the MET inspectors have always been difficult. Table 4: Enrolment in Primary Schools 2000-2013 Year No Primary School Total Enrolment 2000 117 16697 2005 124 17032 2010 128 16848 2013 131 17273 Source: Ministry of Education and Training Annual Reports The primary schools are situated in a village community environment and the attendance rate of children should be at a high level. Town officers and school principals cooperate to ensure that children are at school during class hours. However, in some communities the attendance of children is affected by the commitment of parents to send them to school. The financial circumstances of the families often become the motivation for their children to abstain from attending school. Part of ensuring equity is to see that students stay in school as long as possible. The application of the universal basic education policy from age 6 to age 14, covering form 1 and form 2, as part of primary schooling has not been an easy task for MET, either. Form 1 and form 2 have traditionally been in the secondary school cohort, and which are mostly run under the church education systems. Their position had been to retain form 1 and form 2 as part of their secondary schools, but Government should be prepared to bear all the costs for the required resources. However, the MET has already begun setting up a number of middle schools throughout Tongatapu and form 1 and form 2 in a number of primary schools. This work is continuing. In order to maintain quality in primary education, the challenge is in the area of literacy and numeracy. In 2000 and subsequent years programs to improve literacy and numeracy were being put in place. Over the next five years from 2000, the children at risk with literacy and numeracy 53 was reduced from around 5% to 4.4% in 2002 and 2.7% in 2004, through the implementation of projects to evaluate literacy and numeracy in primary schools (MET, 2000, 2005). However, an impact study - Tonga Early Grade Reading Assessment (TEGRA) conducted in 2009 reported that around 70% of children in primary school did not know the Tongan alphabet by class 3, which affects mastering reading and writing. Hence, there was an urgent need to improve the quality of the outcomes in literacy and numeracy. In 2011, an assessment at class 4 and class 6 using Standard Testing for Tongan, English and Maths (STATS) found that less than 50% of students were able achieve a satisfactory level of literacy in Tongan and English and only 20% in class 4 and 35% in class 6 achieved a satisfactory level of numeracy.23 Over the last several years the assessment of the level of competence of children has been ongoing using various models for assessment, and monitoring and evaluation of performance of children in literacy and numeracy. In addition, several activity programs have been introduced into the school environment as learning tools. The difficult task now is to ensure that children leave primary education with a satisfactory level of competence in literacy and numeracy. However, tentative reports from church-based secondary schools indicate that a large percentage of pupils enrolling still have difficulties in reading and comprehension and basic numeracy. The recently approved Tongan Language Policy effectively makes the Tongan language as the first medium of teaching for the first three years of primary school. The rationale is to ensure that young children are competent in the Tonga Language first, but at the same time, they will need to hear oral English so that they do not encounter problems when English is introduced at the next level. One of the core problems, has been the lack of experienced staff which has affected the progress towards quality education in primary schooling. The professional support services to primary schools, especially in the outer islands, had been affected by the loss of field officers through voluntary redundancy programs in 2005 and through natural attrition over the years. The professional support is important in training teachers to utilise teaching and learning resources efficiently and effectively and in ensuring that their performance are appraised regularly. Professional development for teachers is significant because of the new curriculum now being introduced into the primary school level.

2.2. Policy Considerations24 Minimum Quality Standards As a matter of policy, maintaining minimum quality standards are required to keep school performance at a satisfactory level. The challenge in the provision of universal basic education is ensuring quality in delivery and improving the performance of students. However, there is a cost in maintaining quality. The school facilities, equipment and materials vary in quality, and while 23 Statistics provided by the MET 24 The discussions in this section is based on cluster consultation with the education sector stakeholders, annual reports of MET and its strategic plans 54 it is important that this is standardised, maintenance and replacement are an expensive exercise for schools. The annual budget of the MET can only fund the salaries of teachers and their teaching materials and very little is left to fund other needs. Over the years, the funding provided by Government, has not been entirely sufficient to cover the costs required by primary schools to meet the quality standards. The parents-teachers associations and the community have to participate in bearing the cost of providing the appropriate equipment, materials and amenities to maintain the standards in the delivery of the curriculum. In this regard, the relationship between the schools and the communities is important in improving the outcomes. Financing Education Table 5 shows Government spending in education with contribution from the development partners. The increase in the allocation from 12% in 2005/2006 to 17% in 2010/2011 has been the result of the introduction of grant assistance to vocational and technical institutes and a number of middle schools in Tongatapu, managed by the church-based education systems and private organisations. The grant assistance to non-government secondary schools also increased. There has not been any substantial increase in the normal allocation to the education sector since 2000. The contribution by the development partners, therefore, has been crucial. Table 5: Education Share of the National Budget 2000-2014 Year Share of the Staffing Share of Donor Spending as Budget Government Budget % of sector spending 2000/2001 $12.04m 1244 12% - 2005/2006 $18.3m 1595 12% 19.2% 2010/2011 $26.8m 1036 17% 9.3% 2014/2015 $38.5m 1142 16% 23.7% Source: Budget Estimates, Ministry of Finance and National Planning Trained teachers available in sufficient numbers to cater for the needs of primary schools across Tonga has been a concern in recent years. There are 132 primary schools all over Tonga, (and 65 are in Tongatapu alone) catering for more than 17,000 students. They must all be sufficiently staffed which means staffing is paid for from the annual budget of MET.25 At times, capping the annual budget of the MET and recruitment of staff as part of restrictive fiscal policy measures, often affects the recruitment of a sufficient number of teachers for the primary schools. This means that fewer teachers would be available and hence the teacher-student ratio would exceed the standard of 1:25. This can undermine the quality of education and the performance of students. In 2009/2010 and in subsequent years, recruitment by the MET was restricted resulting in shortage of teaching staff for both primary and secondary schools. The development partners were then willing to provide budget support towards paying for the salaries of extra teaching staff to be recruited to supplement the existing cadre. They are now providing funding, under TESP, for the recruitment of relieving teachers so that other teachers could go on further training or go on leave. 25 Statistics provided by MET 55 3. Enabling Factors The achievements that has been witnessed in the management of the education sector in Tonga is due to the establishment of sound legislative and policy frameworks, comprehensive plans and strategies that have positive impact on the quality of education for the primary school level. These are described below.

3.1. Technical Considerations ECE and Inclusive Education (IE) Recognition26 In 2000, ECE and IE were specifically stated as areas of priority as it became clear that both needed to be accessible and available. The ECE is the foundation for primary schooling and all children including those from disadvantaged families would benefit from pre-schooling. The development of children is fostered in the early years with an appropriate curriculum which lays down the foundation for formal education. A survey in 2005 on the need for special education for children with disability, established that there should be equal access to education and training by those with special learning needs and those with disabilities to develop to their full potential. The PRIDE project, (between 2005-2010), as part of implementing the Tonga Education Policy Framework (TEPF) 2004-2019, developed an ECE policy framework as well as certificate and diploma programs for ECE and IE teachers which are now delivered by the Tonga Institute of Education (TIOE). The work also included the design of an appropriate curriculum for use by the ECE centres and the provision of teaching resources with the MET, in partnership with the Tonga Preschool Association, being responsible for coordination, registration and provision of support. In 2010, MET had created organisational work units, with budgets, for ECE and IE and their responsibilities included the provision of resources to pilot schools for IE, registration of the ECE centres, provision of teaching resources for classroom delivery of lessons, training of teaching staff and promotion of public awareness. Both the National Early Childhood Education Policy and the National Inclusive Education Policy have been approved by MET for implementation. They provide the guidelines, procedures and processes for ECE and IE providers. Universal Access Primary schooling in Tonga has always been compulsory and free and the objective has been to ensure that all children in all parts of Tonga, irrespective of geographical location and economic and social status, have equal access to quality education. This has been the cornerstone in achieving the high ratio of enrolment at the primary school level. One of the longest standing policy in education, as defined by law, is that there shall be a school within ‘walking distance (2 26 See MET Annual Report: 2000, 2005, 2010 56 miles) measured by the nearest available route’ or in remote islands where there are pupils regardless of numbers, to ensure access.27 The Education Act also allows the Minister to establish new Government schools in any locality. By the beginning of 2000, compulsory education was six years from the age of six and secondary schooling for five years to form 5 (MET, 2000). The Education Act now extends the compulsory school age from age 4 to age 18. It is a large responsibility and it requires effective monitoring and evaluation, as it includes two years of ECE, six years of primary schooling and six years of secondary schooling. The extension to age 18 has implications on the legal minimum working age which is 15. This needs to be resolved but it is possible that students can enter the workforce as a trainee, if they leave early. In this regard, technical and vocational training in secondary schools becomes the instrument for giving young trainees the skills to enter the workforce. The policy arrangements in this area has not been formalised. Quality In 2000s, the ‘quality’ in the provision of universal basic education was highlighted by surveys and studies as a priority in getting students ready for secondary schooling. The focus had been on the support services to teachers, the availability of required resources, the relevance of the curriculum programs and literacy and numeracy. The level of competence and quality of teachers is significant in maintaining quality in provision. The work on teacher registration is now ongoing and is part of the defined quality standards under the Education Act. It will be enforced as soon as training of all teachers in the teaching profession completes. Over the last two decades the qualifications of teachers had been upgraded from three- tiered certificate in teaching to a diploma, which was introduced in 1986. By 2010, it was reported that around 79% of teachers were in possession of diplomas or higher qualifications. Teachers are supported by continuous in-service training programs. The major districts and outer islands, are administered by resident senior education officers whose task is to provide support services to the teachers and liaise with the head office. A Teacher Resource Centre had also been set up to provide teachers with teaching resources and teaching aid, and making them readily available. By 2005, strong emphasis was placed on ‘Quality Assurance’ under a framework of Minimum Service Standards (MSS) which cover the curriculum, examination and school assessment. The enforcement of compliance with the MSS is administered by the Schools Division of the MET with responsibilities for both primary and secondary schools. Over the last 10 years, work has been done to review the national curriculum. The revision of primary level (class 1 to form 2) curriculum has already been undertaken with focus on the core subjects and including creative 27 To ensure accessibility, during the 1880s, all primary schools which were informally set up by missionaries were nationalised as government schools. By the end of the 1970s, all primary schools run by church-based education systems were phased out and nationalised into Government primary schools. 57 technology, Japanese language, movement and fitness, and Tongan society and culture. The revision of the curriculum continues to form 3 to form 7 levels. At the same time, the MET has developed partnerships with Government Ministries such as MAFFF, MEIDECC and MOH on certain aspects of school activities relating to their areas of responsibility. New assessment methods such as STATS and TEGRA have been developed to help maintain the quality and standards. The schools are to take the lead in ensuring that quality standards are adhered to. In this regard, school-based management programs in primary schools have been designed to strengthen good leadership, ownership of school programs and activities and developing a fruitful community relationship in the school environment, with school principals talking the lead.

3.2. Policy Considerations Plans and Strategies One of the milestones for the education sector is the completion of the revision of the Education Act 2013 and regulations, which are now in operation. The Act provides for the Advisory Council for Education (first set up by the 1974 version of the Act), consisting of representatives from the non-government education managing authorities. The Council provides policy advice to the Minister. The Act also provides for the registration of teachers, the management of ECE, IE and compulsory education, and the control of the curriculum, higher education and technical and vocational training. Tonga is committed to international instruments such as the MDGs and UNESCO declarations such as ‘Education for All’ and ‘Education for Sustainable Development’ and collaborates with the development partners such as the WB, EU, NZAID, AusAID and Japanese International Cooperation Agency (JICA). Hence, the MET set a target in 2010, that by 2015, all children have access and complete free and compulsory education. It seems that this target has been met. The Strategic Plan of the MET 1996-2000, saw emphasis on universal access and equity with the following strategies: - There shall be universal access to quality basic education from Class 1 to Form 2, Government and non-Government school have equal access to teachers, classrooms and resource materials - Equity outcomes are achieved in gender balance, distribution of resources to outer islands and rural areas and educational achievement - education programs are development for early childhood The expected outcomes of the Plan included: - Equity of access to educational services and educational achievement for both sexes, rural and urban areas and outer islands and for all social and economic groups at all levels of education 58 - Adequate and quality facilities, and resources in all schools, government and non- government at all levels - All schools and all levels staffed by qualified, competent and dedicated teachers - High literacy and numeracy achievements with less than 5% of students at risk by Class 4 The foregoing became the basis for continuing the emphasis on access and equity, which were highlighted as part of the national objectives of TNSDP 8 2004-2009, - ‘well educated and skilled labour force and healthy population’ and ‘good quality primary education with equal opportunity and access for both men and women’. The current Corporate Plan (2015/16-2017/18) for the MET essentially continues to put emphasis on the same: - Integration of the Tongan language into educational programs - Minimum service standards - Quality curriculum and assessment methods - Demand driven training for skills for employment - Equitable education system - Accessible, conducive and safe teaching and learning environment There is now a focus on linking training and employment, which is in line with the expectation in the TSDF II for a focus on ‘improved education and training providing life time learning’. Tonga Education Policy Framework (TEPF) The TEPF 2004-2019, is the policy foundation for the education sector with three major goals: 1. To improve equitable access to and quality of universal basic education for all children in Tonga up to Year 8 (Form 2) 2. To improve the access to and quality of post-basic education and training to cater for the different abilities and needs of students 3. To improve the administration of education and training so that the quality of educational performance is enhanced The TEPF is the product of a comprehensive review of the education sector written into the Final Report: Tonga Education Sector Study (TESS) (March 2003). It was intended to, inter alia, set guidelines and provide a framework and context for the future development of Tonga’s education sector. Seventeen policy areas were identified for further policy development, and the following are directly relevant to the MDGs, which included: - Universal basic education to Year 8 (Form 2) - Early childhood education - Special education - Language policy - Skill development and lifelong learning 59 The policy outcome expected included: - education should be available to all children on an equitable basis - should be of high quality, should promote student achievement at a high level an should meet individual and national needs - should be compulsory and free The TEPF had been the foundation of the reforms in the education sector since 2005 and the basis for the design of TESP (see below). The Tonga Lakalaka Education Policy Framework (TLEPF) 2012-2019, updated and revised the TEPF and its implementation is now supported by TESP. Tonga Education Sector Program (TESP) The TESP was initiated in 2005 and supported by the New Zealand Government and the WB. It became the instrument for achieving the goals of the TEPF. While the net enrolment ratio at the primary school level remained high, the quality of education was the concern and the TESP was designed to address the relevant issues, especially the minimum standard requirements and funding the gaps, especially for the poorer schools and communities. An Education Sector Committee was set up to enhance partnership between the MET other relevant Ministries and key stakeholders to dialogue and report on the implementation of the programs under TESP. The TESP put in place a Tonga Schools Grants Program (TSGP), a funding mechanism for primary and secondary schools to meet the prescribed quality standards and finance non-salary inputs to improve school and student performance. By 2010, it had covered more than 150 schools. The TESP continues TSGP to cover the teaching and learning resources, to maximise the outcomes for the student. The TSGP is now provided under an annual operational plan, where the management of the TSGP and the school is a partnership between the school and the parents-teachers association. 4. The MDG Milestones and Consequences The previous sections have outlined the major policy and technical considerations in terms of the challenges and the enabling factors that have supported the achievement of the targets for universal primary education. Tonga has been able to maintain a high ratio for net enrolment and high proportion for students enrolling in grade one (class 1) and reaching the final grade (class 6). This is because of the consistent and remarkable attention given to quality, equity and access to education. It has given all children everywhere in Tonga the opportunity to go to school. The literacy rate is also very high, for the age group 15-24 and it is an indication of the ability of the education system in Tonga to ensure that boys and girls, as they progress through the education system, are competent in literacy and numeracy. It is a milestone that Tonga has been able to review and modernise its Education Act during the period of the MDGs. The new Act will enhance the quality and strategic management of education 60 in Tonga. The work on ECE and IE, which are incorporated into the new Act, has extended further the effort to ensure that all boys and girls, regardless of social background, mental and physical ability, geographical location and so on, are able to complete a full course of primary education. The Act is supported by the TEPF, a corporate plan and TESP, which forms a good model for strategic management of the education sector. The education sector in Tonga has found itself being lifted to a new level where it must be strategically guided as an effective instrument for social and economic development. The MET has begun laying down the basis for it in terms of a sound legislative and policy framework, new processes for maintaining quality and the relevance of education in Tonga. It is imperative that the current level of work, as described in the sections above, with the assistance of the development partners, continues and is further enhanced and sufficiently resourced. 61 Goal 3: Promote gender equality and empower women Courtesy: Christopher Paquette 62 Target Table 5: Target 3A: Eliminate gender disparity in primary and secondary education preferably by 2005, and in all levels of education no later than 2015 Indicators 1990 1995 2000 2005 2010 2015 Target Status

3.1 Ratios of girls to boys in primary, secondary and tertiary education Primary 87 89 89 88 90.1 100 On (1997) (2001) (2006) (2008) (2013) target Secondary 97 99 94.3 97 93.8 100 On (1997) (2013) target Tertiary 67 69 99 - 110.6* 100 On (1997) (2014) target

3.2 Share of women in 33.74 35.7 35.7 39.2 38.0 - 50% Below wage employment in (1986) (1996) (1996) (2006) (2011) Target the non-agricultural sector

3.3 Proportion of seats held by women in national parliament Total seats 33 34 35 32 30 26 Seats held by 1 2 2 1 1 0 women % 3 5.9 5.7 3.1 3.3 0 50% Off target Source: Ministry of Education 2015, Statistics Department 2015, *=provisional 1. Progress and Achievement of Targets ‘The ratio of girls to boys (for every 100 boys) in enrolment in school, (or gender parity index) is an indicator of gender equality in education. Closing the disparity in enrolment in school is a first step toward giving girls and women a good education which will guarantee good health, improvement in their position in society, economic opportunities and the welfare of the family.’ For Tonga, the disparity is minimal and the MET has been successful in being able to maintain this over time. The ratios are higher at the secondary school level than at the primary school level because of the tendency for more boys to repeat class 6 (grade 6), while more girls than boys proceed to the secondary school level. However, the enrolment of girls at the tertiary level over time have been much guided by the availability of the courses of their preference in technical institutes. ‘The share of women in wage employment in the non-agricultural sector (industries and services) as a percentage of the total number of working age population in wage employment’, has not changed substantially over the last 25 years. This measures the degree in which women have equal access to men in wage employment in the non-agricultural sector.’ 63 The proportion of seats held by women in parliament has not improved beyond two members in the last 25 years. Final Performance Status: For ratio of boys to girls in primary, secondary and tertiary education: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good On Target Strong For share of women in wage employment: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Moderate For seats held by women: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very poor Below Target Weak Overall: For eliminating gender disparity in enrolment: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong 64 2. The Challenges

2.1. Technical Considerations Ratios of Girls to Boys Primary Schools Although the disparity between girls and boys in enrolment at the primary school level is minimal, the difference is due to a number of factors. These include the variations in the birth rates for boys and girls from year to year. The difference may also be due to internal migration of families from one district to another. It may also be due to outward and inward migration of children of Tongans living overseas and expatriates working in Tonga. Some may have already been in secondary schools, whose age is still of primary school level. Others in class 6 may be dropping out of school or repeating. Repeaters are given two years to attempt the entry examination to secondary schools, administered to class 6. For instance, around 35% of students in class 6 were repeating in 2000 compared to 26% in 2005, with more boys than girls repeating (MET: 2000, 2005). Table 6 shows the distribution of total national enrolment in primary schools between girls and boys. The disparity is quite small and can be accounted for, as explained above. Table 6: Total Enrolment of Boys and Girls at Primary School Level 2000-2013 Year Girls Boys 2000 46.7% 53.3% 2005 47.3% 52.7% 2010 47.1% 52.9% 2013 47.4% 52.6% Source: Ministry of Education and Training Annual Reports Table 7 shows the enrolment in primary schooling of all girls in Tongatapu and in the outer islands. This distribution is considered normal as it is also a reflection of the general distribution of Tonga’s population, where 73% live in Tongatapu. Table 7: Enrolment in Tongatapu v Outer Islands 2000-2013 Year Girls in Tongatapu Girls in Outer islands 2000 67.1% 32.9% 2005 69.8% 30.2% 2010 72.6% 27.4% 2013 72.7% 27.3% Source: Ministry of Education and Training Annual Reports 65 The enrolment of girls in Tongatapu (Table 8) shares a similar pattern to the enrolment in the outer islands. This is consistent with the pattern observed for the total enrolment nationally (Table 6). Table 8: Enrolment of Girls v Boys in Tongtapu and Outer Islands 2000-2013 Year Tongatapu – Tongatapu – Outer island – Outer islands – Girls Boys Girls Boys 2000 46.8% 53.2% 46.3% 53.7% 2005 48.0% 52% 45.7% 54.3% 2010 47.4% 52.6% 46.6% 53.4% 2013 47.8% 52.2% 37.1% 62.9% Source: Ministry of Education and Training Annual Report Both Table 6 to Table 8 show consistency in the data and confirm that the disparity between girls and boys in enrolment is not significant. The disparity is small and the reasons have already been explained above. Secondary Schools28 One of the main challenges at the secondary school level is reducing the dropout rate, for both boys and girls. The Education Act 2013 has raised the compulsory education age to 18 which effectively means, everyone has to complete secondary school education. A large number of students, 78% of all secondary school enrolment, are under church-based and privately-run school systems. They lack an effective tracking system to trace those who have left school, find out where they are and deal with them. Presently, there is no central database or complete statistics available for policy-making. The MOTEYS introduced technical and vocation training into secondary schools, in 2010 as a trial strategy to deal with students at risk of dropping out. The TAP – consisting of representatives from the education providers, Government and non-Government, with assistance from the Australian Government – coordinated the task of providing the secondary schools with training equipment and funding the writing of course materials (based on vocational and technical courses unit standards) and training of the course instructors. This had created alternative pathways of learning for students. After one year, reports from secondary schools indicated that this trial had a positive effect in reducing the drop-out rate, for both boys and girls. This work still continues as a partnership between the secondary schools under the church-based and privately-run school systems, the post-secondary technical institutes and the Tonga Association for Technical and Vocational Education and Training (TATVET). The courses that are run at the secondary school level would qualify students to either enter the workforce or to proceed to undertake courses at the higher vocational and technical institutes. Courses introduced into secondary schools include catering, hospitality, business, carpentry, automotive engineering and so on. These are alternatives choices for those at form 3 and form 4, where the drop-out rate is higher. 28 The discussion in this section is based on consultation with key informants in the education sector 66 However, there are problems with access at the secondary school level that may affect the disparity in enrolment. There are around 40 secondary schools across Tonga, of which 31 are non- government schools and up to 30 are located in urban centres or peri-urban centres. This means that secondary schools will not be readily accessible for all students, especially those in the rural areas. Therefore, girls may be more susceptible to dropping out of school. The inaccessibility contributes to two problems. One problem is students abstain more often or drop out of school altogether because of the inability to meet transportation costs and school obligations. Therefore, students from rural areas will continue to be underrepresented at the secondary level, especially girls. The other is the fact that inaccessibility of secondary schooling promotes internal migration to urban centres and thereby aggravating other problems such as overcrowding, unemployment and crime and so on. Overall, 72% of all girls were enrolling in schools in Tongatapu and 28% in schools in the outer islands. This is still proportionate to the geographical distribution of the general population. Table 9 shows proportionate distribution between boys and girls in total enrolment in secondary schools. Table 9: Proportion of Girls in Overall Enrolment in Secondary Schools – 2000-2013 Year Girls Boys 2000 48.9% 51.1% 2005 49.5% 50.5% 2010 49.7% 50.3% 2013 48.4% 51.6% Source: Ministry of Education and Training Annual Reports Table 10 shows that more girls are enrolling in non-government schools, which also host girls- only schools. At the community level, it is a major consideration for parents to enroll their children in their own church-based schools. Table 10: Proportion of Girls Enrolled in Government v Non-Government Schools – 2000-2013 Girls – Government Boys Girls – Non Boys Government 2000 44.2% 55.8% 50.4% 49.6% 2005 43.9% 56.1% 52.5% 47.5% 2010 42.8% 57.2% 53.6% 46.4% 2013 44.6% 55.4% 50.2% 49.8% Source: Ministry of Education and Training Annual Reports Overall, the ratio between girls and boys enrolling at secondary school level, may be affected by the number of students repeating, especially from form 5 upwards and the number of students leaving school. The data is not disaggregated, but a total of 3,103 who registered to sit for form 5, form 6 and form 7 examinations in 2005, for example, 15.9% were repeaters in these levels and 9.6% only were leaving. The figures differ from year to year but tentative information from the non-government schools indicate that more boys than girls are repeating. The variations may also be accounted for by outward and inward migration (MET, 2005). 67 Tertiary Institutions29 One of the major challenges in the education sector is maintaining a balance between the academic training and technical and vocational training. Since the 1960s, the focus of the national curriculum put emphasis on academic training for students. Many scholarships (study awards) were offered to young students to study in universities in New Zealand, Australia and the Pacific region in various academic and professional fields. This was part of the national plan to train Tongan nationals to replace the expatriates who were working in Tonga in professional areas since the 1940s. This strategy has benefitted Tonga’s social and economic development significantly. However, this also means that choices were limited for students who were not academically predisposed. In 1985, the Tonga Maritime Polytechnic Institute (TMPI) and later the Tonga Institute of Science and Technology (TIST) were set up by Government to provide technical training which were attractive to boys only, including maritime training, automotive engineering, carpentry and joinery, electrical engineering, welding and so on. It was not until the early 1990s, that vocational training courses, were introduced under the Community Development Training Centre (CDTC) in tourism, hospitality, agriculture and accounting and later IT, which provided girls leaving secondary schooling and women in the workforce with an opportunity to gain qualifications. In 2007, the National Centre for Vocational Studies (now under the CDTC) further introduced diploma level courses in IT, international business, hospitality and tourism development. The TIOE enrolls teachers for certificate level training and now for diplomas hence the higher percentage of females. These are providing women with more choices in qualifications they prefer. Table 11shows enrolment in these tertiary institutes, by male versus female. Overall, 42% of the total enrolment were women in 2000 and 2005, but increased to around 58% by 2013. Table 11: Enrolment in Government Technical Institutes, 2000-2013 CDTC TIST/TMPI TIOE Total 2000 Male 62 232 129 432 Female 98 0 215 313 Total 160 232 344 736 %Female 61.3 0 62.5 42.5 2005 Male 181 422 91 694 Female 321 0 188 509 Total 502 422 279 1203 %Female 64 0 67% 42.3 2013 Male 205 253 96 554 Female 552 12 218 782 Total 757 265 314 1336 %Female 58.5 Source: Ministry of Education Annual Reports (excluding in-house police and nursing training) 29 The discussion in this section is based on consultation with key informants in the education sector. 68 This effort by the MET to introduce more qualifications was complimented by courses offered by the Catholic Church-based vocational training institutes offering certificates in cookery, hospitality, sewing, art and craft and secretarial, which were attractive to girls. Later in the early 2000s, other church-based education systems, especially the Free Wesleyan Church and the private organisations established training institutes to provide further training in IT, business, tourism and other vocational training courses. Beginning from mid-2005, diploma level qualifications were further introduced to meet Tonga’s needs under non-Government vocational and technical institutes, which resulted in the increase in the number of students enrolled, as in Table 12. This is the outcome of twining arrangements between the vocational and technical institutes and similar technical institutes in New Zealand and Australia. Table 12: Enrolment in Non-Government Tertiary Institutes 2005-2013 2005 Institutes Male Female Total %Female Hango Agriculture College 26 5 31 16 Tupou Tertiary Institute 86 128 214 60 Ahopanilolo Technical College 33 57 90 63 St Joseph’s Business College 0 106 106 100 Montforte Technical School 53 0 53 0 Total 198 296 494 60 2013 Institute Male Female Total %Female Hango Agriculture College 43 9 52 17 Tupou Tertiary Institute 172 197 309 64 Ahopanilolo Technical College 48 87 135 64 St Joseph’s Business College 0 95 95 100 Montforte Technical School 98 8 106 8 Unuaki o Tonga 142 113 255 44 Atenisi 13 10 23 43 Total 516 519 1035 50.1 Source: Ministry of Education Annual Reports Resource Disparity While the disparity between girls and boys in enrolment has been reduced to a minimum, there is disparity in resourcing between Government schools and non-Government school. Non- Government schools are responsible for around 80% of secondary schooling and around 50% of post-secondary. The reports indicate that Government schools are fairly well resourced with equipment and training materials for the day to day administration of the schools. For instance, during 2000s an estimated 38,000 library books in addition to prescribed textbooks were available for 3,590 students in 8 Government schools. This is compared to 11,365 students who were enrolled in the 31 non-Government schools having access to fairly the same amount of resource materials. The 69 facilities in Government schools were reported to be in good condition (MET: 2000, 2005). On the other hand, reports from non-Government schools indicated that they did not have access to the equipment and training materials required and available to Government schools. In order to address the disparity, school grants from Government is administered by the MET for distribution to non-Government schools. The grant is made on a per head basis in enrolment, with attached conditions that part of the grant will be utilised to bridge the gaps in resource requirements and part will be used to cover teaching staff and overhead costs. However, according to information from non-Government schools, the grant of TOP$1,200 for vocational and technical institutes, for example, may not cover all the resource requirements. It was calculated in 2010, that the total cost of training a student in a trade or vocation at a technical institute, would vary between TOP$1,800 and TOP$2,400 depending on the qualification. However, the MET has indicated that this grant will increase in the near future. Women in Wage Employment It was reported in 2010, that the formal employment situation had improved since 1976 in terms of the number of people in the working age population in formal employment. However, little progress has been made on the type of occupation in which women are engaged in, as many were still in the low-paid menial work, subordinate positions in clerical, administrative or secretarial work. Although almost half of the Public Service are female, not as many as it could be are at the decision making level. The disparity between men and women is clear in the private sector. In 2010, it was reported that there were 423 male compared to 129 female employers. There were also 8,361 male workers compared to 4,900 female workers only in the private sector. However, more women than men work in the craft industry, with 9,181 female workers compared to 2,463 males.30 The informal sector is important for women for income generation. They are engaged in small scale production in agriculture and fishing for consumption and sell the surplus in the markets. While they are in handicraft production for cultural obligations, they can also sell them in the open markets for a high price. The MAFFF has been working in the area of food and nutrition, handicraft promotion, vegetable cash cropping, chicken rearing and gardening to encourage income generating opportunities. The Women and Development Division, of MIA also works with women’s association to develop the handicraft industry and source markets for them. (Full discussion of the involvement of both men and women in the informal sector has been made under Goal 1). The share of women in non-agricultural wage employment in Tonga is also influenced by the availability of career choices. Tonga had been gradual in its efforts to allow access and choice for women in vocational training. The technical training institutes are still concentrated in the urban centres in Tongatapu. Limited efforts have been made to extend more technical and vocational training into secondary schools, which are more spread out and have presence in the outer islands. Timely and ready access to vocational and technical training by both men and women allows them to make a decision early on their career and profession. Prior to 2000, some of the training courses offered by the technical institutes were seen by women as ‘culturally appropriate’ for men 30 Review of the National Policy on Gender and Development 2014 70 only – especially in the trades. Now that choices are available, there should be a change in the trend in the next decade or so where the share of women in wage employment improves substantially. Women in Parliament The number of seats in parliament held by women since 1990 is very low. However, there is nothing in the Constitution of Tonga and its laws that prohibit women from running for parliament. The cultural perception in the division of labour in the Tonga society may still have strong influence on the public perception of the role of women in decision making, especially at the political level. Government agencies and CSOs which have mandates for women’s affairs and civic education, have conducted training and public awareness programs in several areas including gender equality, women in politics, the election process, women’s rights and so on. The Political Reform of 2010 resulted in increasing the number of people’s representatives in parliament from 9 to 17. There was lobby from women’s groups for a quota for women representatives in parliament. However, the reforms did not result in legislative provisions implicating gender and the political status of women in Tonga. After the political reform of 2010, more women began to stand as candidates for election. In the 2010 election, 10 women stood as candidates, but none was successful. However, one female was appointed as Minister and therefore eligible to sit in parliament. Under the Constitution of Tonga, the elected Government may appoint up to four members of its Cabinet from outside parliament. In the 2014 election 16 women stood as candidates but again, no one was successful. No one from outside parliament was appointed as Minister, although advocates for women’s rights were lobbying for such appointment of women Ministers.

2.2. Policy Consideration There are a number of key policy frameworks that support the need to mainstream gender effectively and reduce disparity between men and women in education, employment and decision making. National Gender Policy31 The National Policy on Gender and Development was approved by the Government in 2001and the National Centre for Women and Children was set up in conjunction with the Catholics Women’s League to assist Government in the implementation of activities. It emphasised the role of the family, the equality of opportunity for both men and women and the elimination of discrimination in the workplace. It covered the following areas: Child Rights International Network Gender and the Family Gender and Religion 31 This section is based on consultation with the relevant staff of MIA. 71 Gender and, Culture and Society Gender and Health Gender and Education Gender and Politics Gender and the Economy Gender and, Regional, Outer Island and Rural Development Gender and the Public Sector Gender and the Private Sector The National Policy covers issues on disparity between women and men in education and employment. However, there has not been any formal evaluation of its impact and whether it was mainstreamed effectively until it was reviewed in 2014. The review identified the fact that women are not entitled to own land and this had been a major barrier in accessing finance. Land is required by the banks as collateral for loans, and therefore women are at a disadvantage as they may not have access to the finance capital in order to enter the small business sector or engage in an income generating activity. This had been one of the core issues when the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW) was first put to public discussion in 2009. However, the work of the TCCI and the Women-in-Business Association has been significant in encouraging women to enter the small business sector. The mainstreaming of gender equality into all spheres of the economy and society has remained weak. It has not been properly interwoven with national policies and objectives and have been downgraded in the implementation process. This is largely due to the absence of the appropriate legislative framework and monitoring and evaluation. However, the Gender Mainstream Office is now set up under the MIA which is responsible for stronger mainstreaming of gender. After the review in 2014, the mission of the National Policy was stated as: “That all men, women, children and the family as a whole achieve equal access to economic, social, political and religious opportunities and benefits”. It covers 10 major gender equity issues and the relevant six for the MDGs are stated below: Family and social issues Unequal access to employment and productive assets Unequal political representation and Participation in Decision-Making Different vulnerability, roles and capacity to respond to disasters and Environmental and climate change not properly acknowledged, by national strategies. Vulnerable women and The weak enabling environment for gender mainstreaming Tonga has also been committed to the following conventions related to gender: - Beijing Platform for Action on Women 1995 72 - Commonwealth Plan of Action for Gender Equality 2005-2015 - Revised Pacific Platform of Action for Gender Equality 2005-2015 It is yet to be seen how effective would be the mainstreaming of the provisions of the National Policy on Gender and Development, this time. With specific regards to representation in parliament, one of the challenges is the gendered stereotypes about occupation suitable for women and traditional expectation for them and their place in society. The traditional view is that leadership is a role for men, and this may have influenced very much the outcomes of the elections in Tonga. More importantly, it is the perception of women and their role in society, the economy and politics that needs to be managed. The representation of women in parliament in Tonga is the lowest in the Pacific.32 CEDAW In 2009, the Tongan parliament did not vote in favour of CEDAW, as discussed in the first MDGs Report, for reasons that a ratification of CEDAW would result in women having the right to succession to the Throne, inherit nobility titles and estates, and qualify to register tax and town allotments. The customs which assign specific roles to women, which are at odds with CEDAW, such as the ‘fahu’, would erode. The Government that followed in 2011, considered the ratification but did not cause any further dialogue on the CEDAW. However, the current Government that took office at the beginning of 2015, brought it forth for public discussion. The dialogue and opposition to the ratification has focused on two sensitive issues - same sex marriage and abortion. At the time of writing the report, dialogue was still on-going with Government considering a referendum on the ratification in the near future. 3. Enabling Factors

3.1. Technical Considerations Catering for Different Needs The recent revision by the MET has now widened the scope of the national curriculum to cater for the different abilities of young children at the primary school level. New areas are now being introduced into the syllabus such as movement and fitness, creative technology and foreign languages which will give young children avenues to explore their talents and travel along a learning pathway that will secure them future opportunities. At this stage, the introduction of vocational and technical training into the secondary school level, as previously discussed, has been gradual and needs further assistance. It has shown positive impact on the attendance and has also provided young people with basic skills they can take to the workplace when they leave school. Reports from secondary schools indicate positive impact 32 Information provided by key informants. 73 on attendance, morale and motivation to remain in the school environment. The provision of such training opportunities ensures that both girls and boys have the same opportunities for training and future employment. The introduction of more vocational qualifications by the technical institutes since the early 2000 provided opportunities for female students to enroll in the qualification of their choice. The qualifications have been adopted either from some of the New Zealand polytechnic institutes or from the Australian TAFE system. These qualifications are competency-based and accredited. The work of the Tonga National Qualifications and Accreditation Board (TNQAB), in monitoring the quality in the delivery and accreditation is significant in ensuring that the qualifications are accepted by the relevant industries when students leave school. There is a long-standing cooperative relationship between the MET and non-government education authorities. This relationship is largely based on the provisions of the Education Act, but at the same time, it is also based on the commitment of both sides to carry out their respective responsibilities to the education sector. The non-government education authorities are required to deliver the national curriculum as prescribed and report on school performance. They also participate at the policy level through committees and taskforces appointed to look at specific aspects of the education sector or review policy, guidelines and plans. Both jointly administer national examinations and review the curriculum and work together on extra-curricular activities. This relationship is beneficial in building cooperative efforts to improve the enrolment and performance at school of both boys and girls (MET, 2000; 2005; 2010). Women in Employment and Politics If all the initiatives described above continue and mature into the future, they will be beneficial for both men but especially women. Women will be better skilled which will allow them to realise their full potentials in the employment markets. National employment and the participation of women in the non-agriculture sector must be addressed both at the policy level and at the planning and implementation level. Apart from the National Policy on Gender and Development, previously described, there is no national legislation as yet, on employment, workplace discrimination and gender equality. The time is ripe for such important issues to be discussed and formalised into policy. By law, women have the rights to vote and can run for office. They can also lease land and own property and enjoy the freedom of speech. The lobby for a quota for women representatives in parliament has not been successful but it is a good start.

3.2. Policy Considerations Effective Education Policy In 2000, a long term goal was declared by the MET that ‘every child’ will develop a love of learning and pursuit of knowledge and ready for secondary education with high proficiency in literacy and numeracy, and mastering the basic skills in subjects set by the MET. 74 The MET have come a long way in ensuring that there is access, quality and equity in the provision of education in Tonga. The new Education Act should allow effective reforms to the management of the education sector. The development partners, as a commitment to international development, have provided technical assistance and financing through projects to ensure that the objectives of the Education Act and those set for the education sector are realised. The TLEPF now in place will be the focal point for action to ensure that people are transitioned effectively and efficiently, both men and women, from the education system to the employment markets. Rights of the Child33 Tonga had acceded to the Convention on the Rights of the Child in 1995 and became the basis of work during 2000s to protect women and children who were victims of abuse and violence. The new Government that took over in 2011, also looked at the issues affecting vulnerable children including violence, sexual abuse, child labour and malnutrition. There are no officially reported figures on child labour but there are incidences of violence against children and sexual abuse. While several cases have been reported to the police, still many others remain unseen and unheard of because of public rebuke and stigmatisation. Children who are vulnerable to these problems have a high tendency to drop out of school. The UNICEF joined the Tonga parliament that year in a one day forum to look at the issues. It was reported that children drop out of school to work to supplement the incomes of the family. Dis-parented children are also vulnerable to dropping out of school. Extending the compulsory education age from 4 to 18 could assist in reducing the dropout rate. Revised National Policy on Gender and Development and CEDAW As for women, the revised National Policy on Gender and Development in 2014 is now accompanied by an Action Plan which addresses the issues regarding equal employment opportunities for women and leadership and political participation. The Action Plan outlines key actions to be undertaken as follows, for employment and political participation: Employment: - Identify the gaps and adopt the appropriate measures to increase the participation of women and equal access to all sectors, categories and levels of employment - Promote the adoption of policy and measures for equal opportunity, equal pay and equal access to promotion - Facilitate the access by women to financing and capital for small and micro enterprises - Support the facilitation of access by women to land and ownership of productive assets - Identify opportunities for income generation for women in rural areas and outer islands and business development in the productive sectors and traditional industries - Provide support in training in business management and skills required to enter the small business and formal micro-enterprise sector 33 Based on consultation with the Crisis Centre for Women and Children. 75 Political Participation: - Identify and manage impediments to the participation and success of women in election - Support the promotion and awareness of the leadership role of women and benefits of fair representation of women in decision making and in politics - Promote women participation in decision making institutions These are significant initiatives and if properly resourced and implemented, they will address the gaps that exist in the effort to secure for women greater employment opportunities and opportunities for political participation in the future. The CEDAW also provides a platform for action on political participation and equal employment opportunities for women. Part II article 7 provides for the right to vote in election and running for office. Part III article 11, also provides for the rights of women for employment opportunities and freedom of choice of profession and rights to receive vocational training. Tonga has already met these requirements but the greater task is promoting public awareness and civic education. 4. The MDG Milestones and Consequences Tonga has been able to maintain a high ratio in the enrolment of girls at all levels of education – primary, secondary and tertiary. Tonga has also been relatively been successful in removing all barriers to girls’ rights to education. The legislative and policy frameworks that guarantee their full participation in education and ensuring access to quality education are in place. The wider provision of education and training has enabled women to have choice on the training they prefer and the career they want to pursue in the future in the open employment markets. Tonga has reviewed the National Policy on Gender and Development in 2014 and refocusing it, inter alia, on equal opportunity for employment, and access to economic assets and capital and the participation of women in decision making and in politics. It is also significant to see that CEDAW is being considered as it also has focus on the same important factors. In this regard, there is a need to manage the public and cultural perception on the role of women and their contribution to decision making and the economy. Therefore, Tonga has done well in minimising the gender disparity at all levels in education. However, more needs to be done, through policy development to ensure that women have a fair share of the employment opportunities available in the economy. Mainstreaming gender into all levels of the economy, society and politics and promoting public awareness and civic education, should be accelerated. Work done by the UNDP in collaboration with other development partners in this area needs to be strengthened in the future. 76 Goal 4: Reduce Child Mortality Photos: Matangitonga 77 Target Table 6: Target 4A: Reduce by two thirds, between 1990 and 2015, the under- five mortality rate Indicators 1990 1995 2000 2005 2010 2015 Target Status

4.1 Under-five mortality 27 19 20 3.7 19.7 10.7 8 On rate (per 1000) (2001) (2013) target 4.2A Infant mortality rate 9 17.4 13 10.1 16 9.5 3 On (from birth to 1, per (2013) target 1000) 4.2B Infant deaths 23 15 32 27 44 25 - (absolute number) (2013) No of live births 2548 2443 2457 2680 2744 2626 - (2013)

4.3 Proportion of 1 year- 94 95 97 99.5 99.2 99.6 100 On old children (1994) (1996) (2001) (2013) target immunised against measles (%) Source: Ministry of Health 2015 1. Progress and Achievements of Targets ‘The under-five mortality rate is the probability that a child is born and dies before reaching the age of 5. The rate is calculated on a per 1000 live birth basis. The infant mortality rate is the probability that a child is born and dies before first birthday. It is also calculated on a per 1000 live birth basis.’ The rates for both under-5 and infant mortality fluctuate over the last 25 years, as shown in the Target Table 6 above. In this regard, it should be noted that the population base (Tonga’s population) for calculating the mortality rates is small that the rates are expected to fluctuate widely. The Demographic and Health Survey (DHS) 201234 found that the childhood mortality rates declined for the 5-9 and 10-14 age groups, while the under-5 mortality and infant mortality rates tend to remain stable, but fluctuating within the range of not higher than 32.6 for under-5 mortality and 25.1 for infant mortality. Therefore, the challenge is the stability of the rates over time and to a point, the rate does not decline any more. It is advisable to look at the absolute number of deaths. Over the last 25 years, the infant mortality rate had varied between 9 and 17, and for the under-5 mortality rate it varied between 3 and 27. The absolute number of infant deaths are low compared to the total number of live births, where it varies between 0.6% and 1.6% only of all live births for infant deaths, for instance. 34 The Demographic Health Survey (DHS) was conducted in 2012 and reported in 2014. It contains valuable information on the specific health targets and indicators for the MDGs and will be utilised in the discussion in this section and the next two sections on the MDGs health indicators. 78 According to the MOH officials and medical specialists, Tonga has achieved very low mortality rates in both under-5 mortality and infant mortality. They are relatively very low that it is considered satisfactory. To reduce it further will require the very best technology and very strong public health outreach. The Tonga Health Sector Analysis (Levisay and Evans, 2014) report states that while infant and under-five mortality are relatively low, the rates have not been further reduced in the last 20 years. The MOH may have reached the limit of what it can do with the current resources and it is worth investigating further if there are remedial factors that could influence mortality. Furthermore, the mortality rates will still be affected by a number of behavioural factors (relating to the mother and child) which are usually beyond the control of the health service providers. Compared to other Pacific islands, Tonga is doing very well on both under-5 and infant mortality rates which are much lower than most Pacific island countries. The proportion of children immunised against measles have remained consistently high over the last 25 years. Final Performance Status: For under 5 mortality: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong For infant mortality: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong For immunisation against measles: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good On Target Strong 79 Overall: For child mortality: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong 2. The Challenges

2.1. Technical Considerations Child Mortality The DHS 2012 reported that there is no marked difference between rural and urban childhood mortality rates. The difference is found within Tongatapu where urban infant mortality and under- 5 mortality rates are lower than rural infant and under-5 mortality rates. The outer islands was much lower than Tongatapu for both infant mortality and under-5 mortality. The care given to the child is important. The parents are the primary caregivers and are responsible for the well-being of the child. According to medical specialists, the main cause of child mortality in the past had been diarrhea, but it can be easily treated and should not cause mortality. In recent years, invasive infection caused by pneumonia has become a major cause of child mortality. In addition, the number of congenial abnormality and neo-natal mortality is also becoming prevalent. While such cases can be monitored before birth, the possibility that the infant will die in the first month is high. If the infant survives the possibility that it will live with a disability is also high but it will be expensive to manage the care required.35 The mortality rates are also affected substantially by the fertility behavior of the mother. Infants and children have a greater probability of dying if the fertility behavior is of high risk. These include mothers who are too young (less than 18), mothers who are too old (34 or more), if the birth interval is short (less than 24 months) and birth order is high (4 births or higher). The DHS 2012 found that a total of 32% of births are in either one of these high risk categories. An additional 25% are multiple high risk, especially a combination of mothers too old and higher birth order, and a combination of short birth interval and higher birth order. About 23% of births are first order to mothers in the 18-34 age category (considered to be an unavoidable risk category). Therefore, only 20% of births are outside the high risk categories. Around 65% of married women have a high probability of giving birth exposing the child to high risk of mortality – 35% to single risk and 30% to multiple risk. 35 Based on dialogue with medical specialists at the main referral hospital, Vaiola. 80 Factors Influencing Child Mortality Broadly speaking, the infant mortality rate and the under-5 mortality rate are influenced by social and economic factors, which are beyond the control of the hospitals, such as the mother’s level of education, economic status and social situation. The educational level of the mother has influence on the chances of child survival. The DHS 2012 found that mothers with secondary education only are associated with higher infant mortality rate and under-5 mortality rate, compared to mothers with more than secondary education. If the mother is unaware of the health status of the child, the child suffers. Often some parents leave it too late before they seek medical attention. If the visit to the hospital is perceived as a difficult task, the mother may be encouraged to seek traditional medicine. The mother’s wealth status has an inverse relationship with childhood mortality rates, according to the DHS 2012. The poorest households have a higher infant mortality rate and under-five mortality rate. The wealthiest households have a much lower infant mortality rate and an under- 5 mortality rate. If the parents are unemployed, for instance, the nutritional status of the mother is weak, it will influence the decision whether to breastfeed the child. If the child is weaned off too early the child is fed with the wrong solids. If the child is fed on the wrong solids his or her development is already harmed. In the future, if the child has health problems, his or her performance at school will be affected. The problem is more serious when the family is either managed by a single mother, or the mother is physically abused36 or the father is absent. Cases of children dying from malnutrition, although few, have been identified and attributed to neglect, negligence and ignorance. Immunisation against measles There is a high proportion of 1-year olds that have been immunised against measles. Immunising children against the vaccine-preventable diseases including measles plays a crucial role in the reduction of infant and child mortality.37 Children are considered fully immunised if they have been vaccinated against TB, diphtheria, pertussis, tetanus, polio and measles by the age of 12months. The DHS 2012, found that the vaccination coverage tend to be higher among female babies than male babies. There is also a tendency for higher birth order to be less likely to be immunised. Those living in urban Tongatapu are more likely to be immunised than those in rural Tongatapu, Babies at the sixthth or higher birth order are less likely to be fully immunised than first order 36 It had been suggested that mothers who are physically abused, would be willing to talk and explain their situation if a separate unit within MOH is set up to deal with mothers as victims of violence. 37 The DHS 2012 quoted 66% as the proportion of 1-year old vaccinated against measles, lower than the MOH 99.6% for 2013. This is due to differences in the methodology used. The DHS collected data, from immunisation cards held by the mother and the mother’s recall or verbal report which can be incorrect. The MOH collects data from the records of all the hospitals, health centres, clinics, and records of home visits by district nurses. Hence, the MOH data is more accurate and complete. 81 births. Children in urban Tongatapu and the outer islands are more likely to be fully immunised than those in the rural areas. The reason being that high risk families may have migrated to rural Tongatapu. However, the MOH is ensuring that the coverage remains high to protect children from the disease.

2.2. Policy Considerations Financing The recurrent budget for the health sector has remained relatively stable at the same level for the last 15 years, at around 12-13%. Financing the health sector is crucial to the delivery of health services nation-wide. If the key to improving the child mortality rates is the availability of medical supplies, equipment, and medical personnel, then it is vital that the budgetary allocation for the health sector is kept at a reasonable level. The greatest challenge is how to provide the full range of health services with the limited financial resources available. Over the years changes in financial instructions and restrictive fiscal policies have curtailed the delivery of health services, for lack of financial resources. Deploying nursing staff, health workers and medical doctors to the rural areas and outer islands require sufficient funding to enable service delivery in these areas. There is one main referral hospital in Tongatapu, three community hospitals in the outer islands, 14 health centres and 34 reproductive and child health clinics. Such infrastructures must be sufficiently equipped and manned with the appropriate health care and medical expertise in order to deliver quality services. The assessment by United Nationals Population Fund (UNFPA) in 2014 indicates that there may be heavy workloads in reproductive and child health clinics with equipment that should eventually be replaced (see UNAIDS, 2014). Capacity Over the years, Tonga’s health sector has suffered from the outward migration or long-term study leave overseas of medical and nursing personnel. During 2000-2004, a consistent focus was given to training to replace staff lost to outward migration and long-term absence. The current staffing capacity is often stretched to the limit, to provide 24-hour seven-days health services, especially the medical and nursing staff in the hospitals, when capacity is low. A number of reports have recommended undertaking workforce planning and appropriate rostering as a method of relieving the pressure on staff working overtime (Mehan, 2013; Levisay and Evans, 2014). The recommended ratio is 2.3 health workers (doctors, nurses, midwives) per 1,000 population in order to provide 80% coverage of basic essential health services. Currently, the ratio of nurses per 1,000 is higher than this recommended ratio at 3.45 whereas it is low for doctors (0.60) and midwives (0.20) (Mehan, 2013). The ratio in 2000, was about the same and therefore, the situation has not changed over the years (see MOH, 2000). According to the health officials, Tonga needs to train more doctors in larger numbers than before in order to relive the critical situation. 82 The baseline hospital activities have grown over the years, compounded by increased chronic illnesses such as NCDs, leaving less resources for other services. The development partners begun to address the situation in early 2000s. The growth of salary and staffing costs have consumed a large proportion of the current budget hence severely limiting the budget for operation, goods and services (Mehan, 2013). While this should be addressed immediately, presently, the critical gaps are being filled in by the development partners through their capacity development and institutional strengthening programs (Levisay and Evans, 2014). Health officials have cautioned that Tonga’s health system has not been robust enough to allow care outside the purview of the hospitals and at home. While there are health centres in rural areas, people still prefer to visit the main hospitals instead. When this happens the resources at the hospitals are strained and staff have to work for long hours. There are now super-health centres in some of the rural districts but it is not yet within the capacity of the MOH to provide them with a resident medical officer, because of shortage of staff in the referral as well as in the community hospitals. 3. Enabling Factors

3.1. Technical Considerations Development Partners Assistance Tonga’s health sector is highly dependent on the development partners which fund projects, activities and personnel. The development partners provide 25% of the total budget for the health sector. Over the last 15 years, while funding through the budget remained static, the contribution by the development partners have actually increased over the years. The THSSP, funded by the Australian Government, has been one of the largest contributors to capacity building and institutional strengthening in the health sector. Substantial funding were also provided by the Governments of Japan, New Zealand and the People’s Republic of China as well as WHO, UNICEF, UNFPA and SPC (see Mehan, 2013; Levisay and Evans, 2014; THSSP, 2009-2015). This funding has enabled the delivery of a number of significant activities, especially in tertiary level clinical assistance as well as through other modalities. Under the THSSP, these included twining arrangements between the referral hospital Vaiola and the St John of God Hospital in Australia, the establishment of a critical staffing deficiency fund, primary prevention, training and attachment and so on (THSSP, 2009-2015). Child health has also benefitted from this assistance. Partnerships Over the last 15 years, the MOH has created partnership arrangements with the church sector through the CLF. The community are more united under their churches and this has been the enabling factor for some of the health campaigns by the MOH in the past. The partnership has been utilised, in order to have a wider coverage, for the delivery of immunisation programs and projects for the elimination of some of the communicable diseases. 83 Recently, the ‘Health Promoting Church Partnership’ has been focusing on various health promoting activities to address the risk factors in NCDs. The CLF with the support of the MIA and MOH have planned activities in HIV/AIDS, healthy lifestyles and other priority areas. A partnership to encourage mothers to seek medical assistance and care during pregnancy, after childbirth and before children are one year old, should be established. The partnership between MOH and the MET for visit by health professionals to the primary schools have been fruitful over the years. These visits on child health, dental care and immunisation have yielded good results in terms of coverage and findings. Recently, visits have focused on rheumatic heart conditions and childhood obesity. These partnerships have shown positive impact and should be reinforced and extended to the community in areas including child health, especially in villages where there are no health centres or reproductive and child health clinics. These partnerships would be well supported by media exposures and ‘social marketing’ through social media. The TFHA has been in existence since the 1970s and have been collaborating with MOH on service delivery. It is supported by the UNFPA and other development partners and provides advice on family planning, maternal and child health support, and fertility and counselling assistance. Part of its work is to produce educational materials and information and communication programs as well as programs to facilitate access and acceptance of contraceptive advice. Health workers are trained to visit villages and run training and counselling services on sexual and reproductive health including HIV/AIDS (IPPF Website, 2015). Telehealth38 Tonga has been connected by fast internet cable to the world. The development partners have begun looking at utilising this technology under an ‘e-health’ project framework. Its scope is to use mobile phones and similar devices to connect people via the fast broadband internet to their health service providers and clinics for consultation, instructions on medication and information on health services. One aspect of the idea is the connection with other countries for specialist support. The telehealth technology connects via the internet and satellite and facilitates virtual intensive care, visual link to operating theatres and emergency departments, remote diagnosis and remote consultations with doctors, nurses and midwives. The same technology can be adapted to cover remote areas in Tonga and connect health centres and clinics with the main hospital, on child health and in emergencies.

3.2. Policy Considerations Strategic Plan The MOH has established a long term vision that by 2020 Tonga is the healthiest nation compared with its Pacific neighbours. It has also put in place a mission which is ‘to support and improve the health of the nation by providing quality, effective and sustainable health services and being accountable for the health outcomes (MOH, 2008; 2012; 2015-2020). 38 Based on consultation with key development partner. 84 In 2000 the priorities were the control and elimination of communicable diseases such as tuberculosis, typhoid and leprosy and reduce morbidity and mortality. Furthermore, reduction in the incidence of NCDs and complications and premature death from NCDs through primary and secondary prevention interventions, were important. Maternal child health was also identified as a priority, especially providing quality reproductive health including child health services (MOH, 2000). In 2008, the focus of the MOH Corporate Plan 2008-2012 were on six areas – NCDs and communicable diseases became top priority, in addition to curative health, districts and community health centres, staff development, customer service and information technology. These areas will continue to be important as they are at the core of the responsibilities of MOH and are also retained in its current Corporate Plan 20012-2015. Therefore, there is a long-term focus on the highest priorities in the health sector including child health. Donor Funded Projects and Programs The THSSP has been the longest running donor funded project in MOH. It started in the late 1990s and focused on the introduction of management reforms. At the same time, other projects were also under way such as the Strengthening of Reproductive Health, Family Planning and the Sexual Health Program by UNFPA, the Diabetic Project with Prince of Wales Hospital in Australia, funded by AusAID, and a Health and Leadership Program organised by SPC. These were in addition to training and fellowships funded by other development partners (THSSP, 2009- 2015; MOH, 2010). By 2005 the THSSP with WB continued to support health reforms, improving the capacity of MOH to develop and implement health policy and improving the technical quality of health facilities, were undertaken. The Government of Japan was also funding the refurbishment of the main referral hospital, in addition to funding equipment. The WHO and UNFPA were supporting local activities including providing budget support. Other projects were underway by 2010. The THSSP covered strengthening the MOH and the work to combat NCDs. The THPF was also set up to implement activities addressing the risk factors in NCDs. The Japanese Government funded activities in dental care in schools under the ‘malimali project’ as well as major health infrastructural projects. The Australian Government and the People’s Republic of China supported smaller construction and renovation work, especially in the rural areas and outer islands. The WHO had been providing fellowships and scholarships, training activities, surveys and research and projects in water and sanitation. UNFPA helped in funding equipment (MOH, 2010). 4. The MDG Milestones and Consequences Tonga has been able to maintain a high level of immunisation against measles as well as a low level of under-5 and infant mortality rates over the last 15 years of the MDGs. The absolute number of deaths has been kept very low over time and this is a remarkable achievement. However, this is achieved with the current level of resources available to the MOH but at the 85 same time, the development partners and health-related international agencies provided resources to fill-in critical gaps. Furthermore, attention should be given to the robustness of the health care system and its capability to operate outside of the confines of community hospitals, health centres and clinics. The available equipment and infrastructures are a critical factor in the effectiveness of the child health services at the hospital and at the community level. However, work is still required to develop effective partnership for the further extension and effective coverage of the maternal and child health services, especially to the rural and remote areas. There are a number of critical factors that needs to be addressed because of their influence on child mortality. The social and fertility behaviours of the mother is important. As shown in the discussion above the level of education, wealth quintile and social circumstances of the family, all influence the health of the child. The task is to address these facts through designing appropriate strategies and creating new partnerships. There is available technology now to assist in outreach, training and advice. The traditional mode of delivery of maternal and child health services should be supplemented by using the available technology to extend the coverage and improve effectiveness. 86 Goal 5: Improve Maternal Health Photos: Courtesy of Jotham Habakkuk 87 Target Table 7: Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Indicators 1990 1995 2000 2005 2010 2015 Target Status

5.1 Maternal mortality 0.39 2.0 8.1 27.8 36.4 76.2 0.13 On ratio (per 100000 live (2013) target births) 5.1A Number of maternal 1 5 2 6 1 2 - - deaths

5.2 Proportion of births 91 93 92.1 96.1 - 98 100 On attended by skilled (2012) target health personnel Source: Ministry of Health 2015, DHS 2012 1. Progress and Achievement of Targets ‘Maternal mortality ratio is the ratio of the number of maternal deaths in a given period of time, per 100,000 live births during the same period of time.’ The maternal mortality ratio for Tonga has been fluctuating over the last 25 years, but the actual number of maternal deaths have been quite small. It is virtually very small that it is almost not a possibility to reduce it further. ‘The proportion of births attended by skilled health personnel, is the percentage of live births attended by doctors, nurses and midwives.’ The proportion has been kept at a consistently very high level over the last 25 years. Because of the small Tongan population size, the ratio for maternal mortality can show large statistical instabilities and wide fluctuations, and hence the ratio should be interpreted with caution. Therefore, the absolute numbers are more realistic and accurate guide. It is considered that both the targets for maternal mortality ratio and proportion of births attended by skilled personnel have been achieved. Final Performance Status: For maternal mortality: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong 88 For proportion of births attended by skilled health personnel: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong Overall: For reducing by two third maternal mortality ratio: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong Target Table 8: Target 5B: Achieve by 2015, universal access to reproductive health Indicators 1990 1995 2000 2005 2010 2015 Target Status

5.3 Contraceptive 39 39 30.7 19.7 31.5 35.6 100 Below prevalence rate (2013) target

5.4 Adolescent birth rate 0 23 25 13.8 29.1 35.8 Below (per 1000) (2013) target 5.5A Antenatal coverage (at No 22.4 98.5 31.2 28.5 23.3 100 Near least one visit) data (2002) (2010) (2013) target 5.5B Antenatal coverage (at No No No 68.8 69.4 75.2 100 Near least four visits) data data data (2013) target

5.6 Unmet need for family No No No No No 25% 0 Below planning data data data data data (2012) target Source: Ministry of Health 2015, DHS 2012 2. Progress and Achievement of Targets ‘The contraceptive prevalent rate is the percentage of women at the reproductive age who are currently using or whose sexual partner is currently using at least one contraceptive method.’ The rate for Tonga has been consistently low over time. ‘The adolescent birth rate is the annual number of live births to adolescent women (age 15-19) per 1000 population.’ The rate for Tonga is moderate (as a value of 10 or less, is considered low, and a value of 50 or more – in a range of 2 to 230 – is high). The maternal mortality of young adolescents contributes to the overall maternal mortality ratio. At this level the risk of dying in childbirth is higher and also puts in jeopardy the health and well-being of both mother and child. 89 ‘Ante-natal coverage is the percentage of women age 15-49 with a live birth in a given time period that received ante-natal care provided by a skilled health personnel.’ The percentage for ‘at least four visits’ as recommended by WHO, is relatively higher – at almost 69% or above since 2005 with the remainder having at least one visit. ‘Unmet need for family planning is the percentage of women of reproductive age, either married or in an union who have an unmet need for family planning, meaning women who want to stop or delay childbearing but are not using a contraceptive method.’ The DHS 2012 found that 25% of women had unmet needs for family planning. The percentage is high compare to a low level of contraceptive prevalence rate. Given the above explanations, the situation could have been better. The expectation is that the contraceptive prevalence rate and ante-natal coverage should be higher, and the adolescent birth rate and unmet need for family planning should lower. As such, the progress towards the target is rated ‘satisfactory’ only, and the achievement of the target is rated as ‘below target’, although there was ‘strong’ support from the Government and the development partners. Final Performance Status: For contraceptive prevalence rate: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong Adolescent birth rate: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong Ante-natal coverage: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good Near Target Strong 90 Unmet need for family planning: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong Overall: For access to reproductive health services: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong 3. The Challenges

3.1. Technical Consideration Maternal Health The well-being of mother and child can be influenced by the accessibility and availability of the appropriate services. Immunisation of pregnant mothers is important during the ante-natal care period. The National Immunisation Policy and Handbook for health care workers was first introduced in 2003. It was revised again in 2005 to include a Cold Chain Policy. This has been the basis of expanding immunisation coverage for the mother and child. The TT1 and TT2 coverage for ante-natal mothers have been very high over the years (MOH, 2010). However, the challenge in maintaining the high level coverage is the shortage of staff to provide the services especially in remote areas. This has been an outstanding issue for the MOH for a number of years because of limited resources to reach remote areas where transportation is a problem, especially the outer islands where both land and sea travel are required (UNFPA, 2014). Furthermore, the health of the mother and child, especially infants, are influenced by the availability of advice. For example, the effective and efficient provision of reproductive health advice and education will have an effect on the decision of the mother to participate in ante-natal care and address potential risks and complications. In addition, the length of time for breastfeeding is at the discretion of the mother, which is influenced by her level of education to comprehend its importance. The early weaning with inappropriate food solids would be more harmful than good to an infant (GOT and UNICEF, 2006). 91 Contraception The use of contraceptive methods to space births has been running counter to cultural and religious belief on the irrelevance of contraception. These are significant factors in the currently low contraceptive prevalence rate and high level of unmet need for family planning (see Target Table 8). The review by UNFPA (2014) found that for the community, reproductive health is not a priority and therefore the demand for services is expected to be low. This is coupled with the fact that in remote and rural areas, geographical remoteness and high transportation cost, can restrict access to contraceptive methods and reproductive health services. Because the services are mainly clinic-based, the marketing and outside delivery of certain reproductive health commodities needs to be developed and undertaken. The awareness of a contraceptive method is fairly high, with 93% of all women and 97% of all men knowing at least one contraceptive method. This awareness is important in planning or avoiding a pregnancy and gaining access to family planning services. However, the contraceptive prevalent rate is low - for all women it is 20% and 34% for married women (DHS, 2012). The current use of contraceptives increases only with the increasing number of children. Only 2% of childless women use a contraceptive method while it is 54% for married women with five or more children. Other factors also influence the likelihood of contraceptive use. Women in the rural areas (35%) and outer islands (38%) are more likely to use a contraceptive method than those in urban areas (32%). In addition, those in the lowest wealth quintile (36%) are more likely to use a contraceptive method than those in the higher wealth quintile (28%). The use of a contraceptive method is more prevalent as age increases for both men and women (DHS: 2012). Family Planning Needs The DHS 2012 finds that making an informed decision is important in family planning and making information available about contraceptive methods is part of the service delivery requirements. Hence, users of contraceptive methods need to be informed on the potential side effects of the contraceptive methods they use, what to do if there is a problem and alternatives available. Only then that users will be able to make informed choices on the method they want. The DHS 2012 indicated that 68% of current users of contraceptive methods were provided with full information in order to make informed choices. For married women who are currently not using a contraceptive method, only 14% stated that they intended to use family planning services in the future while 75% stated that they do not have the intention to use a contraceptive method in the future. However, about 74% of married women with two or more children were not intending to use contraceptive methods. The reasons vary from health concerns to religious probation and wanting more children and less to do with the availability of information, access or knowledge of contraception. This is where the challenge is to convince all women on the need for family planning. If a currently married woman does not want any more children or want to wait two or more years for her next child and is not using contraception, she is considered to have an unmet need for family planning. Currently, 25% of all married women have an unmet need for family planning, 92 where 13.2 are unmet need for spacing and 12% for unmet need for limiting the number of children, which is still high. The unmet need for family planning among women in urban areas (29%) is higher than in rural areas (25%). For demand that has been met, only 53% of women in urban Tongatapu, 57% in rural Tongatapu and 63% in the outer island have met their needs for family planning. The met demand is slightly higher for women with secondary education (35%) than women with post-secondary (31%), especially for limiting the number of children. Around 41% of women in the lowest wealth quintile have met demand compared to 32% in the highest wealth quintile. Overall, these figures are still low. Adolescence Health In the area of adolescence health, there is an increase in the number of teenage pregnancies and is also associated with limited ante-natal care. The current prevalence rate is 35.8, an increase from 25 in 2000. The social stigmatisation and condemnation of unmarried pregnant teenagers discourage them from utilising contraception and maternal and child health services. If they visit the maternal and child health clinics it will be late in their pregnancy undermining their own health and the health of the child. Otherwise, some do not seek or receive medical care until their delivery or when a complication occurs. It is possible that some are not on the records of the clinics or hospitals, did not receive ante-natal care or assisted in delivery by a trained attendant. Hence, they account for some of those whose delivery were not in the clinics or hospitals and were not assisted by trained professionals. It is a challenge for community and health education programs to address.39

3.2. Policy Consideration Tonga adopted a primary health care approach after the 1978 Alma-Ata Declaration and made commitment towards the goal of ‘health for all’ by the year 2000, a 20 year period. The primary health care approach is focused on equity, universal accessibility, socio-cultural acceptability, appropriateness and affordability. This commitment has made substantial impact on life expectancy and the reduction in mortality rates over the 20 years as well as improvement in health care, sanitation and immunisation. It has also been supported by an effective public health education program (GOT with UNICEF, 2006). The greatest challenge is how to continue to deliver the services and maintain quality. The resources available over the years has not increased substantially despite the rise in the demand for accessible and quality health care services and the rising cost of doing so. This means that shortages of essential drugs and medical doctors, especially specialists, will occur from time to time. The shortage of doctors is due to those going on study leave, resignation and engagement of some in management duties. In the rural areas the shortage of skilled staff becomes critical, especially where complications and emergencies require specialised intervention. Nursing staff, especially those who work at the health centres and clinics in the rural and remote areas, are usually in need of specialised training, skills upgrading and post-graduate training. 39 Based on consultation with key informants in the MOH 93 In addition, the cost of maintaining a large number of staff keeps rising that the share of salaries and wages in the annual budget takes a large percentage. Hence, the role of the development partners becomes crucial in funding improvement in critical health infrastructure, training, equipment and specialised staff. Over the last twenty years or so the involvement of the development partners in the health sector had become critical, especially in maintaining the quality of health services and supplementing the capacity shortages. 4. Enabling Factors

4.1. Technical Considerations Access to Ante-natal Care The benefit of having access to a health facility is the access to ante-natal care by expectant mothers, which is at a high level, as outlined in Table 13. The DHS 2012 indicates that the proportion of women who delivered in a public health facility is 97%. An additional 1% give birth in a private facility and another 1% had home birth. Around 99% of mothers age less than 20 delivered in a public health facility whereas 97.2% of those between the age of 20-34 and 93.2% of those between the age of 35-49, delivered in a public facility. A similar pattern is observed for birth order, where a higher percentage for lower birth order went to a public facility for ante natal care and slightly lower percentage for higher birth order. The proportion of mothers accessing health facilities were roughly the same regardless of residence, region, mother’s education and wealth quintile. For ante-natal care, those visiting 3 times or less were slightly lower, than those visiting four times or more. Table 13: Access to Maternal Health Background Public Sector Private Sector Other Characteristics Mother’s age at birth <20 99 1 0 20-34 97.2 1.1 0.9 35-49 93.5 2.9 2.4 ________________________________________________________________ Birth order 1 98.5 1.1 0.2 2-3 96.5 1.4 1.1 4-5 95.7 1.1 1.3 6+ 95.0 2.2 2.2 ________________________________________________________________ Residence Urban 95.8 1.9 1.4 Rural 96.8 1.2 1.0 ________________________________________________________________ 94 Table 13: Access to Maternal Heath (cont) Region Urban Tongatapu 95.8 1.9 1.4 Rural Tongatapu 96.6 1.4 0.9 Outer islands 97.4 0.9 1.2 ________________________________________________________________ Mother’s education Primary or less NP NP NP Secondary 96.8 1.1 1.1 More than secondary 96.7 2.2 0.5 ________________________________________________________________ Ante-natal care visits None NP NP NP 1-3 92.1 6.1 1.8 4+ 97.1 1.6 1.1 ________________________________________________________________ Wealth quintile Lowest 96.2 0.5 2.3 Second 98.2 0 0 Middle 98.0 0 0.2 Fourth 97.3 2.5 0 Highest 92.5 4.9 1.5 ________________________________________________________________ Total 96.6 1.4 1.1 ________________________________________________________________ Source: DHS 2012 Access to Ante-Natal Care and Attendance by Skilled Professionals The rate of attendance by skilled health professionals in livebirth is also high. The most important factor in delivery is that the birth is attended by a skilled attendant in the form of a midwife, auxiliary nurse or auxiliary midwife and not a traditional mid-wife. This can determine the chances of survival of the mother during and immediately after the delivery, according to the DHS 2012. It found that most women (98%) delivered with the attendance of skilled health professionals. At the same time, 39% of pregnant women (from higher wealth quintiles and higher levels of education) were attended to in their delivery by a medical doctor because of obstetric risks, especially those in their first pregnancy. About 58% of pregnant women more likely to be from lower wealth quintiles and lower educational background were attended by a trained midwife or trained nurse. The younger single mothers tend to access less ante-natal care, for reasons already explained. Access to ante-natal care is very high with 99% of all mothers having access to a health professional, regardless of wealth status, educational level, region and place of residence. There is also a marginal reduction in the attendance of those age less than 20. However, this shows the effectiveness of the nurses and midwifery outreach program. In an emergency, the main hospital in Tongatapu can be rapidly accessed by road and by air from the remote outer islands, and by boat from nearby islands. The outreach programs to pregnant mothers is vital and seeing a medical doctor is important to prevent pre-birth complications. Continuing to visit the reproductive and 95 child health clinics is also important for immunisation and monitoring the health of children in rural areas (DHS, 2012). Frequency of Visit for Ante-natal Care Table 14 below outlines the number of visits for ante-natal care in Tonga. The proportion is high. Table 14: Frequency of Visit for Ante-Natal Care No and timing of visit Urban Rural Total Number of ANC visit None 1.3 0.6 0.7 1 0.9 1.3 1.2 2-3 5.6 6.6 6.4 4+ 71.7 70.0 70.4 Missing 20.5 21.6 21.3 No of months pregnant at time of ANC visit None 1.3 0.6 0.7 <4 24.2 20.5 21.3 4-5 39.9 41.7 41.3 6-7 27.1 29.4 28.9 8+ 6.2 5.6 5.7 Missing 1.4 2.3 2.1 ___________________________________________________________________________________ Source: DHS 2012 Visiting a health professional is important in ante-natal care because of screening and advice on diet, and knowing what to do and expect during pregnancy. Approximately 70% of pregnant women visited a health professional at least four times for ante- natal care in their most recent pregnancy, according to the DHS 2012. Only 6% had two to three visits and 1% had only one visit. Therefore, a total of around 78% had at least one visit to a health professional for ante-natal care.

4.2. Policy Consideration Over the years, Tonga has maintained the lowest level of maternal mortality among the Pacific island countries, according to health officials. This is due to the consistent policy focus in its plans to improve maternal and child health and the provision of resources and infrastructures. There are 34 reproductive and child health clinics across Tonga and staffed by qualified nurses and health workers. Mothers have universal access to the clinics as well as the hospitals for the ante-natal, delivery and post-natal care, regardless of wealth status, level of education, place of residence and birth order. The design of manuals defining standards, standard operating procedures and package services at the health centre level is work that is currently being undertaken. It will be extended to cover 96 standards and package services for maternal and child health clinics and the hospitals. It is a long term effort for accreditation of services (Levisay and Evans, 2014). The Tonga National Reproductive Health Policy is the basis for integrating family planning services into other services such as ‘Safe Motherhood’, ‘Family Planning and Reproductive Health Commodity Security’, ‘Adolescent Sexual and Reproductive Health’, ‘Sexually Transmitted Infections and HIV’ and ‘Men As Partners in Reproductive Health’. It also supports the delivery of reproductive health services through the private sector. This involves private sector partners willing to provide services in specific geographical areas and for specific groups who are marginalised or isolated. Their activities would be coordinated by the TFHA under a National Coordinating Committee. In the near future social marketing through the social media will be trialed as a way of extending the outreach and marketing of commodities (UNAIDS, 2014). Adolescence sexual and reproductive health is important, and it is also part of the Tonga National Reproductive Health Policy. The TFHA is responsible for its implementation and coordination, and supervised by MOH. The former has the clinics and staff for the delivery of the services to adolescence and youth under the ‘youth friendly service’ banner. It provides family planning and contraceptive use advice, STI screening, peer education and counselling. These are in addition to MOH run clinics, also designated as ‘youth friendly’, offering ante natal and post-natal care, child health services and family planning clinics. The engagement of the community is important, in order to articulate their needs and help to focus and prioritise activities and programs, and hence a sense of community ownership (UNAIDS, 2014). In order to address maternal health, effective family planning, trained birth attendants and a well- established emergency obstetric care are important. Family planning is the cheapest way to address maternal health at the strategic level. It is important to both mother and child, as the welfare of the latter depends on the welfare of the former. Therefore, investment in family planning should be a priority. In making family planning available, accessible, affordable and acceptable it should also be used to meet the ‘unmet needs’ for family planning services.40 At the policy level, population planning should be part of development planning. The growth rate for Tonga’s population of 0.2%, is low because of net migration, but it doesn’t reflect the high fertility and birth rate for Tonga, averaging of 2,700 births per year. Population growth should be addressed now as it will have serious consequences on Tonga’s ability to provide social services, employment, law and order and so on. It will also affect the ability of the health service providers to cope. 5. The MDGs Milestones and Consequences Tonga has done well in keeping maternal mortality low. The actual number of maternal deaths is very low over the period of the MDGs. There are challenges in keeping the outreach for ante- natal care at the quality required, especially in the outer islands, rural areas and remote islands. The proportion of births attended by skilled health professionals has also been maintained at a 40 Based on consultation with key informants, MOH 97 very high level, showing that accessibility of health centres and hospitals, and the availability of skilled health personnel. It should also be noted that Tonga has been able to make available nation-wide the reproductive and child health clinics. It has maintained a high level of awareness of reproductive health services and contraceptive methods, as well as service for adolescent health. However, Tonga is also facing the challenges of low use of contraceptives, high unmet needs for family planning and low level of comprehensive knowledge of HIV/AIDS. Adolescent pregnancy is becoming an issue for health professions and service providers. The challenges are significant because of the high fertility rate and its implication on population growth and the impact in the long run on maternal mortality and the quality of the provision of ante-natal care. It is an issue that should be noted now for action in the sense that population planning should be part of development planning. The NCDs is the epidemic and is already becoming the burden of disease. Maternal and child health could become the next burden, if the issues are not dealt with now. 98 Goal 6: Combat HIV/AIDS, and NCDs Photos: Tanja Jørgensen 99 Target Table 9: Target 6A: Have halted by 2015 and begun to reverse the spread of HV/AIDS Indicators 1990 1995 2000 2005 2010 2015 Target Status

6.1 HIV prevalence among population aged 15-24 years 0 - NO known PLHIV among this age while 0 On Tonga is amongst the lowest HIV prevalence target (0.002) in the Pacific

6.2 Condom use at last high-risk sex Male - 25.5% 23% 100% Off (2008) (2012) target Female - 18.9% 5.3% 100% Off (2008) (2012) target

6.3 Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS Male 17.6% 21% 100% Off (2008) (2012) target Female 18.8% 18% Off (2008) (2012) target Source: Ministry of Health 2015, SPC 2008, DHS 2012 Target Table 10: Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it Indicators 1990 1995 2000 2005 2010 2015

6.4 Proportion of population with (Definition of advance HIV infection - by CD4 count or status advanced HIV infection with of Opportunistic Infections (OI)) access to antiretroviral drugs Currently there are only 2 people living with HIV (PLHIV) in Tonga. Both are enrolled in the HIV Care Program provided by the Ministry of Health. Both PLHIV are on Antiretroviral Therapy (ART) and are closely monitored by the Treatment Core Team lead by the medical office in charge of the Communicable Disease Section, Public Health. With the support of the Global Fund to fight against AIDS, TB & Malaria Grant, ARV are readily available to both clients, (HIV prevalence for Tonga is 0.002%) Source: Ministry of Health 2015 100 1. Progress and Achievement of Targets ‘HIV prevalence among the population aged 15-24 years, is the number of individuals aged 15-24 living with HIV as a percentage of the total population aged 15-24.’ Tonga does not have a known PLHIV in this age group. ‘Condom use at last high risk sex is the percentage of young men and women aged 15-24 reporting the use of a condom the last time they had sexual intercourse with a non-marital, non- cohabiting sexual partner in the last 12 months.’ Condom use in this age group is very low, particularly for women. ‘The proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS is the proportion of population aged 15-24 correctly identifying the two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful, uninfected partner), knowing that a healthy-looking person can transmit HIV and rejecting the two most common local misconceptions about HIV transmission.’ This is very low as well for both men and women in this age group. ‘Proportion of population with advanced HIV infection with access to antiretroviral drugs is the proportion of eligible adults and children living with HIV currently receiving antiretroviral therapy is defined as the percentage of adults and children who are currently receiving antiretroviral therapy (ART) of all adults and children who are eligible for ART.’ Currently, there are two people living with HIV and are on ATR. However, the prevalence rate is 0.002. Final Performance Status: For HIV Prevalence: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good On Target Strong For Prevalence of Condom Use: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Poor Off Target Moderate 101 Comprehensive knowledge of HIV/AIDS: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Poor Off Target Moderate For advanced HIV infection having access to drugs: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong Overall: Spread of HIV halted: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good On target Strong Universal access to treatment: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good On target Strong 2. The Challenges

2.1. Technical Considerations While the HIV prevalence rate is very low for the age group 15-24, the rate of condom use is also low despite widespread distribution and awareness. At the same time, the comprehensive knowledge of HIV is very low. The DHS 2012 indicated that the rate of condom use for the 15-24 age group is 23% for males and 5.3% for females. This is a decline from 25.5% and 18.9% respectively in 2008. Overall, only 102 18% of women and 21% of men have comprehensive knowledge of HIV/AIDS, compared to 18.8% and 17.6% respectively in 2008 (SPC, 2008). Hence, there is a need to look at the cultural, gender and religious factors that undermine the understanding of the need to use condoms for protection and the comprehensive knowledge of HIV/AIDS. This is important to be resolved as it is always possible for HIV to still spread through infection, despite the existing low prevalence. PLHIV and Risky Behaviour The social stigmatisation and discrimination continues to be a barrier to the treatment and care of HIV/AIDS patients. This was clear from the DHS 2012, that people have low levels of tolerance and acceptance of those with HIV/AIDS. The same low level of acceptance and tolerance was found by the Second Generation Surveillance Youth Survey (SGSYS) of 2008. The ‘Tonga HIV and Human Rights Compliance Legislation Review’ of 2009, looked at creating and strengthening an enabling environment for preventing stigmatisation and discrimination on the basis of HIV status, sexual orientation and gender (although there is no legislation yet)(UNAIDS, 2014). There is economic and social costs of low level of acceptance and tolerance of PLHIV, to individuals and families in terms of loss of income because of denial of access to employment and services and social isolation. The negative attitudes towards PLHIV has been observed in various surveys and reports and likely to stem from irrational fear of HIV and AIDS. If people have limited knowledge of transmission and fear of contact, then acceptance of PLHIV will also be limited. Improving knowledge and reassurance will not only improve acceptance, it will also encourage people to come forth for testing. The impact would be an increase in the level of prevention and treatment but at the same time, it will also reduce the potential level of transmissibility (DHS 2012). It is not an easy task as the level of understanding and knowledge of HIV/AIDS is also linked to ignorance of HIV transmission and safe sex. In addition, the economic and social status of the people who may be most at risk, also influence this level of understanding. Economic hardship and breaking down in traditions and extended family networks push families into situations where overcrowded housing and abuse of substances and alcohol, have caused family members to engage in risky sexual behaviours. They are the people most at risk to spread HIV. At the community level, the risk is real because negative attitudes towards PLHIV will not encourage those at risk to come forth and seek health care, testing and counselling. This puts the whole community at risk, as those who may be infected would be unaware of their HIV status. The potential to infect others and spread HIV would be greater. If stigmatisation could be reduced and confidentiality assured, they will encourage health-seeking behavior. The risk to the community would then be reduced. Community and religious leaders could play an effective role in promoting the understanding and eliminating stigma and discrimination (DHS 2012). Some are often concerned that sex education in schools would promote ‘promiscuity’ rather than protection. Church teachings come into conflict with the urgent need for sex education. The appropriateness of sex education in schools is prompted by the fact that surveys have indicated 103 that young girls are becoming sexually active at a very young age, as they reach menarche at an early stage (MOH, 2008-2013). While the prevalence is very low for HIV, the evidence shows the increased prevalence in sexually transmitted infections (STIs), especially among the younger population, who are becoming more sexually active. The SGSYS 2008, found that for youth age 15-24, the mean age of first sex is 17.8 for females and 17.2 for males with 5.5% of females having first sex at the age of below 15. For those who are sexually active 9.6% of females and 18.4% of males reported having more than one partner, and less than 25% only, reported having used condoms.

2.2. Policy Considerations Currently, Tonga does not have a HIV legislation. However, HIV is considered under the Public Health Act as a notifiable disease. A legislation can become the instrument for creating an enabling environment for greater protection and preventing stigma and discrimination on the basis of HIV status. The rights of PLHIV would be effectively secured if the legislative framework is in place. Other Pacific island countries have moved to introduce a national HIV legislation with some legislation as rights-based. Such efforts should be preceded by consultation on an appropriate HIV policy which would be the basis for a HIV legislation (SPC website, 2015). The Tonga National Strategic Plan for HIV and STIs 2009-2013 which has replaced the 2001- 2005 Plan identified the need to recognise human rights in HIV/AIDS. The PLHIV have rights to privacy, protection from stigmatisation and free from discrimination on the basis of sexual orientation and gender. The Plan is in alignment with the Pacific Regional Strategy on HIV and STIs 2009-2013, with has focus on universal access to prevention, care, treatment and support (UNAIDS, 2014). While the Plan had been put in place, the capacity to implement the monitoring and evaluation system had been weak. The importance of monitoring and evaluation, is to enable a more sensitive surveillance, which will improve the early detection and intervention UNAIDS, 2014). There is a need to put in place a monitoring and evaluation system that is robust and effective. The lack of one hinders the analysis and utilisation of data for policy making, as sound policy making relies on data and evidence. Furthermore, there is lack of capacity within the HIV sector to manage monitoring and evaluation. There is no coordinated approach for collecting data and reporting them. While data may be collected at the organisational level, there is no coordination of database management and reporting of activities and outcomes at the national level (UNAIDS, 2012). A robust and effective monitoring and evaluation system would help to track the progress in the implementation of activities and provide strategic information as the basis for evidence based decision making. The monitoring and evaluation system can assess the achievement of goals and strategies and higher level outcomes at the national level. It can also monitor outputs at the activity level and assess whether the outputs make a contribution to the national level outcomes (UNAIDS, 2014). 104 3. Enabling Factors

3.1. Technical Considerations Legislative and Policy Framework Testing for HIV is available in all the hospitals in Tonga and through TFHA clinics in Tongatapu and outer islands. Routine testing is conducted for ante natal women, blood donors, new employees, immigration requirements and highly mobile men in uniform. The TFHA provides clinics in the outer islands which undertakes the tests and treatment of STIs and dealing with reproductive issues. This is part of the Tonga National Reproductive Health Program for the prevention and treatment of HIV under the Tonga National Reproductive Health Policy. They promote the integration of family planning services with other areas of service including adolescence sexual and reproductive health, HIV and STIs through partnership between MOH and TFHA. This is because of the interdependence of these services and at the same time, address holistically any weaknesses. Prevalence In 2011, the Political Declaration of HIV was adopted by member states including Tonga. Tonga reports on the status of progress towards the set targets (UNAIDS, 2014). Table 15 shows very low HIV prevalence: Table 15: The Incidence of HIV/AIDs 1987-2012 Year Male Female >15 15-19 20-24 25-49 50 1987 1 0 1 1 1989 2 0 1 1 2 1992 1 0 1 1 1996 2 1 3 3 1998 0 2 1 1 2 1999 1 1 2 2 2000 1 0 1 1 2002 1 0 1 1 2005 0 1 1 1 2207 1 0 1 1 2008 1 1 2 2 2009 1 0 1 1 2012 0 1 1 1 Total 12 7 0 2 2 15 19 Source: UNAIDS 2014 It has been reported that out of the 19 HIV cases, 11 have died, six have moved overseas and only two are remaining in Tonga (UNAIDS, 2014). 105 Over the years, the community outreach and awareness programs in HIV/AIDS prevention, through partnership with NGOs and stakeholders, had been strong. Promoting safe sex and safer sexual behavior had been a major part of this approach. The promotion and distribution of condoms throughout various locations over a three year period 2011-2013 gained widespread support. The number of sites and clinics available for counselling and testing and the number of trained counsellors and peer education activities increased during the period. The Treatment Core Team provides the support services and ensures the availability of the resources and services required including laboratory, pharmacy and medical staff. Condom Use Table 16 show low levels of prevalence in condom use, which is a major risk factor in spreading HIV infection. Table 16: Condom Use Last High Risk Sex Characteristics Use condom at last high risk sex last 12 months Women Men Age 15-19 NP 27.0 20-24 5.1 21.0 _____________________________________________________________ Marital status Never married NP 23.1 Ever married 4.9 22.8 _____________________________________________________________ Knows condom source Yes 9.1 25.8 No NP NP _____________________________________________________________ Residence Urban NP 22.5 Rural 4.8 23.2 _____________________________________________________________ Region Urban Tongatapu NP 22.5 Rural Tongatapu 6.3 24.3 Outer islands NP NP _____________________________________________________________ Education Primary or less NP NP Secondary 6.8 24.3 More than secondary NP NP _____________________________________________________________ Total 15-24 5.3 23 _____________________________________________________________ Source: DHS 2012 NP=No published Among men age 15-24, 61% had high-risk sexual intercourse, with neither a spouse nor a live-in partner, compared to only 19% for women of the same age group. The rate of condom use among young men was higher at 23% than young women at only 5.3%. The DHS 2012 also finds that 106 higher risk intercourse was higher among younger women age 15-19 at 35% than women in 20- 24 age group, at 16%. For younger men, those at the age group 15-19, 74% had higher risk sexual intercourse compared to 56% only for men aged 20-24 (DHS 2012). Similar findings were made by the SGSYS 2008. Comprehensive Knowledge of HIV/AIDs ‘A comprehensive knowledge of HIV/AIDS is – knowing that the use of condom consistently and being faithful to one partner only, reduce the chances of contracting the AIDS virus, that a healthy looking person can have the AIDS virus and rejecting the misconception that the AIDS virus spread through mosquito bites and sharing food with someone with the AIDS virus.’ Table 17 shows the level of comprehensive knowledge of HIV/AIDs for the age group 15-24. Table 17: Comprehensive Knowledge of HIV/AIDS Women Men Age 15-19 10.2 12.9 20-24 14.6 15.6 _____________________________________________________________ Marital status Never married 11.6 13.4 Married 13.7 17.1 _____________________________________________________________ Residence Urban 10.6 12.2 Rural 12.5 14.6 _____________________________________________________________ Region Urban Tongatapu 10.6 12.2 Rural Tongatapu 12.3 16.1 Outer islands 13 11.5 _____________________________________________________________ Education Primary or less NP NP Secondary 10.4 12.6 More than secondary 19.6 24.9 Wealth quintile Lowest 11.2 13.1 Second 9.8 14.9 Middle 12.4 14.2 Fourth 10.8 13.7 Highest 16 14.2 _____________________________________________________________ Total 12.1 14.0 _____________________________________________________________ Source: DHS 2012 Most people who are sexually active, age 15-49, have heard of HIV/AIDS. However, only 21% of men had a comprehensive knowledge of HIV compared to 18% of women age 15-49. Those at 107 age 15-24, 92.1% of women and 89.9% of men have learnt about the AIDS virus. However, Table 17 shows the level of comprehensive knowledge by people in the high risk age group 15-24, which is very low with only 12.1% of women and 14% of men (DHS 2012). These numbers are in line with the earlier findings of the SGSYS in 2008. There is no marked difference in terms of marital status, residence and region except for level of education and wealth quintile. However, those with comprehensive knowledge of HIV/AIDS were higher for those with more than secondary level of education and are in the highest wealth quintile than those with lower levels of qualification and are in the lowest wealth quintiles. The level of comprehensive knowledge about HIV is important in preventing HIV infection and the various strategies for preventing it. For Tonga, while the level of comprehensive knowledge is very low, the level of awareness of HIV/AIDS is high. According to the DHS 2012, 73% of women and 77% of men, in the sexually active age group 15-49, know about the protection from using condoms, and 71% of women and 74% of men are also aware of the protection from limiting intercourse using condom to one uninfected partner. Although the level of comprehensive knowledge and condom use are low, being faithful and abstaining are the major intervening factors. Around 89% of women and 86% of men are aware that being faithful and limiting intercourse to one uninfected partner is protective. Around 81% of women and 79% of men know that abstaining from having sex is also protective. However, there is still widespread misconception of how HIV is spread. About 75% of men and women (age 15-49) know that a healthy looking person can carry the AIDS virus but only 33% knew that mosquitoes cannot spread it and only about 50% knew that sharing food with an AIDS patient is not a risk.

3.2. Policy Considerations Strategic Leadership The work in the HIV/AIDS sector is led by the MOH and a Country Coordinating Mechanism chaired by the Minister of Health, with multi-sectoral and multi-disciplinary membership. It is responsible for the oversight of Tonga’s response to HIV. The work has been undertaken under the National Strategic Plan for HIV and STIs, which has been the focal point for action. The focus of the Strategic Plan, as already stated, is the prevention of HIV and STIs, treatment, care and support; creating an enabling environment; and monitoring and evaluation. There is now commitment by the MOH to decentralise health care services to allow universal access with emphasis on NCDs and CDs through its network of hospitals, community health centres and clinics and through partnerships with the community for outreach and coverage of the programs and activities. The commitment by the MOH in meeting the challenges and continuing to provide the required services in the HIV/AIDS sector, despite the low levels of prevalence, is recognised. 108 A review of the first National Strategic Plan for HIV and STI 2001-2005 revealed the need to develop skills in HIV advocacy, education, support, treatment and care; improve the capacity of the health services to address HIV issues, especially testing, treatment and care; and promoting the understanding of social, cultural and economic implications of HIV. The second National Strategic Plan 2008-2013 approved the strategies for dealing with these issues. Partnership on HIV/AIDS and STIs41 Under these plans, the MOH took the lead, in collaboration with its partners in running youth prevention programs, peer education activities, condom campaigns and voluntary confidential counselling and testing. The MET had made efforts to introduce into the school system family life education. However, this should be supplemented with comprehensive sexual and reproductive health programs. This can open up discussions between students and teachers on the reproductive health needs of young people but programs should be accompanied by professional teacher development. The MOH now collaborates with its stakeholders in providing HIV/AIDS and STIs services and implementing the strategies and programs under its current National Strategic Plan to Respond to STIs and HIV/AIDS. The testing and treatment of HIV is an important part of the Strategic Plan. At the same time, the MOH is also improving the management of STIs, train more staff in voluntary confidential counselling and testing, and regularly supply the test kits. The coordination, through the TFHA of the activities of clinics and laboratories is important in maximising screening, care and management (MOH, 2008-2013). Given the low level of prevalence of condom use and younger generation becoming more sexually active, the need for protection from STIs is also significant. The assistance from the development partners towards Tonga’s response to HIV, AIDS and STIs, has been valuable. Tonga is part of the multi-country proposal to the Global Fund for Fighting AIDS, TB and Malaria. The assistance provided for Tonga contributes to improving access to testing and counseling, strengthening the strategic information system for better monitoring and evaluation, technical advice, provision of equipment and improvement of infrastructures. These efforts have resulted in the improvement in the quality and accessibility of the services. 4. The MDG Milestones and Consequences Tonga has done well in keeping a very low prevalence level of HIV for the 15-24 age group. Testing for HIV is available in hospitals and the clinics and in places where it is appropriate and necessary to have the tests. Condoms have been made available through the appropriate channels and reproductive health education programs delivered to the targeted audience including those likely to engage in risky sexual behaviors. There are policies and plans now in place which are the basis for continuing the work to prevent, treat, care and provide support to PLHIV. The MOH in conjunction with partners especially TFHA are working hand in hand to deliver the planned programs and activities with the support of the development partners and international agencies. 41 For general discussions see MOH (2008-2013), UNAIDS (2014). 109 However, there is a need for stronger monitoring and evaluation of progress and collection of data for decision making. It is quite clear that Tonga does not have the appropriate legislative framework to facilitate further the work in the HIV/AIDS sector. The rights of HIV/AIDS persons are not protected by law. The work of health officials are hampered by the cultural stigmatisation and low tolerance for PLHIV. Despite the high level of awareness, the comprehensive knowledge of HIV/AIDS and the level of condom use are low while the prevalence of risky sexual behavior is high. Tonga will need to go beyond the level of protection and put in place the legislative framework and monitoring and evaluation framework to further advance the programs and activities already implemented. It will also need to delve into the community level to eliminate the cultural barriers that inhibit the progress of work in the HIV/AIDS sector and address STIs. 110 Target Table 10: Target 6C: Have halted by 2015 and begun to reverse the incidence of TB and reduced the prevalence of NCDs Indicators 1990 1995 2000 2005 2010 2015 Target Status

6.5. Incidence, prevalence and death rates associated with TB Incidence 25 22 24 19 10 13 0 On (.3%) (.2%) (.2%) (.02%) (.01%) (.01%) target (2014) Prevalence 39 37 32 22 (.02%) 14 18 0 On (.4%) (.4%) (.03%) (.01%) (.02%) target (2014) Death rate 2 2 0 2 1 0.0% 0 On (.008%) (.009%) (0%) (.01%) (.009%) (2014) target

6.6 Proportion of TB cases detected and cured under directly observed treatment short-course No detected 25 22 24 19 11 13 0 On (2014) target %cured 22 17 22 14 10 13 0 On (88%) (77%) (92%) (74%) (91%) (2014) target Source: Ministry of Health 2015 1. Progress and Achievement of Target ‘The incidence of tuberculosis (TB) is defined as the number of new TB cases in one year per 100,000 population. The prevalence of tuberculosis is defined as the number of TB cases in a population at a given point in time (sometimes referred to as "point prevalence") per 100,000 population. Death rates associated with tuberculosis are defined as the estimated number of deaths due to TB in one year per 100,000 population.’ The incidence, prevalence and death rate for TB is very low for Tonga over the last 25 and have been declining over time. ‘The proportion of tuberculosis (TB) cases detected, also known as the TB detection rate, is the number of estimated new TB cases detected in a given year using the DOTS approach) expressed as a percentage of all new TB cases. The proportion of TB cases detected and cured, also known as the TB treatment success rate, is the number of new, TB cases in a given year that were cured or completed a full treatment of DOTS expressed as a percentage of all new TB cases.’ The number detected TB cases is low for Tonga and the percentage cured is high. The incidence and prevalence rates have been kept low as well. This is reflecting on the effectiveness of the programs and assistance from the development partners and leadership by MOH. 111 Final Performance Status: For Tuberculosis incidence, prevalence and death rates: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong For Tuberculosis cases detected and cured: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong For reverse incidence of TB: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On Target Strong Target Table 10: Target 6C: Reduced the prevalence of NCDs Indicators 1990 1995 2000 2005 2010 2015 Target Status

6.7 Incidence, Prevalence & Death associated with diabetes Incidence This is not applicable to Tonga. Prevalence No data No data No data 16.4 34.4 No data 0 Below target Death rate No data No data No data 50 – 80* 94 – 222+ No data 0 Below (males) (males) Target 40 - 70 98 - 190 (females) (females)

6.8 Incidence, Prevalence & Death associated with cardiovascular diseases Incidence This is not applicable to Tonga. Prevalence No data No data No data No data No data No data 0 Below target Death rate No data No data No data 194 - 383 423 - 644 No data 0 Below (males) (males) target 108 - 227 194 - 221 (females) (females) 112

6.9 Incidence, Prevalence & Death associated with hypertension Incidence This is not applicable to Tonga. Prevalence No data No data No data 23.1 27.6 No data 0 Below target Death rate No data No data No data No data No data No data 0 Below Target

6.10 Incidence, Prevalence & No data No data No data No data No data No data 0 Death associated with obesity Incidence This is not applicable to Tonga. Prevalence No data No data No data 60.7 67.5 No data 0 Below target Death rate No data No data No data No data No data No data 0 Below target Source: Ministry of Health 2015, * = estimated 2001-2004, + = estimated 2005-2008 2. Progress and Achievement of Target ‘The diabetes, cardiovascular and hypertension are NCDs as defined by the WHO. The incidence of these diseases refer to the number of new cases of diabetes, cardiovascular and hypertension and in a given year per 100000 population. The prevalence rate is the number of cases in a population at a given point in time. The death rates associated with the diseases are the estimated number of deaths due to the diseases in one year per 100000 population.’ The incidence and prevalence of obesity is the number of new cases of obesity and prevalence is the number of cases of obesity in a given year, as per 100000 population for both. As shown by the numbers in the Target Table 10, NCDs continue to exist as a problem for the MOH and becoming a burden of disease. There are marginal reduction in the prevalence of some of the risk factors while there are significant reduction in others. At the same time, there is a need to reduce the proportion of people still facing high risks to a much lower level. There is also a reduction in the prevalence of hypertension, the major factor in cardio vascular diseases and the leading cause of death in Tonga, but only marginally. Overweight and obesity continue to be a major problem and causes the early onset of NCDs, especially diabetes - the major factor in kidney and eye disease. Final Performance Status: For incidence, prevalence and death rates associated with diabetes: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong 113 For incidence, prevalence and death rates associated with cardiovascular diseases: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong For incidence, prevalence and death rates associated with hypertension: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong For incidence, prevalence of obesity: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Below Target Strong Overall: For reducing the prevalence of NCDs: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder State Satisfactory Below Target Strong 3. The Challenges

3.1. Technical Consideration Tuberculosis The Communicable Disease Unit (CDU) in the MOH has been running the TB Program. In 2000, the MOH set an objective - to achieve 85% success rate for detected new sputum positive cases by adopting direct observed treatment short course (DOTS) as recommended by WHO. This focus continued in 2005 but the detection rate needed to improve. However, by this time the Global Fund to Fight AIDS, TB and Malaria was already in place, which has provided funding support for the TB Program. By 2010, there was no cases of relapse, treatment failure or default, showing 114 the effectiveness of DOTS (MOH, 2000, 2005, 2010, 2012). According to the figures, the target set by the MOH has largely been met since 2010. The challenge now is to ensure that the incidence, prevalence and death rates are kept at this very low level. The SPC has developed the Pacific standards for the management of TB and diabetes, especially screening for diabetes in persons with TB and vice versa and treating TB in persons with diabetes and treating diabetes in persons with TB. Because the association between TB and diabetes are strong, people with diabetes are three times more likely to develop TB than those without it. It means if both are highly prevalent, it becomes a dual burden of disease, and a significant public issue. Hence, the standards were developed to deal with them. According to the SPC there are around 26,000 reported TB cases each year over the last three years but this figure may not reflect the full extent of the disease. This means that there is an average of more than 1,100 cases per country per year, given the 22 countries in the Pacific. The TB Strategic Plan 2015-2019 has been developed by SPC to guide the work on TB by Pacific island countries, including Tonga. It provides support with the help of development partners to Pacific island countries through the TB treatment and support network. It is funded by the Global Fund to Fight AIDS, TB and Malaria and under the Pacific Multi-country Programs Round 7 TB Grant. The network provides high level clinical advice to national TB programs, on care, treatment, management and follow up. Tonga has been tapping into these programs and working with development partners on the elimination of TB. Tonga’s TB Program has been working well in keeping the incidence and prevalence very low, given the very high incidence reported for the region. However, Tonga needs to be vigilant in its outreach to the rural and remote areas. NCDs The NCDs has been increasing since the 1970s especially diabetes and cardio-vascular diseases as well as the number of people who are overweight and obese. The prevalence of diabetes has been increasing since the 1970s and according to the International Diabetic Centre, Tonga has a national prevalence rate of adult obesity (age 20 to 79) of 11.58. Between 2004 and 2012, the percentage of people with raised blood pressure has also been increasing. It has become the ‘most pressing health issue’ requiring the support of all stakeholders including the development partners. The NCDs has become the ‘burden of disease’ and the greatest challenge to Tonga’s health system. It has been estimated that around 75% of Tonga’s population are moderate to high risk of developing NCDs (Levisay and Evan, 2014). The MOH states that the prevalence of NCDs has increased from approximately 7% in 1973 to 15% in 1999 and 18% in 2004. Life expectancy has been reduced from 70 for males and 72 for females in 1969 to 65 and 69 respectively in 2010, as a result (MOH, 2010). The NCDs is now the major cause of morbidity, as in 2010 and is responsible for 10% of hospital admission (MAF Report, 2013). On the other hand, the cause of death by infectious diseases declined from 32% to 6% between 1950 and 1990, while death from diseases of the circulatory system grew from 5.6% to 38% during the same period. By 2010, it was the leading cause of mortality followed by neo-plasma 115 and diseases of the respiratory system (WHO/MOH, 2012). Now, the diseases of the cardio vascular system account for more than 50% of all deaths every year, especially those in their 40s and 50s (MOH, 2008-2013). Table 18 compares the indicators for NCDs for 2008 and 2004. Table 18: NCDs Indicators and Risk Factors 2008 and 2004 Indicator 2008% 2004% NCD as % of all deaths 74 75 Currently smoking total% 22 31 Physical inactivity % 41 43.9 Raised blood pressure % 40 27.6 Raised blood glucose % 17 16.4 Overweight % 87 92.1 Obese % 57 68.7 Raised Cholesterol % 47 49.7 Source: World Bank 2012; STEP Survey 2012 Diabetes Diabetes is life-long in nature and is associated with and/or contributes to the development of cardiovascular diseases, and kidney and eye diseases. Some research indicate that diabetes can contribute to Alzheimer’s disease and dementia. Women who are pregnant with diabetes have a higher risk of passing on in utero their off-springs obesity and diabetes as well as other metabolic disorders (World Bank, 2012). The number of diabetic cases registered by the MOH increased from around 2,000 cases in 2002 to 4,007 in 2010, and in 2011 there were about 6,130 cases. Around 46% of those visiting the Diabetic Centre at the main hospital had certain degrees of glucose intolerance. Amputation increased three times between 2005 and 2010 (World Bank, 2012). It has been reported by the STEPwise Approach to Surveillance (STEP) survey 2004, that the prevalence rate for diabetes was 15.1% with impaired glucose intolerance of 7.85%. The STEP survey conducted in 2012 finds that the prevalence of diabetes is especially high among the 45- 64 age group at 49.3%, and for both sexes it is 34.4%, as shown in the Table 19 below: Table 19: Percentage with Diabetes by Gender and Age Group Raise Blood Glucose or Currently on Medication or Diabetes Men Women Both Age N % 95%CI N % 95%CI n % 95%CI 25-44 475 24.5 +/-5.5 828 29.4 +/-4.1 1303 27.1 +/-3.3 45-64 382 40.7 +/-6.1 602 56.9 +/-5.6 984 49.3 +/-4.4 25-64 857 29.7 +/-4.1 1430 38.6 +/-3.3 2287 34.4 +/-2.9 Source: STEP Survey 2014 116 Hypertension The WHO recorded 39 deaths from hypertension in 2011, or 8.4% of all deaths. The STEP survey of 2012 is the latest to measure hypertension, showing a high prevalence rate, especially in the middle age group 45-64. The prevalence of hypertension in Tonga is 27.6%. Hypertension among men were slightly higher than women, with 28.2% for men and 27.1% for women. Women age 25-44 had a significantly less hyper-tension rate at 14.3% than the hyper-tension rate for women aged 45-64, which was 52.9%. Similarly, the hyper-tension rate for men aged 25-44, at 22.1%, was significantly less than the hyper-tension rate for men aged 45-64, at 41.3%. These patterns are shown in the Table 20 below: Table 20: Percentage with Hypertension - 2012 Men Women Both Age N % 95%CI N % 95%CI N % 95%CI 25-44 486 22.1 +/-4.3 847 14.3 +/-2.7 1333 18.0 +/-2.5 45-64 385 41.3 +/-5.9 614 52.9 +/-5.3 999 47.5 +/-4.2 25-64 871 28.2 +/-3.6 1461 27.1 +/-2.9 2332 27.6 +/-2.4 Source: STEP Survey 2012 The STEP survey also shows that 48.8% have raised blood cholesterol level, with no marked difference between men (49.3%) and women (48.2). Cardiovascular Diseases Cardiovascular diseases are the main causes of death for all ages which was 38% in 2008, the latest estimates. More Tongans are dying from it than from any other communicable diseases, including maternal and perinatal mortality, child mortality and dying from nutritional conditions, added together (World Bank 2012). Table 21 below shows the magnitude. Table 21: Total Death All Ages from Cardiovascular Diseases 2008 Disease % of total death NCD: Cardiovascular disease 38 Chronic respiratory disease 7 Cancers 9 Diabetes 5 Other NCDs 15 Total 74 Communicable diseases, maternal, perinatal, 22 nutritional conditions Injuries 4 Total 26 Source: World Bank 2012 117 More than 50% of those who die from cardiovascular diseases are in middle to upper middle age groups, as shown in Table 22 below: Table 22: Distribution of Cardiovascular Mortality by Age Age group Female Male Total % <1 1 3 4 3 1-14 0 0 0 0 14-24 1 2 3 2 25-34 1 2 3 2 35-44 1 7 8 5 45-54 3 12 15 10 55-64 17 24 41 26 65-74 11 29 40 25 75+ 20 25 45 28 Total 55 105 160 100 Source: UNAIDS 2014 Obesity Tonga has one of the highest rates of obesity and overweight in the world. The average weight of a Tongan male increased over a 30 year period by 17.4kg to an average of 95.7% in 2004, while the average weight for a female increased by 21.1kg to 95 (WHO, 2011). According to the WHO Non-communicable Disease Country Profile 2011 (WB, 2012), it was estimated that in 2008, around 87% of the population were overweight - 84% of males and 89% of females, and around 57% were obese - 46% of males and 68% of females. In 2012, the STEP survey found for the age group 25-64, that 92.1% were overweight – 87.3% for men and 94% for women. Table 23 shows the comparison between the STEP surveys of 2004 and 2012 of the proportion of the population who are overweight: Table 23: Percentage Who Are Overweight Age Group 2004 2012 Age % 95%CI % 95%CI 25-44 92.8 +/-2.5 89.9 +/-2.4 45-64 90.9 +/-3.2 92.3 +/-2.2 25-64 92.1 +/-2.1 90.7 +/-1.8 Source: STEP Survey 2004, 2012 According to the Global School Based Student Health Survey 2012, 61% of boys and 58% of girls between the age of 13-15 are overweight, and one in four boys (24.7%) and one in five girls (19.1%) are obese (World Bank 2012). Table 24 shows the comparison between the STEP surveys of 2004 and 2012 for the proportion of the population who are obese. Furthermore, 68.7% were obese – 57.2% for men and 77.6% for women. In 2012, it was 67.6%, a marginal improvement. 118 Table 24: Percentage Who Are Obese Age Group 2004 2012 Age % 95%CI % 95%CI 25-44 70.2 +/-4.5 67.5 +/-3.6 45-64 65.9 +/-5.3 67.9 +/-3.8 25-64 68.7 +/-4.2 67.6 +/-2.9 Source: STEP Survey 2004, 2012 Obesity is the lifestyle disease in Pacific Island countries and is a recent phenomenon. This reflects the change in the diet and adoption of sedentary lifestyles, from root vegetables, coconut and fish to processed foods with high fat, sugar and salt content, and low intake of fruits and vegetables. Physical inactivity has been a major factor in obesity and being overweight (World Bank, 2012). Risk Factors The STEP Survey The STEP survey is a monitoring mechanism and surveillance tool for risk factors and prevalence of NCDs. The STEP surveys of 2004 and 2012 recognised that NCDs is a substantial burden and dealing with it is a top priority. Over the past 20 years the data have indicated a continuing rise in NCDs because of the prevalence of a number of risk factors such as poor diet, alcohol, physical inactivity and smoking and most of all the increasing overweight and obesity. The prevalence of the behavioral risk factors for both sexes for 2004 and 2012 are shown in Table 25 below: Table 25: NCDs Risk Factors 2004 and 2012 2004 2012 Risk Factors Male Female Both Male% Female Both Smoking daily 46.2 14.3 29.8 46.4 13.4 29.3 Drinking alcohol 13.6 4.6 8.9 8.7 2.8 5.7 Eat <5 servings veg 91.4 92.9 92.2 72.4 73.7 73.1 daily Low level of physical 33.3 53.7 43.9 15.1 31.7 23.7 activity Source: STEP Survey 2004, 2012 The number of women smoking daily declined from 14.3% to 13.4% but not the number of men. Both the number of men and women currently drinking alcohol declined from a total of 8.9% to 119 5.7%. There was also noticeable improvement in the number of men and women eating vegetables daily as well as in physical activity. As in Table 26, there is a reduction in the number of people who are currently consuming alcohol and those who are overweight. However, there was only marginal improvement in the reduction in the number of people who are currently smoking and those who are obese. The significant improvement comes from the reduction in the number of people with low level of physical activity and low consumption of fruits and vegetables. Overall those who are high NCDs risk, was reduced from 60.7% in 2004 to 57.1% in 2012. Table 26: Comparison of Risk Factors STEP Survey 2004 and 2012 NCD Indicators 25-64 years STEP survey 2004 STEPS Survey 2012 2004-2012 Trend Low physical activity 43.9% +/-5.9 23.7% +/-2.2 Significantly improved Fruit and vegetable consumption 92.2% +/-2.1 73.1% +/-3.0 Significantly improved Alcohol consumption 8.9% +/-5.2 5.7% +/-3.0 Improved Smoke any tobacco products 29.8% +/-3.7 29.3% +/-1.3 Marginally improved Overweight 92.1% +/-2.1 90.7% +/-1.8 Improved Obesity 68.7% +/-4.2 67.6% +/-2.9 Marginally improved Combined high NCD risk factors 60.7% +/-4.4 57.1% +/-4.6 Improved Source: STEP Survey 2004, 2012 Poor Diet and Physical Inactivity The STEP survey of 2004 points to low levels of consumption of fruits and vegetables, which are below the recommended standards of five or more servings per day. In 2012, there was significant improvement. The figures from the MAFFF Quarantine Division indicate the importation of meat products and processed foods, which are high in sugar, salt and fat content. In 2014, Tonga imported 10 million kilograms of meat (beef, mutton, chicken). Tonga also imported also 5.3 million kilograms of fruits and 5 million kilograms of vegetables. The local market also supplies vegetables. Therefore the supply of vegetables may be sufficient but prices and dietary habits may have an impact on the levels of consumption. Recently, the duties on vegetables and fruits have been removed so that the consumption level improves because of lower prices. The STEP survey 2012 indicates that although there has been a 19% improvement in the consumption of vegetables and fruits to the standard, still a large of number of people are below it. One in every four Tongans, do not engage in sufficient physical activity that are beneficial to their health. The STEP survey 2012 found that only 52.4% of the age group 25 to 64 are engaged in high level physical activity and only 46.2% in the age group 45-64. Only 36% of women engage 120 in high level physical activity compared to 69.7% for men. Overall, 23.7% are at high risk because of low physical activity. High level physical activity as part of work contributed the highest and recreational-related activities contributed the least. Around 47% of people are engaged in low level physical activities that are not beneficial to their health, and especially women. Since the 2004 STEP survey, the number of people who are inactive or low in physical activity decreased substantially by 2012. However, the engagement in physical activity tend to decrease with age, especially the 45-64 age group. The persistently high prevalence of people who are overweight (90.7%) and obese (67.6%) is due to poor diet and consumption of processed food stuff that are high in sugar, fat and salt and physical inactivity. Alcohol and Tobacco Consumption Smoking is more prevalent among men than among women, as in Table 27. Around 46.4% of men are daily smokers compared to 13.4% for women. Overall 29.3% of people are daily smokers and daily smoking are equally prevalent in both 25-44 age group and 45-64 age group. Table 27: Prevalence of Smoking STEP Survey 2012 Men Women Both Age N % 95%CI N % 95%CI N % 95%CI 25-44 518 45.8 +/-5.1 881 15.6 +/-2.9 1399 30.3 +/-3.1 45-64 409 47.8 +/-5.5 640 9.0 +/-3.1 1049 27.3 +/-3.8 25-64 927 46.4 +/-4.0 1521 13.4 +/-2.4 2448 29.3 +/-2.6 Source: STEP Survey 2004, 2012 Alcohol consumption is higher and more prevalent among men (16.4%) than women (2.8%) due to social stigmatisation of women drinking. Men are more at risk because of heavy drinking.

3.2. Policy Consideration Financial Burden It is predicted that the burden of NCDs is going to strain health financing because the technology required and treatment are expensive. The funding through the budget has been stable around an average of 12% of the total Government budget and it is unlikely to be sufficient to meet the rising cost in the future. The growth in the need for NCDs drugs will require a substantial part of the drug budget. If the budget is not going to increase, then MOH will have to make savings from its budget and to introduce ‘user pay’ into more and more of its services to fund the extra cost for NCDs (Levisay and Evan, 2014). 121 The MOH is working with partners to improve the legislative framework that would enable the reduction in the levels of tobacco and alcohol consumption. Tonga’s Tobacco Control Act 2000, was amended in 2008, but its enforcement often runs into problems because of lack of resources. The Act prohibits advertising and places restrictions on sale and smoking of tobacco products. Proposals have also been made to raise the duties and levies on tobacco import. While it increases revenues for Government, it may not reduce the consumption at the lower wealth quintiles, where people are more likely to smoke more. It is noted that in 2004, 12% of all deaths in the age group 30-44 and 9% for all deaths in the age group 30 and over, were attributed to tobacco use. Access to tobacco is high in Tonga. According to the WHO report in 2011, Tonga scores low on the important aspects of tobacco regulations – monitoring tobacco use and prevention policies, protecting people from tobacco smoke, warnings of dangers of smoking and enforcing bans. Similarly, taxes could also be levied for specific food items which are high in saturated fat, sugar and salt content (World Bank, 2012). 4. Enabling Factors

4.1. Technical Consideration Programs The SPC reported good performance in TB treatment between 2000 and 2007. Tonga maintained a high level of treatment success and case treatment, above the internationally recommended targets. The suspect positivity rate was 10, which was the desired rate (SPC, 2009). The support from regional organisations and development partners is continuing in providing support for programs for the treatment and elimination of TB. Currently, the MOH reports satisfactory performance, with very low incidence and prevalence across Tonga. There is a Diabetic Centre at the main hospital providing services, both static and outreach. At the health centres in the rural areas and outer islands, there are NCDs nurses, trained under the THSSP to increase the availability of NCDs services, especially secondary prevention services. This initiative has been regarded as a positive step in dealing with NCDs and the increased utilisation of the health centres. This should be extended to the clinic level ((Levisay and Evan, 2014). The MAFFF through its Food and Women Divisions had been promoting healthy lifestyle through its programs for women as a contribution to combat NCDs. It has also been pursuing food import substitution through its programs for food processing, gardening, healthy cooking, chicken and duck rearing, and provision of vegetable seedlings (MAFFF, 2010, 2013). Financing The funding of NCDs services has traditionally been shared by the MOH and the development partners. The Australian Government has been providing the largest funding for NCDs through the THSSP particularly in the last 10 years. One of the objectives of providing funding as outlined 122 in the Partnership for Development Agreement 2009 between Tonga and Australia is ‘halt the rise in prevalence of non-communicable diseases risk factors’. This focus consumed 46% of the funding over a four year period – 2009-2013. The activities covered included the review of NCD- related legislations, work on behavioural change and NCDs risk factors, primary health care, diabetic centre outreach, provision of critical expatriate staff, funding for urgent hospital needs and hospital twinning arrangements. These were in line with the MOH Corporate Plan 2008- 2012 (Waddington and Todd, 2013). Since 2009, the funding had assisted in a number of significant ways in combating NCDs. Legislations related to tobacco, alcohol, food and physical activity were reviewed. Work on behavioural change focused on smoking, physical activity and diet – the risk factors, through health promotion activities. The MOH worked with partners on the delivery of the health promotion programs both within Government and with the CSOs. The support given to primary health covered the training of NCDs nurses, the rheumatic heart disease program and the operations manual for health centres. The focus on the diabetic centre outreach were on funding drugs and equipment for the centre (Waddington and Todd, 2013). The WHO also assisted in the tobacco tax legislation, promoting healthy eating and physical exercise and strengthening the national food system through the implementation of the Food Act (Levisay and Evan, 2014). Partnerships The MOH has two strong partners in implementing the Tonga National Strategy to Prevent and Control Non-Communicable Diseases 2004-2009 and 2010-2015, the strategy for combating NCDs. The CLF has been working with MOH on its “Health Promoting Church Partnership”, initiated in 2009. It is aimed at promoting and enhancing a healthy lifestyle and minimise the NCDs risks faced by people. Its focus has been on healthy eating, promoting physical activities, and reducing tobacco and alcohol consumption. Under the partnership the ‘Healthy Village’ based on the village churches, run programs such as workshops and training on NCDs awareness, encouraging vegetable growing for household consumption, promoting active physical exercise and sports, anti-smoking and anti-alcohol campaigns and screening for the NCDs risk factors. Healthy eating is promoted strongly during church gatherings and conferences. The THPF was set up in 2007 to work in partnership with the MOH and WHO to promote health and reduce harm from NCDs (THPF, 2013). It has the aim of ‘promoting health and reducing harm from NCDs’. It works on three strategic priorities – reduce harm from tobacco and alcohol abuses, promote physical activity and promote healthy eating. It administers grants for funding small projects and activities that promote healthy lifestyle and healthy eating and prevention and early detection of NCDs. It also acts as the link between the community, NGOs and Government in promoting good health by combating NCDs. The THPF activities are delivered through support for public awareness, promoting physical activity in sports and schools, as well as the promotion of heathy eating through more consumption of fruits and vegetables and less consumption of fat, sugar and salt. Reduction of harm from alcohol is also part of its work through public awareness and campaigns. Its grants 123 programs have funded community level vegetable growing programs, sports equipment, public awareness campaigns and training.

4.2. Policy Considerations In 1999 the National Cordex Alimentarius Committee was established under MAFFF to advice Government on the development of a comprehensive food control system for Tonga through the application of the Codex food standards. By 2005, a National Food Control and Quality Assurance Committee was put in place to look at issues such as protection of consumers from risks of food- borne diseases and from food that are not fit for consumption, both exported, imported and locally produced, and regulating the food system (MAFFF, 2005). A food legislation and regulations and national food standard code were also being drafted, and in 2014 the Food Act was passed by Parliament. 42 The Act establishes the National Food Authority, and part of its responsibilities is to formulate strategies and policies on food, nutrition and food security, including procedures and provide food safety and food quality inspection and certification services. The Authority has the power to ban food or food substances and their importation or cultivation. It is supported by the National Food Council, whose functions is to provide policy advice and implement the provisions of the Act. Their work would see benefits in addressing poor diet of the majority of the Tongan population. The current Tonga National Strategy to Prevent and Control Non-Communicable Diseases is a focus on physical activity, alcohol, tobacco and diet and it aims to contribute to the global target of reducing the death rate from NCDs by 2% per year over and above the existing trend and for Tonga its contribution would be: - Reduce the prevalence of diabetes by 10% - Reduce the prevalence of adult/child obesity by 2% - Improve the rate of moderate intensity (600 METS) Physical Activity per day on most days of the week by 10% - Improve the rate of consumption of 5 servings of fruits and vegetables per day on most days of the week by 10% - Reduce the prevalence of current tobacco smokers by 2% - Reduce the prevalence of binge alcohol drinking amongst youth by 10% The National Strategy is intended to allow people to make informed choices about what is healthy and avoid the risk factors. It is also intended to help those responsible for policy to make the necessary changes to create an enabling environment which will allow people to make the right choices. Working with partners to implement the activities and gain support in the community is emphasised by the National Strategy. The oversight of the National Strategy is undertaken by a National Committee on NCDs which is drawn from the stakeholders and work partners. 42 The regulations are being drafted and once they are approved the Food Act will then be enforced. 124 5. The MDG Milestones and Consequences Tonga has achieved and sustained a very low prevalence for TB. There is a good TB Program in place and good support from the development partners and regional organisations. However, the NCDs is burden of disease and continues to be the national burden of the health system. It will become a costly business in the future. The prevalence of diabetes, cardiovascular diseases, hypertension and obesity still remain at high levels. Around 57% of the population are at high risk in developing NCDs. While improvement has been shown by the data from the STEP surveys, no dramatic change is observed with regards to the prevalence of the risk factors – physical inactivity, poor diet, smoking and alcohol and the prevalence of NCDs. It may take time to further reduce the prevalence rates to a lower level. However, the appropriate infrastructures, policies and strategies (National Strategic Plan) are already in place and this is a milestone during the MDGs period. These have been designed to assist in combating NCDs. There are also strong partners to assist in delivering the programs. There is now a Food Act which can be used to influence the consumption of foods that are harmful to health. Through its partners (THPF, TFHA, CLF, CSOs), MOH has been able to deliver far and wide its programs. The question then is what else Tonga could do to combat NCDs. There are a number of areas in which strong action should be undertaken. One is the sharing of the burden through separation of the policy and strategic oversight responsibilities and service delivery. The MOH must continue to development multiple partnership by creating the capacity at the community level. The decentralisation further of the responsibility for health services, under an appropriate framework, to the sector level, can create capacity to further enhance health service delivery. A significant initiative has been the development of the super health centres. This work should continue to improve this type of infrastructure to bring the services much closer to the community level. The lack of monitoring and evaluation frameworks is a major short-fall. It should be further enhanced so that progress is tracked consistently and frequently. The timely provision of data for decision making and regular repetition of health-related surveys are important in keeping track of progress of the status of health in targeted populations. Financing the health sector is a priority and is going to be a larger burden to bear because of the NCDs and rising costs. Foreseeing this would require predicting whether the health system is robust enough to deal with potential crises because of population growth in the future. Tonga needs to plan for this. 125 Goal 7: Ensure environmental sustainability ‘Eua National Park, Tonga Photo: Polikalepo Kefu 126 Target Table 11: Target 7A: Integrate the principles of sustainable development into country policies and programs to reverse the loss of environmental resources Indicators 1990 1995 2000 2005 2010 2015 Target Status

7.1 Proportion of land 5.5 5.3 6 17.0 12.6 13 0 Near area covered in (1994) (1999) (2006) (2009) (2013) target forest

7.2. CO2 emissions, total per capita and per $1 GDP (PPP) Gigagrams 365.59 242.59 249.07 (1994) (2006) Metric ton per capita 0.8 3 1.3 0.48 2.67 0.35 0 On (1994) (2001) target

7.3. Consumption of the 0.71 0.07 0.03 0.15 0.02 0 On ozone-depleting (1991) (2001) target substances (HCFC- 22 (ODP tons)

7.4 Propor of fish stock No No No No No No in safe biological Data Data Data data data data limits* Source: Tonga National Communication Report 2010, 2014; National Forestry Policy 2009, * - no data is available as data collection is still ongoing and therefore data have not been analysed. 1. Progress and Achievement of Target ‘The proportion of land area covered by forest is the amount of forest area in the total land area. Forest area includes land spanning more than 0.5 hectares with trees higher than 5 metres and a canopy cover of more than 10 per cent. Areas under reforestation that have not yet reached but are expected to reach a tree height of 5 metres and canopy cover of 10 per cent are included, as are temporarily un-stocked areas, resulting from human intervention or natural causes, which are expected to regenerate.’ The figures have shown improvement in the forest cover in Tonga due to regeneration and banning the harvesting of specific species and the reduction in the large scale commercial farming. In 1999, the forest cover for Tonga was 6%, and improved to 17% in 2005. However, forest cover declined to 12.6% of the land area in 2009, of which 11% was natural forest of primary and secondary growth. Presently it is 13%. ‘CO2 emission, is defined as the total carbon dioxide (CO2) emissions from energy, industrial processes, agriculture and waste (minus CO2 removal by sinks), presented as total emissions, emissions per unit population of a country, and emissions per unit value of a country’s gross domestic product (GDP) , expressed in terms of purchasing power parity (PPP).’ Tonga’s CO2 emission is not significant by international standards but it has been kept at a low level since 2010, and is a net sink country. Tonga’s strong compliance with the requirements of the international conventions and the progress in the work of the Tonga Energy Roadmap 2010- 2020 contributes to keeping the rate of carbon emission low. 127 ‘Consumption of ozone-depleting substances is used to monitor the reduction in the usage of Ozone Depleting Substances (ODSs) as a result of the Montreal Protocol. Therefore only ODSs controlled under the Montreal Protocol are covered by the indicator. Reducing consumption ultimately leads to reductions in emissions since most uses of ODSs finally lead to the substances being emitted into the atmosphere. The Units of Measurement are metric tons of ODS weighted by their Ozone Depletion Potential (ODP), otherwise referred to as ODP tons. This indicator signifies the progress made towards meeting the commitments to phase out the use of ODSs of the countries which have ratified the 1987 Montreal Protocol on Substances that Deplete the Ozone Layer and its Amendments of London (1990), Copenhagen (1992), Montreal (1997) and Beijing (1999).’ Tonga has commitment to the Montreal Protocol and reports on its commitment. The consumption of HCFC-22 is now being phased out, under law. The emission level has been declining because of the effective surveillance and monitoring in the importation of goods containing ODS. Final Performance Status: For proportion of land are covered in forest: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Near Target Moderate CO2 emissions: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good On target Strong Consumption of ODS: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very good On target Strong 128 Overall: Reverse loss of environmental resources: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Good Near Target Strong Target Table 12: Target 7B: Reduce bio-diversity loss, achieving, by 2010, a significant reduction in the rate of loss Indicators 1990 1995 2000 2005 2010 2015 Target Status

7.5 Proportion of total - 2.2 2.2 2.2 2.2 2.2 Near water resources used Target

7.6 Proportion of 0.1 9.4 9.4 9.4 9.5 9.52 Near terrestrial and marine (1992) Target area protected

7.7 Proportion of species - - - - - 20.5 Near threatened with Target extinction Source: MEIDECC 2015; National Biodiversity Communication Report, 2010, 2014 2. Progress and Achievement of Target ‘The proportion of total water resources used is the total volume of groundwater and surface water withdrawn from their sources for human use (in the agricultural, domestic/municipal and industrial sectors), expressed as a percentage of the total actual renewable water resources.’ Tonga’s total water resources used has been stable over time, with groundwater mainly used except ‘Eua district which uses surface water. As such, there is sufficient ground water available for consumption. ‘The proportion of terrestrial and marine areas protected is defined as the proportion of a country’s total terrestrial and marine area that is designated as a protected area. Tonga’s areas currently protected have slowly increased since 1990 from 0.1% to 9.52% showing the work that has been done to protect specific marine and terrestrial areas.’ ‘The proportion of species threatened with extinction measures the proportion of threatened species expected to go extinct in the near future without additional conservation action. It is an index based on the number of species in each category of extinction risk on the International Union for Conservation of Nature (IUCN) Red List.’ 129 Tonga has been improving the number of species on the IUCN Red List although there is still more work to do with regards to the marine species. Final Performance Status: For proportion of total water used: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Satisfactory Near Target Strong For proportion of terrestrial and marine area protected: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Good Near Target Strong For proportion of species threatened with extinction: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Good Near Target Strong Overall: Reduce bio-diversity loss: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Good Near Target Strong 130 Target Table 13: Target 7C: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation Indicators 1990 1995 2000 2005 2010 2015 Target Status

7.8 Proportion of population using an improved drinking water source Total 91.5 98.2 98 78 100 Near (1986) (1996) (2006) (2012) Target Urban 96.6 98.3 73 (2012) Rural 90.2 98.1 79 (2012)

7.9 Proportion of population using an improved sanitation facility Total 55 74 82 80 100 (1986) (1996) (2006) (2012) Urban 55 99 96 Near (2012) Target Rural 91 (2012) Source: Statistics Department, 2015, DHS 2012 ‘The proportion of population using an improved drinking water source is the share of the population that uses any types of improved drinking water supplies. An improved drinking water source is a facility that, by nature of its construction, is protected from outside contamination in particular from contamination with fecal matter. Improved drinking water sources include: piped water into dwelling, plot or yard; public tap/standpipe; borehole/tube well; protected dug well; protected spring; rainwater collection and bottled water. Users of bottled water are considered to have access to improved sources only when they have a secondary source which is of an otherwise improved type. The indicator is defined as the proportion of population using an improved sanitation facility. An improved sanitation facility is defined as a facility that hygienically separates human excreta from human, animal and insect contact. Improved sanitation facilities include flush/pour-flush toilets or latrines connected to a sewer, septic tank or pit; ventilated improved pit latrines; pit latrines with a slab or platform of any material which covers the pit entirely, except for the drop hole; and composting toilets/latrines.’ Overall, there is a high proportion of the population having access to safe drinking water and improved sanitation. However, still more work needs to be done to ensure water safety and improved sanitation for the rest of Tonga’s population. 131 Final Performance Status: For proportion using safer drinking water source: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Good Near Target Strong For proportion using improved sanitation: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Good Near Target Strong Overall: Proportion with access to safe drinking water and improved sanitation: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Good Near Target Strong 3. The Challenges

3.1. Technical Considerations Forest Cover The loss of forest cover causes the loss of habitat and species and the introduction of invasive species. The forest ecosystem is essential for water resource replenishment and storage, maintaining soil stability and nutrient cycles, providing traditional medicines, fuelwood, traditional building materials, habitat for birds and terrestrial fauna and hosting species which are critical for the human food chain. Tonga became a party to the International Convention on Biological Diversity in 1998 (and the Cartagena Protocol on Bio-safety in 2003). It has 3 main objectives – conservation of biological diversity, sustainable use of the components of biodiversity and fair and equitable sharing of the benefits of utilising genetic resources. The National Biodiversity Coordinating Committee was established in 2003 to oversee the implementation of the objectives of the 132 Convention and in 2005, the National Environment Coordinating Committee was set up to oversee the implementation of programs and projects. Their first task was to formulate Tonga’s National Biodiversity Strategic Action Plan (NBSAP) (DOE) 2005, the main instrument for implementing the provisions of the Convention. The NBSAP recommended the formulation of a Land Use Policy and an integrated Land Use Plan to allow the holistic allocation of land to legitimate use including agriculture, forestry, watershed, industry, settlement and so on, while at the same time still protecting bio-diversity. These were to be designed together with a National Forestry Policy and Forestry Strategic Action Plan to enforce protection of natural forests, conservation and replanting. By 2005, forest replanting activities were already under way, especially the provision of seedlings for replanting native trees and timber trees for timber production and protecting farmlands from salt spray and wind damage to crops. The replanting was also used as measures of controlling soil erosion, improving soil conditions and rehabilitation of coastal areas, especially in Tongatapu. However, Tonga’s Fourth National Communication Report on Biodiversity (DOE, 2010), required by the Convention reported that in 2009, the total forest cover (woodlands – 74% of forest cover, forest plantation – 6% and wetlands – 20%) was 12.6%, a decline from 17.0% in 2006. This was due to increase in agricultural land use (from 6% to 7% or from 48,000ha to 51,000ha, or 70% of total land area of 69,000ha available) and continued encroachment of settlements to mangrove and wetland areas (total area reduced from 4.3% to 2.6% of land area). The report indicated that in the absence of the proposed Land Use Policy and Land Use Plan, encroachment into forest areas would be unregulated. Tonga’s Fifth National Communication Report 2014 (DOE, 2014) stated that the clearing of forests has been significantly reduced due to substantial decline in large commercial farming especially squash pumpkins for export, from 4,000ha in 1994 to 1,000ha only in 2014. Re- generation and replanting have been slow, hence the forest cover is estimated at 13%, an improvement of 0.4% only. However, the Report stated that some of the species in the forest ecosystem targeted for conservation still need regulatory protection. The harvesting of species that are endemic or near extinction should be subjected to annual bans. Therefore, the proposed Land Use Policy and Land Use Plan would have had value in the protection and conservation of the forest eco-system, if they were in place. The uncontrolled and illegal harvesting, commercial farming, agricultural expansion, encroachment and introduction of invasive species will continue to be the threats and challenges. Carbon Emission and Consumption of Ozone Depleting Substances In 1998, Tonga acceded to the United Nations Framework Convention on Climate Change and has the obligation to communicate what it does in compliance with this Convention. Its First National Communication Report was submitted in 2005, which reported Tonga’s inventory of greenhouse gas emission with the baseline year of 1994, calculated using the prescribed methodology. CO2 was identified as a major greenhouse gas emitted in Tonga after the assessment was conducted in a number of sectors – energy, agriculture, land use and waste. 133 From the energy sector the largest emission of gases were from burning and combustion from energy fuels both traditional and imported as well as the transportation and storage of imported fuels. The emission from the agricultural sector, were inventoried for CH4 in enteric fermentation of livestock, N2O from leaching from the agricultural soils and cultivation of histosols, and CH4 and CO from burning of savannas and agricultural residues. Calculations of emission were also made on land use change and forest and woody biomass stock, forest grassland conversion, abandonment of managed land and agriculturally impacted soil. The emission from waste was calculated on the methane emission from solid waste disposal sites (particularly in the Tongatapu landfill) and treatment of waste water (managed on site through septic tanks, pour and pit latrines) and sludge and indirect nitrous oxide from human waste. The sources of sinks mainly came from biomass and corals where the former is a significant emitter of CO2. It was then established for 1994 that Tonga’s CO2 emission was 365.59 Gigagrams and 3.68 metric tons per capita, with CO2 removal of -595.24.Gg. The biggest emission of CO2 came from land use change and forestry sector with 78.12% of the emission and 21.88% from the energy sector. Around 71% of Tonga’s energy supply come from imported fuel (mainly for transportation use) and the rest from biomass fuel, which is increasingly replaced by liquefied petroleum gas. In 2000, around 53.29% of energy supply was from imported fuels and 46.52% from biomass. In 2012, the stock-take established that CO2 emission was 242.59Gg with CO2 removal of 1977.95Gg in 2000, reflecting that Tonga is still a net sink of CO2. The largest emission of CO2 was still from land use change and forestry, mainly from grassland and forest conversion of biomass, with 60.87% and from the energy sector from emission from road transportation and energy generation, it was 39.13%. The CO2 emission per head decreased from 3.68 in 1994 to 2.42 metric tonnes per capita in 2000, an increase in net removal. As for ozone layer protection, Tonga had initially monitored the import of ODS through mutual agreement between the Customs Department (CD), Department of Environment (DOE at the time) and Ministry of Labour, Commerce and Industries (MLCI at the time) since 2004 and in 2010 the Ozone Layer Protection Act was in force. Its object is to protect health and the environment from adverse effects of modification of the ozone layer, phase out ODS and carry out the obligations under the Montreal Protocol. The National Ozone Advisory Committee was established by the Act to carry out the functions of the Act. The Act prohibits the importation of specific ozone depleting substances (ODS) including HCFC (except exemptions), its manufacture in Tonga, sale or export. The amendment of the Act in 2014, prohibits as from 2016, the importation of goods containing HCFC and hence it will be completely phased out. The amendments made the Act more elaborate and more comprehensive in its coverage, as well as processes and procedures to be applied in carrying out the provisions of the Act. Water Resources Tonga is heavily dependent on groundwater and rain water for drinking. In 2005, the Joint Report by WHO and SOPAC stated that for drinking water the reticulated water supply covers 97% of 134 the urban population while the rural areas are covered by individual water supply untreated. Water quality monitoring is undertaken in the urban areas to comply with the WHO standards. Extraction from thin freshwater lens within highly porous limestone substrates and rainwater harvesting are the major sources of freshwater in Tonga (according to the Diagnostic Study 2007). Surface water can only be found in a few volcanic islands in the Tonga group. Groundwater is the primary source of water for household use, with rain water used for drinking mainly and if there is plenty then it is also used for washing clothes and bathing. Where rainwater is insufficient, groundwater is boiled for drinking. It has been estimated (ADB, 2011) that 68% use rain water for drinking and 25% use piped water for drinking with 7% drinking bottled water. The threat of contamination to the ground water supply, comes especially from waste water. The management of wastewater is still with households because there is no centralised sanitation system. Poorly constructed or inappropriate sanitation systems tend to allow pathogens and nutrients to make ingress into the groundwater. There is also the threat from contamination of hand operated wells unprotected from human interference, especially in the outer islands (MLSNR and TWAL, 2015). Terrestrial and Marine Protected Areas Terrestrial and marine protected areas are a part of the NBSAP 2005. In 2006, there were 8 parks and 10 reserves as marine protected areas. Terrestrial protected areas, mainly forest parks – cover 9.8% of land area in 2006. In 2010, 14.5% of the terrestrial surface of Tonga and 2.5% of its territorial waters were protected, according to the World Bank database on protected areas. The Program of Work on Protected Areas 2011 (under NBSAP), set a target for protection of 5% for territorial waters and 17% for terrestrial surface by 2020. However, the Government now sets a target of 20% marine protected areas and 30% terrestrial protected areas. This target is achievable according to MEIDECC. There are now 15 marine protected areas and the Fisheries Department is currently working with around 34 coastal communities on identification and protecting more marine protected areas. The communities are responsible for their management and there will be more marine protected areas to be established in the near future.43 Marine protected areas are vital fisheries management tools, according to the Fourth National Communication Report (DOE, 2010), and they can serve communities well if they are properly management. However, its success has been undermined by the lack of compliance, especially encroachment by night divers and reef fishers. Some marine protected areas face threats from sand removal, off-shore sand dredging and coastal pollution from land based activities. Terrestrial protected areas are equally important as sources of medicinal plants and cultural ornaments, as well as habitat for species important in the food chain. Terrestrial protected areas face the same threat as forest eco-systems (previously described). Although there are environmental plans, there may be no real commitment to implementation as resources and skilled manpower are not always available. The institutional arrangements may not be clearly delineated as there is also a need to ensure that the legal framework is conducive to 43 Information supplied by MEIDECC 135 environmental conservation and protection and allowing participation by communities and CSOs. These issues are being looked at by the relevant Government agencies. Proportion of Species Threatened with Extinction44 Tonga’s Fifth National Communication Report 2014 (DOE, 2014) outlined the status of plant species in Tonga whether they are abundant, endangered, rare or extinct. It was found after public consultation that fruit trees had the highest extinction rate with 30% and followed by medicinal plants at 13%. Timber plants and coastal plants both had an extinction rate of 4% with the least being cultural and ornamental plants at 2%. In terms of rarity, 22% of cultural and ornamental species as well as 32% for medicinal and coastal species are rare. Plants that are endangered were highest for cultural species at 54% and lowest for medicinal plants with 38%. The most abundant is the timber species and the least abundant is the cultural species at 14%. The IUCN assessed five species and declared four as threatened and which are on its Red List. However, the report states that the overall status is not at a critical level because of the low rate of species loss or extinction and with remedial action being undertaken. Of all the 581 plant species describe for Tonga, 60 were identified as threatened in 2006 and 31 have now shown improvement. However, the Fourth Nation Communication Report (DOE, 2010) has identified another 25 species as threatened. Therefore, 9.3% are endangered and threatened with extinction. Declining populations have been caused by uncontrolled utilisation of plants for medicine, timber, firewood and cultural purposes. Conservation is an effective means of decreasing the number of threatened species, as the number of species identified as threatened will continue to increase in the years to come. The MAFFF has continued to increase the seedlings for sale to be used in the farming system and to conserve cultural and medicinal plants. Of the more than 345,481 seedlings, if all survived, this would be equivalent to 4150ha of fully stocked forest plantation. It would be a significant contribution to biodiversity and conservation. The determination of the status of marine biodiversity in Tonga is complicated in terms of abundance and the detrimental effect of human activities. However, the assessment focused on commercial species only, because of the impact on livelihoods, especially at the coastal zones. It was found that 39 edible species were endangered or 5% of the listed edible species. This was recognised in the Fifth National Communication Report for Tonga of 2014. The status of Tonga’s marine ecosystem is yet to be explored fully. Although some information are available, there is still lack of resource assessment to ascertain the status of the marine eco-system. The problem of overharvesting and over exploitation are the major causes of change to the marine ecosystem. 44 See National Communication Report (2014) 136 Drinking Water Resources Access to safe drinking water impacts on improved health outcomes in terms of reducing cases of water-bourne diseases such as cholera and dysentery. The DHS 2012 stated that 78% of households in Tonga have an improved source of drinking water from a piped source. Households in rural areas had greater access to a piped source with 79% than urban areas with 73%. However, 16% of households use non-improved water sources, common in rural areas. Treating water for drinking, only 43% used an appropriate method – boiling. The use of an appropriate treatment method was higher in urban areas – 55% than in rural areas – 40%. The demand for water is greatest in Tongatapu where 73% of the population resides and in the Nuku’alofa area where 35% live. Meeting future demands is the challenge. In 2005, it was estimated that water production for the Nuku’alofa area will have to peak at 10,000m3 per day to meet future demand. It was forecasted that demand would be rising from 8,170m3 per day in 2005 to 8,682m3 per day in 2015. The abstraction in 2005, was 6-7000m3 per day and extra wells were required for production. A safe level was established at 19,000m3. After the existing 17 wells were upgraded, construction of 12 new wells and an additional 4000m3 reservoir constructed in 2012, the water system now is able to extract 13,000m3 per day to meet the demand, although it is still below the recommended safety level (ADB, 2011). Improved Sanitation Facility Tonga lacks a centralised reticulated sewerage system. As reported by the Diagnostic Study 2007 that in Nuku’alofa, the sanitation systems consist predominantly of flush toilets with septic tanks and vertical soak ways. In non-urban areas pit latrine are still used by many households. The challenge in the use of the septic tank is where the tanks do not have bases or the tank had disintegrated over the years. The problem is the tendency of the sludge and effluent to seep through and contaminate the soil and ground water. The MOH is instrumental in reviewing septic building plans and inspection of septic tanks. They enforce standards and codes for the design and building of septic tanks as part of issuing building permits. However, where the design and construction is faulty then there is high tendency for the contaminants to be introduced into the surrounding environment and to the groundwater. In low lying areas, septic tanks can be inundated when they are flooded in heavy rain, bringing the contaminants to the surface and exposing residents to waterborne diseases. Similar problems are experienced in the outer islands, like Ha’apai. In the rural areas, where the community runs the water supply system, rubbish dumps, septic tanks, pit latrine, roaming livestock, pesticide and fertilizers used in gardens can contaminate the ground water (Fusimalohi, 2008). The DHS 2012 points out that eight in ten household or 80% had an improved sanitation facility in the form of flush to septic tank, while another 12% had other forms of improved sanitation. Around 8% of households had non-improved facility. Those who had an improved sanitation facility were higher in the urban areas with 96% of households than in rural areas with 91%. 137

3.2. Policy Considerations Land Use Policy and Plan The NBSAP recognised the threat to bio-diversity from indiscriminate expansion of agriculture impacting on species, biodiversity cycles and the spread of invasive species, although food security and export oriented crop production are important. As previously described, it proposed the establishment of an integrated Land Use Policy and Land Use Plan, for sustainable allocation of land to legitimate and priority use. A National Forestry Policy (and Action Plan) was also proposed to ensure the sustainable management of the natural forests left in Tonga. At the same time, short-term measures were to be undertaken such as replanting, protection of remaining natural forests and review of legislations. The Fifth National Communication Report of 2014 stated that the proposed Land Use Policy and Land Use Plan have not been approved. Their absence has resulted in the indiscriminate expansion of large commercial agriculture and settlement of wetlands. The purpose of the National Land Use Policy, which is still in draft form is to: - Facilitate and advocate for sustainable land use - Provide a framework upon which consensus can be reached among the Tongan stakeholders on a national vision, fundamental principles, and strategies of land use in Tonga - Set out principles upon which the interests of all stakeholders can be balanced out - Provide a framework for dispute and conflict resolution - Prepare land users to adapt to changing circumstances - Support the progressive move towards integrated land use The National Forestry Policy formulated in 2010 (with Action Plan) was not implemented in full and the National Agricultural Policy as envisaged in 2005 is yet to be completed. However, they would be vital as a way forward for managing the forest eco-system for Tonga and reducing the loss of forest areas. Existing laws relating to protected areas and mangroves should continue to be enforced. Policy Coordination Tonga like many other countries has made commitment to the Montreal Protocol to phase out HCFCs. This commitment includes reducing supply through ODS import and export control system where quota may be imposed and duty and price adjustment to discourage imports. Another strategy is to reduce demand through instituting best practices in the servicing sector and promoting public awareness. It is estimated that for each kilogram of HCFC-22 not emitted because of best practices in refrigeration, will result in saving of 1.8 CO2-equivalent (CCC, 2012). Apart from the promotion of renewable energy to reduce reliance on fossil fuels, there is no policy yet to reduce the number of second-hand vehicles imported to Tonga. In 2014, there are more than 15000 vehicles on Tonga’s roads. The emission of CO2 from the agricultural sector has not been formally addressed under policy, although there are provisions in the Ozone Protection Act for prohibition of specific products used in agriculture. 138 Tonga does not have a legislation or policy which are specific to biodiversity conservation. As such, the overall management and protection of its biodiversity is left to the jurisdiction of a number of agencies. Continuous restructuring of the Public Service disperses the responsibilities across sectors and the long-term focus on bio-diversity. While there are sectoral responsibilities, there are no cross-sectoral policies or legislations. As such, it may have been difficult to draft a Land Use Policy and a National Agricultural Policy and to implement fully the National Forestry Policy. The cross-sectoral nature of bio-diversity requires strong coordination and close collaboration. However, this depends on the willingness of the key partners to commit themselves to the purposes of bio-diversity. In addition, if financing of bio-diversity activities are limited then the work will be slowed down and key partners lose focus and commitment. As for water resources, the role of the MOH in water and sanitation is crucial in ensuring that the standards are met. Under law it is responsible for monitoring water quality and inspection and imposing the sanitation standards in dwelling and work facilities. However, better coordination of its role with the activities of other agencies whose activities has implications on water and sanitation, ought to be strengthened, especially agencies such as MEIDECC, MOI, TWB as well as Village Water Committees. 4. Enabling Factors

4.1. Technical Considerations Some of the reports that have been compiled in the last 15 years have all recommended strategies and activities for enhancing the effectiveness of the work in the bio-diversity and climate change areas, especially for emission mitigation and bio diversity conservation. Emission A number of recommendations were made in the First National Communication Report (and Strategic Action Plan) of 2005 to mitigate the emission of greenhouse gases. In the energy sector, transportation and power generation are heavily dependent on imported fuels. While there is a need for a vibrant energy sector, there is also a need for viable options. In 1991, 69.7% of the energy supply were imported petroleum and biomass supply, at 30%. By 2000, petroleum was 75.3% of energy supply with biomass declining to 24% only. At the time, renewable energy supply was only 0.2%. The First National Communication Report (DOE, 2005) also recommended a number of mitigating measures. These included the introduction of energy efficiency labelling and energy efficiency standards, and restrictions on the import of low efficiency and large engine vehicles. Part of the measures were also to improve efficiency in power generation and biomass domestic use and increase the utilisation of renewable energy and looking into fuel substitution. For the agriculture sector, more efficient livestock management and effective use of fertilizers were recommended. For land use change, improving agroforestry systems and expanding forest areas, and proper management of land use through policy, were priorities. Similarly, the Second 139 National Communication Report (DOE, 2010) recommended strengthening energy efficiency and renewable energy development for the energy sector as well as the development of biofuel. It was also recommended that the focus should continue on reduction of emission from transportation and power generation. The waste sector would be able to minimise emission through proper waste disposal, composting and recycling and so on. At this stage, the MLNR and TWAL (2015) are looking at implementing a project that will see better solid waste management. This project has the objectives of: - Expanding and upgrading the capacity of Waste Authority Limited existing leachate/septage liquid treatment facilitates at the Tapuhia Waste Management facility; - Improve the regulatory requirements and annual certification of onsite household sanitation facilities, through improved legislation and regulations combined with informing and increasing community awareness of the importance of operating and maintaining environmentally safe household septic systems; - Undertake pilot construction and upgrading of onsite, household sanitation facilities for low income, Nuku’alofa households currently without access to septic tank treatment systems For monitoring of the ODS consumption and prohibition, the work of the National Ozone Advisory Committee under the Ozone Protection Act is significant in meeting Tonga’s obligations under the Montreal Protocol and ensuring that it contributes to protecting the ozone layer. The Committee provides the Minister with advice on the exercise of his powers under the Act. Biodiversity Conservation As for bio-diversity conservation, the Fifth National Communication Report (DOE, 2014) outlines the threats contributing to the degradation of biodiversity, such as climate change, overharvesting, overfishing, the introduction of invasive species and so on, thereby having serious implications on people’s livelihoods. The relevant sectors are now willing to mainstream biodiversity and conservation into their policies, plans and programs in order to address the threats. The BDSNAP which implements the provisions of the Convention on Biological Diversity, has made positive impact in bringing together the partners and has raised greater community awareness on the importance of conservation of biodiversity and conservation and sustainable use of resources. Both are linked to community livelihoods and people could see the potential loss of their future livelihoods, if unsustainable practice would continue. With financial assistance from development partners, communities have been willing to participate in efforts to replenish resources, and reducing unsustainable practices. While Tonga is meeting its obligations under the Conventions, work is being undertaken to extend the protection to more endangered and rare species that are significant for biodiversity. The Land Use Policy and Land Use Plan are in draft form and should be used soon to inspire discussions on their implications on biodiversity. 140

4.2. Policy Considerations Over the years, a number of initiatives have facilitated the work towards the achievement of the objectives of the Conventions. In particular, the Tonga Energy Roadmap 2010-2020 now promotes renewable energy within an appropriate legal framework and partnerships with development partners and investors. A National Forestry Policy was recommended to encourage production of high value tree species, protection of natural forests and replanting. It is now being revised for further implementation. According to the Fifth National Communication Report (DOE, 2014) the BDSNAP also improved some of the institutional arrangements and regulatory frameworks. These include the use of environment impact assessment, integration of biodiversity into policies, plans and programs, and putting in place frameworks for implementation of projects. The MEIDECC now integrates together the functions related to the environment, climate change and biodiversity as well as disaster management. This is one step ahead in coordinating activities in these areas through national committees and the activities of stakeholders who are engaged at the sector level. This integration is important in ensuring that Tonga is complying with the relevant conventions and that matters relating to the environment, climate change and biodiversity are mainstreamed into the policies, plans and programs of the relevant Government agencies. As for water resources, the Tonga Government has established a National Water Resource Committee to oversee and coordinate all water resource issues and works. A Water Management Bill has also been proposed to allow better management of the groundwater sources and regulations for enforcement. It will also clarify the mandate of the MOH, MEIDECC and the TWB. The proposed restructuring of the public enterprises will see the Tonga Water Board and Tonga Waste Authority merge. This will further facilitate the integration of water and sanitation activities. 5. The MDG Milestones and Consequences Tonga has undertaken a lot of work to ensure environmental sustainability. However, it needs to strengthen its commitment to extending forest cover and put in place the Land Use Policy and Land Use Plan to assist in ensuring sustainable land use and protection of forests resources. This should be supported by a review of the National Forestry Policy and National Agricultural Policy and the accompanying plans. This is one aspect of contributing to maintaining biodiversity. Tonga has done well in complying with its obligations under the conventions on biodiversity and climate change. However, the MOF and MAFFFF could still do more in undertaking activities relating to the protection of marine and terrestrial species which are important to biodiversity and livelihoods, especially those that are endangered because of human exploitation. Water and sanitation has not posed any major concern in Tonga. But at the same time, there is a need for more effective coordination of the work of the MOH, Government agencies and communities. Improved drinking water and sanitation has impact on the health of the general population. So far, there has not been any reports of major outbreaks of water-bourne diseases. 141 Overall, Tonga has done well in these areas of environmental sustainability. If resources are secured and capacity further enhanced to implement further the activities described in this section, environmental sustainability would be secured for Tonga. 142 Goal 8: Develop a global partnership for development Photo: Australian High Commission, MEIDECC 143 Target Table 14: Target 8A: Develop further an open, rule-based, predictable, non- discriminatory trading and financial system. Indicators 1990 1995 2000 2005 2010 2015 Target Status

8.1 Net ODA Total and to $25m $84m $138m On the least developed (2014) target countries as % of OECD/DAC donors gross income

8.2 Proportion of total On bilateral, sector target allocable ODA of OECD/DAC donor to basic social services Basic education 9m 9m Primary health care 27m* 6m Nutrition Not available Safe water 14m 5m Sanitation 0.2m 0.5m

8.3 Proportion of bilateral 16m 24m On official development target assistance of OECD/DAC donors that is untied

8.4 ODA received in small On island developing target States as a proportion of their gross national income USD 29.75 38.8 18.8 31.5 23.15 (2010) % of GNI 25.4 23.6 12.8 15 6.4 (2010) % of GDP 10.7 12.4 6.5 (2010) Source: Ministry of Finance and National Planning; *includes funding of hospital upgrading and rebuilding. 1. Progress and Achievement of Target Net ODA as a percentage of OECD/DAC donor gross income is intended to measure the total overseas development assistance to the least development countries. For Tonga the total ODA has increased since 2005. Similarly, the proportion of bilateral ODA for basic social services have been substantial in building critical infrastructures and improving and maintaining the quality of service delivery. These have been explained in the relevant sections in this report, especially for health, education, water and sanitation. Tonga’s development partners are now increasingly untying their direct aid assistance, through aid funded programs and budget support, allowing not only international but also national 144 procurement of goods and services. Many of these funded programs and projects as well as budget support have already been described in the previous sections. The ODA received in Tonga as a proportion of GNI and GDP are to monitor development assistance towards meeting the special needs of small island states like Tonga, especially constraints such as narrow resource base, small domestic markets, high transport costs, fragile environment and so on. Some of the programs and activities described in this report, which relate to some of these constraints have received ODA assistance. The ODA tend to fluctuate over the years depending on the special needs to be addressed. Final Performance Status: For net ODA total transfer: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On target Strong For total bilateral allocation: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On target Strong For total bilateral allocation: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On target Strong For ODA received: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On target Strong 145 Overall: For open trading and financial system: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On target Strong Target Table 15: Target 8C: Address the special needs of small island developing states Indicators 1990 1995 2000 2005 2010 2015 Target Status

8.5 Proportion of total - $3.5m $13.4m $19.04m $19.89m On developed country target imports (by value and excluding arms) from developing countries and least developed countries admitted free of duty

8.6 Average tariffs This is not applicable to Tonga. imposed by developed countries on agricultural products and textiles and clothing from developing countries Agricultural support 1.21 0.69% 1.05% On estimate for OECD (2004) target countries as % of their gross domestic products

8.7 Proportion of ODA 9% 14.3% $8.4 m On provided to help target build trade capacity Source: Ministry of Finance and National Planning 2015, *=revised estimates 2014/2015 2. Progress and Achievement of Target The proportion of total developed country imports from developing countries admitted free of duty is an indicator that monitors the result of the effort by the developed countries to reduce or remove tariff barriers to imports from developing countries, increase market access and duty-free and quota free. The return from export into developed country economies has been increasing 146 over the years reflecting on the effectiveness of trade arrangements between Tonga and its trading partners. The agricultural support estimate for OECD countries as a percentage of GDP has been steady since 2005. Tonga’s economy relies in part on agriculture for export earnings and is currently exporting produce to markets in OECD countries. The proportion of ODA provided to help build trade capacity has been steady as well for Tonga. This amount has been dedicated towards improving capacity to produce, compete and maximize the benefits from trade and investment opportunities. Final Performance Status: For total imports from developed countries State of Progress Towards the Degree of Achievement of Degree of Support by State Target Target and Stakeholder Very Good On target Strong For agricultural support State of Progress Towards the Degree of Achievement of Degree of Support by State Target Target and Stakeholder Very Good On target Strong For proportion of ODA for trade State of Progress Towards the Degree of Achievement of Degree of Support by State Target Target and Stakeholder Very Good On target Strong Overall: For addressing special needs State of Progress Towards the Degree of Achievement of Degree of Support by State Target Target and Stakeholder Very Good On target Strong 147 3. The Challenges Economic Difficulties The economic climate in which the delivery of aid assistance by the development partners and formation of partnership during the MDGs period, has been a difficult one. Between the late 1990s and early 2000s, Tonga’s economic performance was reasonably strong. However, it became volatile between mid-2000 to 2010, due to the decline in remittances, tourism receipts and the volume of exports associated with the global economic crises. The oil price spikes in 2008 meant that the costs of imports and transport cost for exports increased and thereby affecting competitiveness. Economic activity contracted by about 0.5% for 2009-2010. Economic volatility was also exacerbated by natural disasters – a devastating cyclone in 2001, a tsunami in 2009 and another cyclone in 2010 (WB, 2011). The latest was another destructive cyclone in 2014. The economy grew by only 1.3% in 2012-2013, down from 4.7% growth in 2011-2012, but only 0.5% in 2013-2014. This growth pattern has been largely due to the completion of major donor- funded infrastructure projects. Over the period the growth of the economy had depended on donor funded infrastructure and weak flow of remittances. It is expected that growth in 2014-2015 would be 2.4% (ADB, 2013; 2014). Tonga’s economic context described in section 1, shows that it is dependent on a narrow base in agriculture and fisheries and a small tourism sector. It is also dependent on a regular flow of remittances from Tongans overseas, now around 20% of GDP and developmental activities by development partners, 10% of GDP. Tonga also depends on aid flows for its developmental needs and its capacity to absorb and mobilise aid assistance and meet the milestones expected by development partners have often been questioned. The development partners and the responsible agencies have now put in place the appropriate coordinating frameworks to ensure effective and efficient aid management. The MFNP works with the development partners to ensure that aid assistance is targeted in high priority areas, that there is monitoring and evaluation and there are appropriate accountability frameworks in place. Tonga participates in dialogue and forums for the promotion of regional and international trade. It is a member of WTO and has signed up to a number of trade arrangements, especially the PACER and PICTA which are regional frameworks for trade. Compliance with the WTO requirements is ongoing and are implemented. There is also bi-lateral trade relations, especially with New Zealand, Australia, United States and Japan, which have been long-standing. Recently, Tonga has established ties with the People’s Republic of China which sees relationships in investments, trade and aid assistance. The EU has also become markets for specific agricultural products and fisheries products. 148 Financing Social and Economic Development45 The total public debt for Tonga is estimated at 50% of GDP and 45% is owed as external debt as at June 2015. The Government is mindful of the high level risk because of the significant level of external debt and is committed to maintaining it at this level. Due consideration would be given to any further external financing, given the vulnerable state of the economy. At the same time, action will be taken to minimise the risk, through improving legislative frameworks and institutional arrangements for debt management. The Medium Term Debt Strategy has been developed as a mechanism, for seeking alternative borrowing strategies to help maintain a balanced composition of public debt. This new Government emphasises fiscal prudence and regular review of debt position and careful planning of future borrowing in its debt management strategy. The provision of very concessional loan terms with a 50% grant component from the WB and ADB represent an avenue for budget support and funding of critical infrastructures and combating climate change impacts. However, debt is currently being serviced at the rate of 2.6% of GDP and 11.8% of recurrent revenue. But this is expected to rise by a further additional 1.6% of GDP. Table 28 shows the debt servicing indicators. Table 28: Sovereign Debt Sustainability Indicators of IMF Indicators IMF Max 2013/14 2014/15 2015/16 2016/17 2017/18 Target % NPV of External Debt as: % GDP 40 41 44 42 39 37 %GDP – Remittances 36 32 35 33 31 29 %export 150 211 202 183 169 152 %export – Remittances 120 90 91 85 79 74 % recurrent revenue 250 206 183 171 165 155 Total Debt Service at: % of export 20 13 12 11 10 8 %export + remittances 16 6 5 5 4 4 %recurrent revenue 20 13 11 10 9 8 Source: Budget Statement 2015 As in Table 28 debt as a percentage of GDP is breached as well as the ceilings in debt as a percentage of export. As a percentage of GDP and remittances, it is close to the limit, and may not permit further lending over the period of the Medium Term Debt Strategy. The annual recurrent budget, around 25% (without external budget support) also attracts budget support from the development partners varying between 2 and 3.5% of GDP. There is tight fiscal measures put in place to ensure tight control of expenditures. On the other hand, revenues from domestic sources to cover payments is around 25% of GDP as well but payments tend to be higher because of budget support. The foreign reserves position of Tonga is reported by the National Reserve Bank to be $302 6, which is the equivalent to 8.6 months of imports compared to 9.1 at the same time in 2014. This 45 See Budget Statement 20515-2016 149 level is considered satisfactory as it is above the recommended minimum of 3 months of imports. The challenge is to maintain this level of foreign reserves given the period ahead when debt obligations are imposed and to absorb any unforeseen external shocks or contingencies. Development assistance is a significant part of the budget, which are both in cash and in kind. For 2015/16 the total estimated expenditure by development partners would be $232.61 million, of which $66 million in cash and $166.61 million in-kind. This is a $15.68 million increase from 2014/2015. The discussions in the previous sections raise the challenges in finding the finances to fund the existing but growing responsibility and new initiatives, and the anticipated growth in the volume and magnitude of the services to be provided in the future, such as in health and education, or the appropriate infrastructures to promote income generating activities in the informal sector. In this regard, the revenue generation capacity of Government is important. The Public Finance Management Reform Roadmap is now being implemented which targets reforming public finance management processes including revenue services, procurement, budgeting, accounting and so on. There is effort now to improve the tax system under a number of initiatives including the public finance management reforms. Tax collection and collection of rates, fees and debts to Government are to be improved and reviews are undertaken to make sure that the loopholes in the system are dealt with. The intention is to find additional revenues without increasing the existing taxes or introducing new ones. The role of the development partners has been instrumental in supplementing the budget and funding specific programs that contributes to social and economic well-being of the country. Tonga’s bilateral partners have increasingly untied their assistance allowing greater autonomy in procurement and also delivering aid through the multilateral development partners, where projects and programs are funded by multiple partners. This has also harmonises the funding and coordination. The education and health sector, as well as the environment sector have benefitted from such assistance which have provided for what the recurrent budget cannot cater. However, according to the MOFNP the provision of aid assistance should be aligned closely with Tonga’s priorities. Aid assistance should be made more predictable through a rolling forward plan. 4. Enabling Factors The assistance provided by development partners are discussed below. There is no room here for detailed discussion. However, the major assistance towards areas that have implications on the MDGs are outlined below. The development partners have always placed priority on the social sector such as education and health including water and sanitation, and other areas of priority. The Joint Policy Action Matrix managed by MOFNP now becomes a coordinating mechanism for the delivery of budget support from some development partners and aid assistance in Tonga by its major development partners. Bilateral relations with the development partners are key to the effectiveness of the aid assistance 150 to Tonga and Tonga’s economic and social development policies and plans have been the basis for discussion of aid assistance to Tonga by its development partners. Australia The Australian aid program for instance allocated a substantial part of its total aid to Tonga in 2013/2014 towards education and health. In education, support had been given to the TESP and scholarships. In the health sector, assistance was provided through the THSSP, which has a strong focus on NCDs and primary health care, and provision of specialist medical staff and equipment. Sanitation and solid waste management in partnership with ADB had also been a focus. In 2012, Australia was Tonga’s largest development partner with 36.8% of all aid from OECD DAC member countries. The Australia-Tonga Partnership for Development represents a commitment to improved governance, sustained macroeconomic stability, public sector capacity development, enhanced private sector development, investment in economic infrastructure, improved access to quality education, community development and environmental sustainability. Tonga also works closely with other development partners to harmonise their assistance. Since, 2011, Australia has been working together with other development partners (New Zealand, EU, WB and ADB) on the Joint Policy Action Matrix for the public sector including public finance management, urban development and infrastructure. New Zealand New Zealand and Australia harmonise the delivery of their aid assistance in Tonga. It also provides support to education through the TESP and the provision of targeted skills training for the private sector and community. In the health sector, assistance is provided through the provision of medical expatriates and medical evacuation from Tonga. It has made contribution to disaster preparedness and response and forestry and the agricultural sector in the area of bio- security and export. In recent years, some of its assistance have been allocated to the energy sector and transport sector, and the justice and police sector. Some of its support is provided for power upgrade network in the outer islands of Ha’apai. The biggest part of its assistance is going to the tourism sector for marketing and rehabilitation of tourism sites. Both Australia and New Zealand are maintaining a ‘head of mission fund’ with the purpose of assisting grassroot and community level projects in income generation, sanitation, health, education and so on. Such funding has been very instrumental in improving people’s lives in rural areas and outer islands. ADB The ADB provides grants and loans for projects in Tonga. Its aid assistance is delivered under a Country Partnership Agreement 2007-2012, which is its first one, and a rolling Country Operating Business Plan, after consultation with the Tonga Government. Since 1972, Tonga has been 151 receiving from ADB grants and loans and technical assistance to projects. Currently, there are six grants and various technical assistance on the ground. At the beginning of the relationship, the focus was on building infrastructure for development especially power and telecommunication and development finance. It was later re-directed towards agriculture and fisheries and economic reform. In early 2000s, public sector reform became a priority. The Country Partnership 2007-2012 had its focus on improving social services delivery in urban areas, fiscal governance and the private sector enabling environment and align them with the need to focus on poverty by the Tonga Government. Presently, the ADB under the Policy Action Matrix and its Country Operating Business Plan is engaged in a number of projects including high-speed broadband connection, and further developing applications in the health and education sectors. Climate resilience is also part of the support focusing on least-cost locally appropriate solutions for climate resilience. Solid waste and sanitation through water supply upgrading and cell improvement and equipment for solid waste disposal were also given priority. In addition, there is support for urban development especially access roads, drainage and renewable energy for the outer islands. World Bank The WB had provided assistance to Tonga since 1985. A first Country Assistance Strategy was drawn up in 2010 for the provision of aid assistance to Tonga. Between 2000 and 2010 the WB had provided assistance in disaster recovery through cyclone relief, rehabilitation of hospital services, provision of school grants for improving educational outcomes and improvement in the transportation infrastructure. The 2010 Country Assistance Strategy has focused on strengthening public finance management, fiscal policy, promoting structural reforms and improving social protection. In its Country Assistance Strategy 2011-2014, structural reforms focused on the energy sector under the Tonga Energy Reform Roadmap 2010-2020, reforming electricity tariff (in view of moving into renewable energy and the need for protection of the poorest consumers) and the petroleum sector (reviewing pricing templates and reducing cost in the supply chain) as well as reforming the public enterprises (improving accountability, reduce cost, restructuring and privatization). Its focus on social protection was on funding initiatives for vulnerable groups in society who would be hit hard during economic downturns. The WB also provide budget support and upgrading of the aviation infrastructures. The European Union Tonga had ties with the European Union since the mid-1970s. During the period of EDF10, 2008- 2013, assistance was available for Tonga intended for the energy sector, water and sanitation and budget support. Prior to this, EU assistance focused on community development in Vava’u, especially in the infrastructure, health and education. The EDF10 provides a grant for supporting the Government budget, with the condition that there is macro-economic stability, efficient and effective public finance management, budget 152 transparency and accountability and a credible energy policy. The energy policy is embodied in the Tonga Energy Roadmap 2010-2020 which is currently being implement under the MEIDECC, with a focus on sustainable renewable energy. The EU also makes contribution through the ADB on solar energy for outer islands. The focus of the Tonga Energy Roadmap 2010-2020 is to meet 50% of the energy demand from renewable sources and thereby reducing the import of fossil fuels as well as the vulnerability of the economy to external shocks caused by hikes in oil prices. The EU has also made contribution to disaster recovery and rehabilitation. Japan The assistance to Tong by the Japanese Government started in 1977 by implementing its first grant aid. Since 1990, it has been implementing its grant assistance through the Grassroots Human Security Project. These involve assistance to communities in upgrading water supplies and upgrading and building new classrooms. Japanese aid assistance is delivered under an Economic Cooperation Scheme with the following pillars: - ‘environment and climate change’, ‘overcoming vulnerabilities and promoting human security’ and ‘enhancing people-people-exchange’. The development cooperation with Tonga are implemented in the areas of: ‘(1) environmental protection and climate change: adaptation and mitigation for climate change, consolidation of accessibility to water resources, (2) improvement of basic social services: improvement of the infrastructure and quality for health and education sectors and (3) enhancement of infrastructures for sustainable social and economic development: development of infrastructures, maintenance, and human resource development in order to create a sound environment to promote the growth of Tonga's industries’. Since 2012, Japan has been funding major projects in climate change (disaster risk management, clean energy, renewable energy), environment conservation (recycling), health and medical services (improvement of hospitals, equipment, primary health care), and quality and access to education. People’s Republic of China The assistance from the People’s Republic of China has been focusing on agriculture and infrastructure. Presently, the assistance has been extended to the health sector with the provision of medical equipment and visiting medical teams. Other infrastructural projects being funded include the sporting infrastructure and Government administration buildings as well as the transport sector upgrading of facilities. 153 Target Table 16: Target 8E: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries Indicators 1990 1995 2000 2005 2010 2015 Target Status

8.8 Proportion of 95 95* On population with (2002) target access to affordable essential drugs on a sustainable basis Source: Ministry of Health 2015 *=estimated. Comment The data from the MOH indicate a high level of accessibility of the general population to essential drugs. All community hospitals across Tonga and the referral hospital in Tongatapu provide the essential drugs for free, with prescription from a medical officer. There are also a number of privately run pharmacies which can provide essential drugs upon prescription but which the public will have to pay. The health centres can also prescribe essential drugs which patients can obtain. Final Performance Status: For access to affordable essential drugs: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On target Strong Target Table 17: Target 8F: In cooperation with the private sector, make available the benefits of new technologies, especially information and communication Indicators 1990 1995 2000 2005 2010 2015 Target Status

8.9 Telephone lines per 4.6 6.8 9.8 10.6 10.8 13.2 On 100 population (2008) target

8.10 Cellular subscribers 0 0.31 0.18 29.84 46.4 66.3 On per 100 population (2007) target

8.11 Internet users per 0.1 1.8 8.4 39.6 On 100 population (2003) (2007) target 154 Comment: The increase in the use of telephone lines between 2008 and 2015 is a result of the deployment of a new network system in 2014, which combined both the fixed line system, the mobile exchange system and the internet system. It was introduced for the fast internet speed with reasonable pricing for the consumers. The substantial increase in the number of cellular and internet users is due to recent commencement of the utilisation of the submarine internet cable in 2013, and mobile 3G network introduced in 2013, by the two communication companies – Tonga Communications Corporation and Digicel, to improve performance and extending coverage across Tonga. Only one company provide a fixed line network with fixed telephone lines – Tonga Communication Corporation. The increase in telephone lines usage between 2008 and 2015 is due to the impact of the deployment of the newly Converged Network in mid-2014, combining the fixed telephone line system (exchange), Mobile Exchange System and the internet system where ADSL2+ (both internet and telephone line using one single line) was introduced in early 2014. Both companies are working to extend their coverage across the country and should have these indicators increased by the end of the year or early 2016. Final Performance Status: For available of new technologies: State of Progress Towards the Degree of Achievement of Degree of State and Target Target Stakeholder Support Very Good On target Strong 155 PART 3 THE FUTURE 156 7. Unfinished Business and Emerging Priorities

7.1. Poverty Eradication It has been identified in the discussions in Part 2, that the proportion of people living in hardship and below the Basic Needs Poverty Line since 2009 (22%) has not been reduced. Although the depth of relative poverty is not severe, it is likely that they are deprived of the opportunity to participate effectively in economic activities and income generation. They are the most vulnerable in economic downturns and natural disasters. It is clear that there are gaps at the policy level and coordination of action in dealing with those living in poverty and hardship. There is no consistent and integrated policy statement or framework to address poverty eradication. The efforts of the actors, both Government and CSOs, have largely been lacking coordination. Because of the absence of a clear statement of policy on poverty eradication embedded in an integrated framework for implementation, there is no focal point for action. The assistance provided to the actors in the field and activities undertaken will then be thinly scattered and uncoordinated. There is a need to look at other areas that have implications on poverty and hardship such as employment creation, skill development, housing, subsidies and more macro-level policy issues such as income distribution, equity and access to basic sanitation, health and education, investment in small infrastructures, internal migration, family planning and population planning, to state a few. The informal sector and youth sector, which is populated by those living in hardship – men, women, young people and children and 60% of the working age population – can become an engine of economic growth. It has to be properly institutionalised under an integrated policy framework with strong links to the formal sector. The informal sector has significant implications on poverty eradication. Tonga must engage the stakeholders and development partners in designing an integrated policy framework to address the policy priority areas that will allow those living in hardship to exploit opportunities, better their conditions and break out of the poverty cycle. Such a policy framework should involve partnership and sharing of responsibilities between Government, the actors and development partners and become a focal point for action.

7.2. Universal Primary Education Tonga has met the targets set by the MDGs on the delivery of universal primary education, and ensuring that all children complete a full course of primary schooling. This has its basis on a strong legislative and policy frameworks, as previously described, which have been the instruments for managing the education sector (Education Act, TESS, TEPF, TESP). The policy on access and equity in the provision of primary education have been maintained and work to maintain quality standards have been significant over the years. 157 Emanating from the legislative and policy frameworks, are a number of significant new priorities. These include the ECE, IE and extending the compulsory education age from 4 to 18 years of age with universal basic education from 4 to 14 (Form 2). The ECE is important as a basis of preparing young children for primary education. Its coverage is still growing and continue spanning into rural and remote areas. The IE is relatively a new policy priority, which takes primary education to a new level, where young children with disability are also brought into the primary school environment to integrate with other young children. It has future economic and social benefits for the disabled and for the community, as they would be able to effectively participate in economic activities and social life, without becoming a burden to their families and communities. Extending the compulsory education age from age 4 to 18 has been under discussion for some years now. It is intended that it will better prepare children for life long education and reduce the rate of students dropping out of school. These will continue to dominate the agenda for education requiring more resources for implementation of programs and activities. The challenge of maintaining quality, equity and relevance will continue into the future as priorities.

7.3. Gender Equality and Women Empowerment There is now a sound framework for the education sector which provides for access and equity for both girls and boys. Providing for gender equality and empowerment of women in the MDGs has made positive impact on the disparity between females and males in enrolment at school. Reduction in the disparity to a minimum has been achieved over the last 15 years. This is important because effectively females and males should be stair-cased from the education system to productive employment. Within this stair-casing process, there is a need to provide choice and access for women and men. While choices have been made available over the years in terms of the training they both prefer, it is not accessible for all, especially secondary and post-secondary education and training. The introduction of the vocational-based subjects (movement and fitness, creative technology, languages) in the primary education curriculum and the technical and vocational courses into the secondary school system is a step in this direction. This leads into technical and vocational training as a choice at the tertiary level. What has been described so far is an emerging field of work, where vocational and technical training becomes an instrument of empowerment that should continue to be pursued and strengthened under Tonga’s education system. This is also part of the Incheon Declaration Education 2030 and MET should continue the work in this direction. When this is maturing, it will have substantial impact on improving the share of women in wage employment. The TCCI hosts initiatives in consultation with the Government and the development partners to encourage women to enter the small business sector. However, until the work described is effectively implemented, the share of women in wage employment remains an unfinished business. The employment market is dictated by the demand for expertise and skills and the ability of the education system to meet the demand. Women would be able to compete effectively in the local and international employment markets, and be able to enter the business sector, if equal opportunities are guaranteed. The National Policy on Gender and Development, the Convention 158 on the Rights of the Child, the CEDAW are instruments for providing boys and girls, men and women with equal opportunity in education, in employment and in politics. As such, it is worthwhile to continue the effort to implement the relevant provisions of these conventions. Political participation by women in politics and representation in parliament may take time to achieve. More work needs to be done in civic education, public awareness and training.

7.4. Child Mortality and Maternal Health Tonga has good track records on child mortality which is maintained at a very low level as in the absolute numbers and is a milestone. It is clear from the records that risky fertility behavior and the mother’s social and behavioural background influence child mortality. This would be where continued efforts are required to provide child health and reproductive health education and outreach programs through the MOH partners. What is emerging from this is the issue of how robust is the health system given the current level of resources to deliver the whole range of services in the health sector including child health, to ensure that people, like mothers, take responsibility for their health and the health of their children outside of the hospital. The maternal mortality ratio is satisfactory, given the absolute number of deaths. The proportion of births attended by skilled health personnel has been maintained at a very high level. Ante-natal care is accessible and visits by pregnant mothers is at a high level. However, the use of contraceptives is still low although there is widespread awareness of contraceptive methods. A large number of women still have unmet needs for family planning. Adolescent birth rate is likely to increase and this will have serious impact on child mortality and maternal health. These should continue to be addressed under current programs but at the same time, they bring forth the emerging priority of family planning and population planning. These are areas of priority that should be dealt with immediately. Future population growth should be planned in view of Tonga’s limited resources and space, its vulnerability to climate change and its cultural and social environment.

7.5. HIV/AIDS and NCDs Tonga has performed well in the HIV/AIDS sector, as far as the expectation of the MDGs Target 6A is concerned. However, the outstanding issue is the prevention measures that would minimise or eliminate the potential threat that the population will be infected and HIV spread because the screening system is not robust enough to detect those who are carriers. Low levels of condom use and comprehensive knowledge of HIV/AIDS as well as the increasing number of people engaging in risky sexual behavior are the major risk factors. The policy framework that allows potential carriers and PLHIV to come forth for screening needs to be strengthened, especially the legislation, public awareness, community involvement and participation and resilient border screening. The progress of work on TB is satisfactory and is maintained at its current level of effectiveness with the support of the development partners. However, the work on the NCDs sector still remain 159 unfinished because of the magnitude of the prevalence of the NCDs and the risk factors. A large part of the Tongan population are overweight and obese. It should be noted that the policy framework and strategies for addressing the NCDs are already in place. The timeframe to undertake the appropriate programs and measures may extend into the future medium-term. The integration of the NCDs policy frameworks and strategies and those in other areas which have implications on the NCDs such as food, tobacco, alcohol, physical activity, education, community development, poverty alleviation, taxation and duties and so on, should now be undertaken. Furthermore, the delivery of the NCDs programs and activities should involve extending and spreading the appropriate infrastructures into the rural and remote areas and networking more partners for the delivery of services.

7.6. Environmental Sustainability Tonga has done fairly well in terms of compliance with the relevant conventions on bio-diversity and climate change. It has also been able to ensure sustainability and address the potential risks in the water and sanitation area. However, the policy framework recommended to be in place including the Land Use Policy and Land Use Plan, National Forestry Policy and National Forestry Plan, and National Agricultural Policy, should be reviewed and approved to be fast tracked for implementation. Support should be given to the work by the MOF and the MEIDECC for protection and conservation of the terrestrial and marine bio-diversity and environment. This is important because of the rate in which human encroachment is damaging the terrestrial environment, especially forest cover and threatened species, and marine environment, especially threatened commercial species and reefs. Important in this work is the conservation of threatened species, terrestrial and marine. This is because of increasing commercialisation of some species and low level of replanting of other species for terrestrial species and violation of seasonal banning of some threatened marine species. Continued support should also be given to the work of MEIDECC to comply with the convention on climate change. The work the TWB, MOH, TWAL and MEIDECC to protect the water resources and improve sanitation is important. Water supply in rural areas could be vulnerable to contamination, especially from waste water and solid waste. As such, it is important that current projects and future ones be given the appropriate support, both at the policy level, and at the program level.

7.7. Global Partnership for Development The role of the development partners in Tonga’s development and in achieving the targets of the MDGs has been very crucial. The total allocation for aid assistance to Tonga has remained steady over the years and as planned. This report has made reference throughout to the financing of programs and projects in all areas of the MDGs, technical assistance and provision of strategic advice. Health and education as well as environmental sustainability have been the greatest beneficiaries of the assistance provided by the development partners. The achievement of the targets under some of the MDGs, can be attributed to the role of the development partners in Tonga’s development. 160 However, in recent years there has been negotiations on the need to open up trade in some of the commodities in markets in OECD countries. While the negotiations are ongoing, it has been difficult and slow. Tonga undertakes some of the bi-lateral negotiations and at the same time joins in the regional trade organisations for multi-lateral negotiations. The work on this front will continue into the future. 161 8. New Challenges and Opportunities

8.1. Reducing Poverty and Hardship Through Policy There is now a general understand of relative poverty and hardship in Tonga. This new understanding must be put into perspective within an integrated policy framework, as poverty eradication is multi-dimensional. The informal sector can become the second engine of growth so that productive employment and decent work for all, and eating a decent meal, is possible. However, there is a need to set the policies right first. The only effective way to coordinate efforts to deal with poverty eradication is to put in place an integrated policy framework both for implementation and for monitoring and evaluation of progress. In thinking about the future and the role of remittances and social protection, they may not be sustainable options. Tonga needs to be innovative in looking at new options and new priorities in dealing with those who live in hardship. While they may rely on traditional industries for their livelihoods, they could be empowered through education and training, resourcing, mentoring and coaching and partnering. There are greater challenges now than before in terms of the impact of climate change on their livelihoods, protection from natural disasters and their vulnerability to economic forces beyond their control. These challenges must be part of policy design and implementation, undertaken in a manner that brings Government agencies, development partners and stakeholders together for action. The problems of poverty eradication are also opportunities to build the informal sector as the second engine of economic growth and bring into the arena of economic activity the strengthens and resources of the men and women in the informal sector. These must be tied to the policy frameworks for developing the private sector in order to build sustainable capacity.

8.2. A More Inclusive Education These emerging priorities in education – ECE, IE and expanding the compulsory school age, will have positive social and economic impact. But at the same, there are costs involved in pursuing these emerging priorities. The ECE is delivered by the church sector with meagre resources and assistance from Government is very limited. The MET is now providing training of teachers and improving the content of the programs that the ECE centres deliver. The greater task is ensuring access and quality. As for IE the trials in delivery is ongoing and the responsibility is expected to be shared by Government and NGOs. It is not clear at this stage how far would be the geographical coverage and the resources available for formalising IE at the primary school level. At the same time, these are an opportunity to provide education for all as an obligation for Tonga to bear and link these to its economic and social goals. The expansion of the compulsory school age from 4 to 18 and universal basic education from age 6 to 14, has its own complexity. It is a costly exercise because of the inclusion of Form 1 at age 13 and Form 2 at age 14, which are secondary school levels. Only a small number of primary schools are extended from class 6 to Form 2. The rest of those who are at age 13 and age 14 are already at the secondary schools under the church education system. It then becomes harder to coordinate universal basic education. For compulsory education, the challenge is what to do with 162 students who want to leave the school system early to join the labour market. Tonga’s working age starts at 15 which is also the law. The law demands that students stay at school until they are over 18 and while at the same time students who are already 15 have a legal right to go to work. These should be resolved at the policy level to ensure better coordination and transition between school and work.

8.3. Women in Employment and Decision Making The disparity between girls and boys in enrolment has been reduced to a minimum but at the same time the disparity between the Government and non-government schools remains a challenge. The quality of education received by women and providing the training of their choice is one of the determining factors in gaining employment. However, having access to training is a greater challenge. The training opportunities are concentrated in urban areas and therefore should be spread out into the rural areas and outer islands to be accessible. While there are policy frameworks already in place, there has to be political commitment to carry them through so that their provisions are implemented. If there are political commitments, then it would be easier to mainstreams provisions regarding education and training as well as employment and participation in politics and decision making. There are more actors now than 15 years ago in the field in Tonga advocating the plight and rights of women. They should form part of the network of partners promoting equality of opportunity in education, employment and in politics.

8.4. Healthy Mother and Child Child mortality and maternal health are linked, not only to other health policy areas but also to policies on national employment, educational opportunities and population planning that determine the wealth status of the households, level of education and fertility behavior. At the broader policy level, the responsibility of policy makers is to target policy areas that have positive impact on the health indicators. There is a need for the deployment of more surveys and data collection to establish the linkages between the macro-level policies and health policies, including child mortality and maternal health. If more and more people engage in high risk fertility behavior, then there will be a greater chance that the health system can be greatly strained. The greater challenge then is the enormous task of integrating population planning into mainstream policy. Financing health services in the future will require a larger budget, as well as the extension of the current infrastructures and networking with a larger number of stakeholders for the delivery of services. Tonga has a youthful population and if population growth is allowed to take its course unchecked, it may have undesirable consequences in the future.

8.5. HIV/AIDS and NCDS Tonga has the advantage of effective protection against HIV/AIDS. However, the attitudes towards PLHIV, stigmatisation and cultural barriers will remain the biggest challenges to prevention. If the legislative framework and monitoring and evaluation framework are in place, 163 they will facilitate the work to remove these limitations and facilitate the work to protect Tonga from HIV/AIDs and prevent potential spread. The new challenges for the NCDs is the cost of extending further the outreach and services. The burden of disease is likely to increase in the future, in order to achieve the critical mass to cause a major behavioural and social change or reversal in the trend. There must be an effort to ensure that the current health system is robust enough to cater for all health services as well as NCDs now and in the future. The data collection system in the health sector should be further strengthened so that data for decision making has integrity and quality required, and that they could be shared in a timely manner. As a matter of policy, the budgetary and finance system should take into account the need to see an increase over time of the recurrent expenditure on health services. The role of the development partners in funding programs that target priority areas including NCDs continues to be crucial. However, developing partnership with stakeholders can result in sharing the burden of the responsibilities and resource requirements.

8.6. The Environment The sustainability of the environment is significant in ensuring a secured economic future for the generations to come. The new challenge now is the coordination at the policy level where there is better integration of strategies, plans and programs targeting priority areas where collaboration and partnership should be fostered. This should result in efficiency and effectiveness and sharing of resources in delivery of programs and activities. The impact on the environment and people should be monitored closely. Frequent restructuring of the public sector, scatter the total responsibilities for environmental sustainability. This makes coordination of programs and activities and monitoring and evaluation harder. The legislative frameworks and policy frameworks that are yet to be in place should be reviewed to ensure that they facilitate collaboration, partnership and sharing of responsibilities and resources. These are important challenges and putting in place such frameworks will assist in better targeting of priorities and effective monitoring and evaluation of programs and activities. 164 9. The Future In View of the Post MDG Sustainable Development Goals In a small and vulnerable economy such as Tonga’s, the benefits of economic growth does not always trickle down to the lowest levels. The market will not be able to correct inequalities and inequity, they must be corrected through sound policy making. Therefore, for Tonga, the new SDGs (Goal 1, Goal 2 and Goal 10) present a new opportunity to look at poverty eradication and reducing inequality under new light and bring in sound policy for addressing poverty eradication. The work that Tonga will do is to build a good policy foundation and monitoring and evaluation framework to bring together the actors in the economy and society. It is possible to create decent work for everyone and it is possible to engage everyone in productive employment. This remains an ongoing challenge for Tonga. Goal 8 of SDGs is the link to a new decade where the focus on both formal and informal sectors will see productive employment and decent work for all becoming a reality. Education is a vital part of Tonga’s development and all the efforts described in this report are intended to ensure that there is a sound foundation for it. The new emphasis on ECE and IE and continued emphasis on quality, access and equity and lately on skill for employment, ties in well into the proposal in the SDGs to ‘ensure inclusive and equitable quality education and life-long learning opportunities for all.’ Tonga has already acceded to the Incheon Declaration Education 2030 at the World Education Forum 2015. The Incheon Declaration, is based on Goal 4 of the SDGs and it encapsulates Tonga’s emerging priorities in education and employment and how to deal with the challenges. It is the bridge for Tonga’s transition from the MDGs to the SDGs with regards to education and training. In a traditional society like Tonga, gender equality and empowering women will persist as issues for dialogue. However, it is possible to see change in the perception, values and institutions in society which will create a conducive climate for pursuing gender equality and empowerment. As such, Goal 5 will provide the avenue to continue the work in this front. Health, as in education, is a significant factor in Tonga’s economic development. It is clear from the discussions that while the health indicators for child mortality are at a satisfactory level, there is still a need to give attention to linkages among policies that have impact on child mortality and maternal health. These policy areas include education and training, employment, sanitation, family planning and so on. For HIV/AIDS, Tonga’s effort for effective protection must also be complemented by strong prevention measures and removal of barriers and restrictions through legislation and putting in place effective frameworks for monitoring and evaluation and tracking of progress. The NCDs remains a top priority for Tonga and would require greater support from the development partners and the stakeholders to address priorities. Goal 3 of the SGDs provides a new platform for renewed commitment to ensuring that the good track records in child mortality and maternal health are sustained and that there is renewed commitment to continue the fight against HIV/AID and NCDs. Environmental sustainability continues to be important for Tonga and transcends over the MDGs period into the future. While Tonga complies fully with the appropriate conventions on climate change the support from the development partners to continue the protection and conservation work on biodiversity and protection of the environment from the effects of climate change and 165 ozone depleting substances is important. The need for sustainable access to water resources, improved sanitation and affordable energy sources will be pressing needs in the future, as the population grows. Therefore, Goal 5, Goal 6, Goal 7, Goal 13, Goal 14 and Goal 15 all provide new opportunities for Tonga to continue to ensure environmental sustainability while meeting the needs of Tonga in the next 15 years. Finally, the role of the development partners in providing financing and technical assistance has been instrumental in the progress towards the MDGs targets. However, the stakeholders and development partners including Government have to come together under one designed policy and strategic framework for action, improve monitoring and evaluation and enhance the availability of data and strategic information for strategic decision making. In this way, there will be better integration, collaboration, coordination and partnership in pursuing one single agenda for Tonga’s development and the SDGs. 166 10. Final Conclusions This report has provide a comprehensive and in-depth analysis of Tonga’s journey towards the MDGs and the set targets over the last 15 years. In the end, it becomes clear that the following are the milestones, as discussed throughout the report.

10.1. Milestones: 1. A better understanding of poverty and hardship in Tonga and action already undertaken to protect the most vulnerable through social protection programs and the work of the CSOs 2. Effective programs delivered by CSOs targeting the vulnerable groups likely to be negatively affected by economic hardship 3. Maintain a high level of enrolment in primary level education through an effective legislative and policy framework allowing equity and access, and good leadership by MET 4. Maintain a high level of literacy among 15-24 age population through the provision of quality education 5. A new Education Act 2013 for effective strategic management of the education sector and the delivery of quality, equitable, accessible, inclusive and relevant education for Tonga 6. Maintain a high ratio of enrolment of girls at primary and secondary school levels as well as post-secondary level through the appropriate policies and strategies to transition them from education to work, good leadership by MET and the non-Government education systems 7. Review and implementation of the National Policy on Gender and Development and accompanied by an Action Plan as the platform for action to promote the participation of women in employment, decision making and in the economy and society with good leadership by MIA 8. Maintain a low level of infant and under-5 mortality rates over the decades through effective and accessible ante-natal and child health services by MOH 9. Maintain a low level of maternal mortality through an effective and accessible ante-natal and post-natal care services provided by MOH 10. Maintain a high proportion of births attended by trained health professionals through effective and quality training and accessible services provided MOH 167 11. Nation-wide coverage of reproductive and child health services through effective policy and program frameworks with MOH and partners taking leadership 12. Maintain a low level of HIV prevalence based on effective strategies and programs for prevention and protection and good leadership by MOH and TFHA 13. Maintain a high level of prevention and protection against HIV/AIDS through health education and outreach programs delivered by MOH and TFHA 14. Maintain an effective TP Program with assistance from the development partners and leadership by MOH 15. A new Food Act for effective strategic management of the food sector and impact on NCDs risk factors 16. A Tonga National Strategy to Prevent and Control Non-Communicable Disease 2010- 2015 (to continue) to guide the work on the NCDs by the MOH and THPF and CLF 17. Effective partnership between the MOH and THPF, TFHA CLF and CSOs in the delivery of NCDs related programs and activities 18. Effective protection and conservation measures on the terrestrial and marine environment through continued compliance with the appropriate conventions and protocols by MEIDECC in association with partners such as MOF, MLNR and CSOs 19. Effective compliance with conventions and protocols on bio-diversity and climate change with the leadership of the Climate Change and Environment Divisions of MEIDECC 20. Effective partnership with development partners for Tonga’s development through various modalities The following will still continue to be part of the development agenda for Tonga in the next decade or so:

10.2. Unfinished Business: 1. eradicate poverty and hardship through social protection and building private sector capacity for sustainable development through partnership between MIA, TCCI and CSOs and with sector Ministries – MAFFF, MOF, MOT 2. provide full and productive employment and decent work for Tonga’s population through the appropriate strategies for linking relevant education and training and employment opportunities through designing policy and implementation frameworks 168 linking the informal sector and the private sector, with effective leadership from MOFNP and MIA and sector Ministries – MFAT, MAFFF, MOF, MOT, MCL and TCCI 3. improve the share of women in the wage employment sector through enforcement of the appropriate conventions and policies and implementation of programs and activities with MIA taking responsibilities 4. allow greater participation of women in politics and decision making through enforcement of the appropriate conventions and policies and implementation of program and activities with MIA taking responsibilities 5. promote more widely reproductive health and family planning services though greater outreach to the community and those at risk with MOH and TFHA and partners sharing responsibility 6. continue the fight against the spread of HIV/AIDS and ensuring effective prevention and protection of Tonga’s population from infection with MOH and TFHA and partners sharing the responsibilities 7. continue the fight against NCDs and the associated risk factors through the implementation of current strategies and programs with increased resource and financial assistance based on the partnership between the MOH, THPF, CLF and CSOs 8. ensure environmental sustainability through conservation and protection of terrestrial and marine environment with stronger commitment by stakeholders to policy and coordination of programs and activities through collaboration between the MEIDECC, MLNR, MOF and CSOs 9. combat the effect of climate change under the relevant conventions and protocols through collaboration between MEIDECC and CSOs and other partners 10. continue to protect and improve water resources and sanitation through the effective management of waste based on collaboration between MEIDECC, TWAL, TWB, MLNR, MOH and partners 11. engage the development partners under an integrated framework for development with the leadership of the MOFNP

10.3. New Priorities: Section 7, 8 and Section 9 provide in broad outline what should be the focus for Tonga in the next 15 years and bring them to bear upon the SDGs, as new priorities. They could be summarised as follows: 169 1. develop an integrated policy framework for addressing poverty and hardship 2. develop an integrated policy framework for developing the informal sector as a second engine of economic growth and link it with the policy framework for developing the private sector 3. reinforce the new focus for education in ECE, IE and compulsory education through the existing policy frameworks and strategic plans as well as the relevant international conventions and protocols 4. forge a strong link between education and training with productive employment by reforming the delivery and ensuring relevance, access and quality 5. enforce the conventions and protocols for gender equality and empowerment 6. review the robustness of the health system to deal with future health problems and potential crises 7. mainstream population and family planning by developing the appropriate legislative and policy frameworks as well as strategic plans for implementation 8. review and further develop an integrated policy and implementation approach in the fight against NCDs 9. review and further develop an integrated policy and implementation approach in the fight against HIV/AIDS 10. review and put in place the proposed policy frameworks for protection and conservation of the environment and resources 11. seek financing of priority development goals for the future 12. develop monitoring and evaluation frameworks for reviewing progress in priority areas with strong implications on the SDGs 13. develop partnership frameworks for collaboration, coordination and action which are important for the delivery of outcomes and making impact for SDGs 14. improve capacity for capturing data and strategic information for decision making across Government agencies having implications on the SDGs These outstanding matters and new challenges are linked to the new SDGs in section 9. 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ANNEX 1 List of People Consulted or Interviewed Foreign Mission Offices  Ms Spohie Temby, Deputy High Commissioner, Australian High Commission - Tonga  Ms Lilika Fusimalohi, Senior Program Manager for Economic and Public Sector, Department of Foreign Affairs and Trade, Australian High Commission - Tonga  Mrs Elizabeth Palu, Health Program Manager, Department of Foreign Affairs and Trade,Australian High Commission – TONGA  Ms Adele Plummer, Deputy High Commissioner, New Zealand High Commission - Tonga  Ms Eriko Oshimi, Chief of Political and Economic Section, Aid Coordinator, Embassy of Japan, Nuku'alofa.  Mrs Balwyn Fa'otusia, EU Coordinator, Ministry of Finance and National Planning Government Ministries MDG Taskforce members  Mr Va'inga Tone – Chairman, Secretary for Foreign Affairs and Trade  Mr 'Ata'ata Finau, Government Statistician  Mr Paula Ma'u, Chief Executive Officer, Ministry of Meteorology, Energy, Information, Disaster Management, Environment, Climate Change and Communications (MEIDECC)  Mr Tatafu Moeaki, Secretary for Finance and National Planning  Dr Siale 'Akauola, Director of Health  Dr Lei Saafi, Acting Director of Health  Mr Claude Tupou, Acting Director for Education and Training  Mrs Losaline Ma'asi, Director for Agriculture, Food, Forests and Fisheries  Mr 'Onetoto 'Anisi, Acting Director for Internal Affairs  Mrs Fuiva Kavaliku, Coordinator, Tonga National Centre for Women and Children  Mrs Siale 'Ilolahia, Director for Civil Society Forum MDG Working committee members  Mr 'Ata'ata Finau, Government Statistician  Mrs Losaline Ma'asi, Director for Agriculture, Food, Forests and Fisheries  Mr Ponepate Taunisila, Chief Assurance Officer - MET  Mr Sione Hufanga, Chief Information Officer - MOH  Mr Vatulele Tuputupu, Deputy Director - MEIDECC  Mr 'Onetoto 'Anisi, Acting Director of Internal Affairs – MIA 181 Statistics Department  Winston Halapua, Senior Statistician Officer  Ms Mele Taumoepeau, Computer Programmer Ministry of Internal Affairs  Mr 'Onetoto 'Anisi, Acting Director - Sports Division  Mrs Pulupaki Ika, Deputy Director - Youth Division  Mrs Kalesita Taumoepeau, Deputy Director - Employment Division  Mrs Tupou'ahau Fakakovietau - Acting Deputy Director - Women's Division Ministry of Health  Dr Lei Saafi, Acting Director of Health  Dr Makameone Taumoepeau, Head of the Obstetrics Ward  Dr Lisiate 'Ulufonua, Medical Superintendent, Vaiola Hospital  Dr Seini Kupu, Public Health Specialist, Ministry of Health  Dr 'Amelia Afuha'amango - Tu'ipulotu, Ministry of Health  Dr Ma'ake Tupou, Specialist in Obstetrics and Gynecology, Ministry of Health  Mr Sione Hufanga, Ministry of Health  Mrs Angela Patolo - Fineanganofo, Tonga - National HIV/STIs Program Coordinator, Ministry of Health  Mr Saia Penitani, Ministry of Health  Sister Afu Tei, Ministry of Health  Mr Sione Hufanga, Chief Information Officer Ministry of Education  Mrs Kalolaine Tafa - Moeaki,  Mr Ponepate Taunisila, Chief Assurance Officer, Ministry of Education and Training  Mr Soane Selui, Chief Education Officer, Ministry of Education and Training  Mr 'Isikeli Oko, Chief Education officer, Ministry of Education and Training  Mr Semisi Pasikala, Chief Education Officer, Ministry of Education and Training  Mrs Kakatisi Taulava, ECE Coordinator, Ministry of Education and Training  Mrs Monalisa Tukuafu, Chair - Tonga Preschool Association  Ms Suliana Kanongata'a  Mrs Seilosehina Fifita MEIDECC  Mrs Lupe Matoto, Director - Environment Department  Mrs Lu'isa Malolo, Director - Climate Change Department  Mr Sione Talolakepa Fulivai - Climate Change Senior Officer  Mr Stan 'Ahio, Telecommunications and Radio Technician 182 MAFFF  Mr 'Emanuele Mo'ale, Deputy Director - MAFFF  Mr Mana'ia Halafihi, Principal Agricultural Officer, MAFFF  Dr Siola'aa Malimali, Acting Head of the Fisheries Department, MAFFF  Mr Vilimo Fakalolo, Deputy Director - Fisheries Department Ministry of Finance and National Planning  Ms Lesieli Tufui Faletau, Deputy Secretary for Finance and National Planning  Mr 'Aholotu Palu, Deputy Secretary for Finance and National Planning  Mr Sione Faleafaa, Principal Economist  Ms 'Ilaisaane Lolo, Principal Economist  Dr Kilisitina Puleiku, Principal Economist  Ms Ma'ata Mafi, Senior Economist CSOs 1. Mrs Seini Filiai, CEO for Tonga Health 2. Mr Siale ‘Ilolahia, Director for Civil Society 3. Mrs ‘Ofa Likiliki,Director for Women and Children Crisis Centre 4. Mr Sione Tutulu Finau, Manager - Performance Appraisal, for Tonga Water Board 5. Mrs ‘Amelia Tipaleli Hoponoa, CEO for Tonga Family Health Association 6. Ms Katherine Mafi, Program Manager for Tonga Family Health Association 7. Reverend Filifai’esea Lilo, Secretary of the National Forum of Church Leaders 8. Ms VanessaLolohea, Director for Tonga National Youth Congress 9. Ms Vanessa Heleta, Director for Talitha Project 10. Mr Siaosi Polovili, Disaster Risk Reduction Officer, Act for Peace 11. Mrs Betty Blake, Director for Ma'a 'a Fafine moe Famili 12. Mr Polikalepo Kefu, Dissemination Officer, Tonga Red Cross Society Private Sectors  Mr Viliami Takau, CEO - Tonga Chamber of Commerce UN Agencies  Ms Milika Tuita, UN Country Development Officer  Mrs Kepreen Ve'etutu, UN Women Project Coordinator  Mr Sione Vaka, UNDP - PRRP, National Project Officer  Mrs Ta'ahiri Hokafonu, UNDP - Reef to Reef, Project Coordinator  Mr Douglas Armour, UNDP - TGSP, Program Manager  Mr Pau Likiliki, FAO Project Coordinator  Ms Elsie Tupou, UNFPA Field Officer 183

ANNEX 2 OUTLINE OF WORK UNDERTAKEN UNDER THE MDGs ACCELERATION FRAMEWORK 2014 Key Activity Result Progress Activity Result 1: Strengthened Policy Framework on  Food Act 2014 reducing the prevalence of NCDs  Establishment of the National NCD Governance System  Establishment of the NCD Focus Group  NCD Policy Review on unhealthy food and tobacco  School Food Policy reviewed and submitted  Workplace Healthy Policy under- review by the PSC  Establishment of the NCD Nurses Cadre  Developing the MAF M&E Framework Activity Result 2: MAF mainstreamed into  Mainstream of MAF into Enhanced national planning framework Balance Scorecard System  MAF national fund pool in the FY2014-15  MAF participation during the 2014 Annual Donor Forum  MAF participation at the MOH corporate planning 2014 workshop Activity Result 3: Public engagement and  MAF Expo – 5th July 2014 advocacy & promoting inclusive participation  NCD Day – 14 Nov 2014 and national ownership of the MAF  Billboards campaign  Posters campaign  Brochures campaign  NCD song – ‘Mata’ikoloa Mole’ (life is too precious to lost early to NCDs 184

ANNEX 3 FINAL STATUS MATRIX FOR THE MDGs INDICATORS Goal 1: Eradicate extreme poverty and hunger Target 1A: Halve, between 1990 and 2015 the proportion of people whose income is less than one dollar a day Indicators 1.1 Proportion of population below $1 (PPP) per day - - - 1.1.A Proportion of people living below National Poverty Line ** M % 1.2 Poverty gap ratio ** M 1.3 Share of poorest quintile in national consumption ** M Target 1B: Achieve full and productive employment and decent work for all, including women and young people Indicators 1.4. Growth rate of GDP per person employed ** M 1.5. Employment-to-population ratio ** M 1.6. Proportion of employed people living below $1 (PPP) per - - - day 1.7. Proportion of own-account and contributing family ** M workers in total employment Target 1C: Halve, between 1990 and 2015, the proportion of people who suffer from hunger Indicators 1.8. Prevalence of underweight children under-five years of age **** S 1.9. Proportion of population below minimum level of dietary **** S energy consumption Goal 2: Achieve Universal Primary Education Target 2A: Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling Indicators 2.1 Net enrolment ratio in primary education **** S 2.2 Proportion of pupils starting grade 1 who reach last grade **** S of primary 2.3 Literacy rate of 15-24 year-olds, women and men **** S 185 Goal 3: Promote gender equality and empower women Target 3A: Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015 Indicators 3.1 Ratios of girls to boys in primary, secondary and tertiary **** S education 3.2 Share of women in wage employment in the non- ** M agricultural sector 3.3 Proportion of seats held by women in national parliament ** W Goal 4: Reduce Child Mortality Target 4A: Reduce by two thirds, between 1990 and 2015, the under-five mortality rate (between 1990 and 2015) Indicators 4.1 Under-five mortality rate **** S 4.2 Infant mortality rate **** S 4.3 Proportion of 1 year-old children immunized against **** S measles Goal 5: Improve Maternal Health Target 5A: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio Indicators 5.1 Maternal mortality ratio **** S 5.2 Proportion of births attended by skilled health personnel **** S Target 5B: Achieve by 2015, universal access to reproductive health Indicators 5.3 Contraceptive prevalence rate ** S 5.4 Adolescent birth rate ** S 5.5A Antenatal coverage (at least one visit) *** S 5.5B Antenatal coverage (at least four visits) **** S 5.6 Unmet need for family planning ** S 186 Goal 6: Combat HIV/AIDS, and NCDs Target 6A: Have halted by 2015 and begun to reverse the spread of HV/AIDS Indicators 6.1 HIV prevalence among population aged 15-24 years **** S 6.2 Condom use at last high-risk sex *** M 6.3 Proportion of population aged 15-24 years with * M comprehensive correct knowledge of HIV/AIDS Target 6B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it Indicators 6.4 Proportion of population with advanced HIV infection with **** S access to antiretroviral drugs Target 6C: Have halted by 2015 and begun to reverse the incidence of TB and reduced the prevalence of NCDs Indicators 6.5 Incidence, prevalence and death rates associated with TB **** S 6.6 Proportion of TB cases detected and cured under directly **** S observe treatment short course 6.7 Incidence, Prevalence & Death associated with diabetes ** S 6.8 Incidence, Prevalence & Death associated with ** S cardiovascular diseases 6.9 Incidence, Prevalence & Death associated with ** S hypertension 6.10 Incidence and Prevalence associated with obesity ** S Goal 7: Ensure environmental sustainability Target 7A: Integrate the principles of sustainable development into country policies and programs to reverse the loss of environmental resources Indicators 7.1 Proportion of land area covered in forest *** M 7.2. CO2 emissions, total per capita and per $1 GDP (PPP) **** S 7.3. Consumption of the ozone-depleting substances (HCFC- **** S 22 (ODP tons) 7.4 Proportion of fish stock in safe biological limits - - - 187 Target 7B: Reduce bio-diversity loss, achieving, by 2010, a significant reduction in the rate of loss Indicators 7.5 Proportion of total water resources used *** S 7.6 Proportion of terrestrial and marine area protected *** S 7.7 Proportion of species threatened with extinction *** S Target 7C: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation Indicators 7.8 Proportion of population using an improved drinking *** S water source 7.9 Proportion of population using an improved sanitation *** S facility Goal 8: Develop a global partnership for development Target 8A: Develop further an open, rule-based, predictable, non-discriminatory trading and financial system. Indicators 8.1 Net ODA Total and to the least developed countries as % **** S of OECD/DAC donors gross income 8.2 Proportion of total bilateral, sector allocable ODA of **** S OECD/DAC donor to basic social services 8.3 Proportion of bilateral official development assistance of **** S OECD/DAC donors that is untied 8.4 ODA received in small island developing States as a **** S proportion of their gross national income Target 8C: Address the special needs of small island developing states Indicators 8.5 Proportion of total developed country imports (by value and excluding arms) from developing countries and least **** S developed countries admitted free of duty 8.6 Average tariffs imposed by developed countries on agricultural products and textiles and clothing from **** S developing countries Agricultural support estimate for OECD countries as % of **** S their gross domestic products 8.7 Proportion of ODA provided to help build trade capacity **** S 188 Target 8E: In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries Indicators 8.8 Proportion of population with access to affordable **** S essential drugs on a sustainable basis Target 8F: In cooperation with the private sector, make available the benefits of new technologies, especially information and communication Indicators 8.9 Telephone lines per 100 population *** S 8.10 Cellular subscribers per 100 population *** S 8.11 Internet users per 100 population *** S 189 Report compiled and written by, TUFI Policy and Strategic Management Consultancy Services Nuku’alofa, Tonga. Email: taniela.fusimalohi@gmail.com Typesetting and Designed by, Printed by, Filimoe’unga ‘Aholelei A&A Retailer (Tonga) Ltd, Printing Email: unga.aho@gmail.com Pahu, Nuku’alofa, Tonga; Ph: +67622331 Email: sales@aagroup.to/print@aagroup.to 190