National health strategic plan 2023 - 2027

1. Message from the Minister of Health: Honourable Vainetutai Rose Toki Brown 14 1. KRA 3 Objectives 73

2. Message from the Secretary of Health: Mr Bob Williams 17 D. Key Result Area 4: Primary Care 75

1. KRA 4 Objectives 78 II EXECUTIVE SUMMARY 18 E. Key Result Area 5: A. Situation Analysis 22 Allied Health and Clinical Support Services 79

1. Country and Demographic Characteristics 22 1. KRA 5 Objectives 80

2. Population Census and Structure 22 F. Key Result Area 6: Oral Health 83 B. Political and Socioeconomic Characteristics 24 1. KRA 6 Objectives 86

1. Health System 26 G. Key Result Area 7: Pa Enua 87

2. Health Legislation 27 1. KRA 7 Objectives 90 H. Key Result Area 8: Partnerships 96 C. Organisational Structure 27 VII IMPLEMENTATION STRUCTURE AND SCHEDULE 98 D. Health Services 30 A. Costing the Health Strategy 98

1. Hospital Services 34 VIII MONITORING AND EVALUATION 102

2. Primary Health Care Services 34

1. Introduction 102

3. Other Health Services 34

2. NHSP Indicators 102

4. Pa Enua Health Clinics 35

3. Disease / Programme-Specific Indicators and Targets 102

5. Referral Services, Secondary and Tertiary Care 35

4. Measurement and Reporting Frequency 102

6. Private Health Providers 35

5. Health Information System / HIU Integration 102 E. Health Situation: Access, Morbidity, Mortality 35 and Health Needs of the Population IX TARGET INDICATORS MONITORING FRAMEWORK 103

1. Health Workforce 42 1. KRA 1 Targets 103

2. Health Financing 43 2. KRA 2 Targets 106

3. Funding Support from Development Partners 45 3. KRA 3 Targets 113

4. Gap Analysis of the Health System 46 4. KRA 4 Targets 115

5. KRA 5 Targets 120 III MY HEALTH, MY FUTURE: 49 TMO essay competition winner year 9-11 category 6. KRA 6 Targets 123

7. KRA 7 Targets 127 IV TE MARAE ORA ARA TANGO ANGA’ANGA: 50 National health strategic plan 2023 - 2027 X COUNTRY COORDINATING MECHANISM 130

1. Methodology 50 1. HAP Supervisory Committee 130

2. Policy, Legal, and Strategic Plan Linkages 50 A. Country Progress and Performance Review Mechanism 130 B. NSDA 2020+ 51 1. Schedule of Reviews 130 C. Alignment of NSDA 2020+ to NHSP 2023+ 52 2. Data Sources 131

3. Dissemination and Communication 131 V NHSP 2023+ GUIDING PRINCIPLES 56 XI MY HEALTH, MY FUTURE:

1. Vision 56 TMO essay competition winner year 12-13 category 134

2. Mission 56 XII APPENDIX 1: NHSP CONSULTATION PROCESS 136

3. Values - EQUIPPER 56

1. Initial Programme – NHSP 2017-21

4. Policy Goals 56 Evaluation and NHSP 2023+ Consultations 136

2. Consultations 137 XIII APPENDIX 2: TMO ORGANIZATIONAL STRUCTURE DIAGRAMS 148 8 9 I. ACKNOWLEDGEMENTS Te Marae Ora [TMO] Ministry of Health Cook Islands would like to acknowledge the utmost support by ADB for the technical assistance of Dr. David Angelson, the author of this document for his immense evaluation and thorough review of the National Health Strategic Plan 2017-2021. The outcomes of that review provided the avenue to develop the new national health strategy through a number of face-to-face, zoom meetings, and workshops implemented since February 2023 to June 2023 with TMO staff both on Rarotonga and Pa Enua; Allied Partners and Non-government organisations; Members of Parliament and Ministers of the Crown; and members of the community. TMO further acknowledges the continuous support of ADB and the Government of the Cook Islands for their financial contributions and pivotal support during the implementation of this project, which completed within six months. Further appreciation to Roana Mataitini, Director of Planning and Funding and Helen Maunga, Policy Advisor of Te Marae Ora Ministry of Health, Cook Islands. Their concerted efforts from the beginning to the timely completion of this project is appreciated. Last, but not least to all the National Tereora College students from Year 9 to Year 13 who participated in the Essay Competition in English or Cook Island Maori. It was a tough essay competition written by 52 brilliant students based on the Theme: “My health, my future’’. Thank you all for participating. You have inspired and made an impression on Te Marae Ora of your insights and passion for a healthy Cook Islands. Congratulations to all winners and meitaki ma’ata to Principal Mrs Teremoana Ngaau and your teachers for your support. The first place winners for Year 9 – 11 and Year 12 – 13 categories is published in this document. The content was prepared by the Planning and Funding Office, Ministry of Health, Government of the Cook Islands. Design and layout for this document is created by Maxine Kokaua. 10 11 JULY 2023, Mitiaro Early Childhood Education Learners. 12 13 MESSAGE FROM THE MINISTER OF HEALTH: Honourable VAINETUTAI ROSE TOKI BROWN Kia Orana tatou katoatoa, On behalf of the Government of the Cook Islands and Minister of the Crown for the Ministry of Health, I am pleased to present to the People of the Cook Islands, international communities and donor partners, the Te Marae Ora Ara-Tango Anga’nga 2023 – 2027: Cook Islands National Health Strategic Plan 2023-2027 (TMO Ara-Tango Anga’nga). I am delighted and proud to have been part of this journey contributing to the shaping and developing of this new national health strategy. More so, this is the first strategic document developed during my term as Minister of the Crown for Te Marae Ora, Ministry of Health Cook Islands. Of course, this strategy is designed and planned to ensure a much dynamic and collaborative health services in the Cook Islands and Pa Enua be improved better than before, in that, all people living in the Cook Islands are living healthier lives and achieving their aspirations. When you read this national health strategy, it provides all the tools how each TMO staff should perform within their respective Directorates by working smarter to ascertain that equitable health services are accessible to everyone with much focus in advocating for a healthy nation in this era for a healthy population. It is my utmost goal for all TMO staff to work strongly together as a Team and perform better with a positive attitude visible to everyone. I have much confidence in the current TMO administration that the Secretary of Health and his team can do their best while they guide and motivate each other to continue moving forward while providing the best health services to all Cook Islanders, residents and visitors to our shores. I would like to express my sincerest appreciation and gratitude to all TMO staff for their commitment and dedication uplifting with pride their own individual responsibilities to provide the best healthcare for our people. This 5-year strategy challenges you all to think positive, be more productive and accountable in the health services that we deliver. “Let’s embrace Te Marae Ora Ara-Tango Anga’nga 2023 – 2027 and Walk the Talk.” Kia orana, e kia manuia 14 15 MESSAGE FROM THE SECRETARY OF HEALTH: MR BOB WILLIAMS Kia Orana, I am delighted to present the Te Marae Ora Ara-Tango Anga’nga 2023 – 2027: Cook Islands National Health Strategic Plan 2023-2027 (TMO Ara- Tango Anga’nga). The TMO Ara-Tango Anga’anga provides the founding pathway (ara-tango) of our collective journey for the next five forward years. This is guided by the 8 Key Results Areas (KRAs) and the 200 target indicators aimed to ensure that “all people living in the Cook Islands are living healthier lives and achieving their aspirations” on Rarotonga and the Pa Enua. The KRAs have increased by one and the target indicators have doubled from that of the Takai’nga Angaanga Tutara A Te Marae Ora 2017-2021: the Cook Islands National Health Strategic Plan 2017-2021: Takai’anga Angaanga Tutara A Te Marae Ora. PART 1 of this document outlines the Evaluation Report of the National Health Strategic Plan 2017-2021 while PART 2 provides the Final Report of the Health Action Plan Framework 2023-2027. As you read the evaluation report, you will note the comprehensive methodology approach conducted and the challenges and limitations in the consultation findings to financing the implementation of the NHSP 2017-2021. TMO endeavoured to fulfil its service delivery sculptured in the NHSP 2017+ across the Cook Islands amid COVID-19 to achieve over 60% of its 121 target indicators. The evaluation report provided some interesting facts worth reading and the pathway to establish the monitoring tool and evaluations for the new NHSP 2023+. In essence, COVID-19 Pandemic, made us stronger, much wiser and better prepared than before. I must compliment my predecessor; Dr Josephine Aumea Herman for the strong leadership and professionalism together with experienced TMO staff, health specialists’ locum and stakeholders navigating our small nation through the beginning of COVID-19 in 2020 complemented with the support from the Government of the Cook Islands. The extra KRA is specific to the Pa Enua while the extra indicators are to address the increasing health needs of the people of the Cook Islands and taking into considerations the lessons learnt from COVID-19, the national health priorities as set out in Te Ara Akapapa’anga Nui 2020+: National Sustainable Development Agenda 2020+, Te Kaveinga Tupu’anga iti Tangata: Cook Islands Population Policy 2022-2023, the World Health Organisation Regional Frameworks and the health strategic priorities as set out in Te Papa Tutara A Te Marae Ora 2017-2036: The Cook Islands National Health Road Map 2017-2036. The TMO Ara-Tango Anga’nga sets the new strategic pathway for TMO as it aspires to escalate and address the key risk factors and social determinants to the increasing rate of Non-communicable diseases (NCDs) which accounts for 72% of deaths in the Cook Islands. Reorienting the delivery of healthcare services with stronger refocus on prevention, early intervention and diagnosis, increased self-empowerment to manage own health, and transforming the Cook Islands health service from a “sick system” to a “people-centred system” contributes to the increase of the key deliverables in this TMO Ara-Tango Anga’anga. The reorientation also called for urgent consideration for increased measures and response to oral health conditions for children, the increasing rate of mental health post COVID-19 and building a resilient health system to effectively respond to the risk and threats of climate change including potential future health emergencies. “Investment in a safe and healthy future Cook Islands can only be achieved through a whole of society response – we as a nation did it once and we can do it again!” Meitaki Ranuinui 16 17 II. EXECUTIVE SUMMARY This report comprises the draft National Health Strategic Plan (NHSP) 2023+; the formal, final NHSP 2023+ will be endorsed by the Cook Islands Cabinet prior to adoption. The NHSP 2023+ will be aligned with the Cook Islands constitution, Te Kavaeinga Tupu‘anga iti Tangata: Cook Islands Population Policy 2022-2032, Te Ara Akapapa’anga Nui – National Sustainable Development Agenda (NSDA) 2020+, and other key Cook Islands Government and health documents. This Strategic Plan discusses historical and anticipated challenges in the health sector, including workforce shortages, especially in specialized and allied health domains, and builds on the evaluation of the NHSP 2017-21 to identify required adjustments and optimal future directions. Following consultation with TMO staff, administration and stakeholders, major themes identified include the need for specialized training of the local workforce, as well as non-communicable diseases (NCDs), which are identified as major contributors to morbidity and mortality, necessitating maximized funding allocations for prevention and treatment. This Strategic Plan also highlights the importance of community-based follow-up care for chronic cases and the need for improved diagnostic capabilities, particularly in radiology and screening. This Strategic Plan outlines a quantitative rubric of target indicators, built into a Target Indicators Monitoring Framework (TIMF), including improvements at clinics, attendance of continuing professional development programming for staff, and the use of Health Information System (HIS) data to drive data-driven, evidence-based best practice. National Health Strategic Plan (NHSP) 2023+ implementation will be overseen by the NHSP Supervisory Committee, which includes multiple stakeholders across the Cook Islands health sector, governmental bodies, and civil society. The report proposes a schedule for reviews, including annual reviews, a mid-term review at the end of 2025, and a final situation analysis and evaluation in June 2027 or at the expiry of the NHSP. 18 19 MAY 2023 LAUNCH OF THE HEALTHY ATIU INITIATIVE by the Minister of Health, Hon. Vainetutai Rose Toki Brown and the Secretary of Health, Mr Bob Williams. 20 21 A. Situation Analysis

1. Country and Demographic Characteristics The Cook Islands (CI) is located in the Southern Pacific Ocean. It lies west of French Polynesia, east of The 2021 census recorded ‘a massive decrease’ of population since the 2016 census, with a nearly 13.7% Tonga/Samoa/Niue/Fiji/Tokelau, and south of the Phoenix and Line Islands portion of Kiribati. The Cook reduction in only five years, attributable to outward migration by Cook Islanders, the return of migrant Islands consists of 15 islands and atolls spread over 2 million km2 of the Pacific Ocean, of which 13 are workers to their countries of origin owing to COVID-related tourism downturns, and mortalities among an regularly inhabited. The islands are geographically divided into two groups, commonly referred to as the aging population.2,3 Northern and Southern Group islands. Comparing the CI population pyramid from the 2016 and 2021 censuses, the ‘indent in the 20-29 age There are marked differences in climate, culture, language, and economic activities between the two groups, groups’ represented one of the most ‘distinct feature[s]’, presumably due to young Cook Islanders migrating with the Northern Group generally consisting of drier atolls, and the Southern Group more frequently comprised overseas ‘for employment opportunities [and/]or tertiary education’.4 of wetter volcanic islands (though there are exceptions). Owing to the current lack of regularly scheduled flights, the Northern Group islands are more isolated than the Southern Group islands collectively called the Pa Enua. The northern Cook Islands include Manihiki, Rakahanga, Pukapuka, Nassau, Penrhyn and Suwarrow, while Aitutaki, Atiu, Mangaia, Mauke, Mitiaro, Palmerston, Takutea, Manuae and the main island of Rarotonga comprise the southern Cook Islands. Avarua, located on Rarotonga, is the nation's capital. Outward migration of lower age groups, coupled with longer life spans and returns of retirees and other aged people leads to a dependency ratio of 72 in the Cook Islands (i.e. 72 dependent children and aged persons per 100 persons of working age), compared to an average of 47 among Upper middle income countries, an Organization for Economic Co-operation and Development (OECD) average of 54, a global average of 55,

2. Population Census and Structure and a Pacific island small states average of 65,6 The most recent census was conducted in 2021, recording a total population of 15,040 (both resident and non-resident). Of the total resident population (14,920), 77.1 per cent are Cook Islands Maori, 8.3 per cent are ‘Part Cook Islands Maori’, and 14.2 per cent are of ‘Other Ethnic Origin’ (numbers do not sum exactly to 100% due to rounding). The distribution of the total population varies considerably by region; nearly 73 per cent live on Rarotonga, 20 per cent live inthe Southern Group islands, and 7.3 per cent in the Northern Group islands. The population density also varies widely by island. While there were about 350 people per km² in Pukapuka (the most densely populated island in the Northern Group), only 7 people per km² inhabited Mitiaro Island (the least densely populated island in the Southern Group). The population density of Rarotonga was 162 people per km². 2 Cook Islands Government. 2022. “Census of Population and Dwellings 2021.” Cook Islands Statistics Office. Rarotonga: GCI. p.16. 3 Circular migration and perma- 1 Blacka, M. J., et al. 2013. “Coastal Adaptation Needs for Extreme Events and Climate Change, Avarua, Rarotonga, Cook Islands - Project Stage 1: Scoping and nent returns of Cook Islanders (along with in-migration by not-yet-resident immigrants) following the cessation of COVID-era lockdowns are expected to impact these Collation of Existing Data.” Water Research Laboratory [WRL] Technical Report 2013/11. Sydney: University of New South Wales School of Civil and Environmental population figures and trends, but exact figures are not available at the time of publication. 4 Op. cit. p.18. 5 Ibidem. 6 World Bank Group. 2022. “Age Dependency Engineering. Ratio (% of Working-Age Population) [SP.POP.DPND].” DataBank. Washington, D.C.: WB/IBRD/IDA. 22 23 which means that the Cook Islands population structure will require attention and planning by TMO and the Likely due to COVID-related economic consequences, whereby tourism-related sectors suffered a dramatic broader Cook Islands government. Population projections for 2022 were for more 70+ year-old women than downturn, the largest employing industry sector in 2021 was public administration, at 17.8%, followed by any working age tranche, and nearly the same situation for men. The continually growing older population will wholesale and retail trade at 17.5%. In 2016 (pre-pandemic), the restaurant and accommodation sector require additional and special planning processes to address their welfare needs - particularly those having to had been the largest single employment sector, but as of 2021 it was the third largest, just behind public do with health. administration and wholesale and retail trade. The projected 2022 population pyramid is below. The 2021 National Health Information Bulletin (NHIB) provides a suite of regionally-common health indicators that serve as a baseline compendium of health status measures. B. Political and Socioeconomic Characteristics The Cook Islands is a self-governing entity in free association with New Zealand since 1965. The government is an independent Westminster parliamentary democracy consisting of 24 elected members, with a separate NUMBER OF SKILLED HEALTH WORKERS PER 10,000 POPULATION 148.8 House of Ariki made up of 24 high chiefs that advise the government in a fashion similar to the House of (physicians, nurses, and allied health workers) Lords and the Canadian Senate, although the Cook Islands government is formally unicameral. Per capita total expenditure on health at average exchange rate (USD) 903.84 Though there has not been an estimate of a Human Development Index score or ranking for the Cook Islands Total expenditure on health as a percentage of gross domestic product (%) 5.38 since 2008, the Cook Islands is in the World Bank ‘High-income’ group, and is assumed to have high human development on axes of lifespan / health span, mean years of schooling and expected years of schooling, Tuberculosis incidence (per 100,000 population) 13 and Gross National Income (GNI) per capita. Cook Islands citizens have good access to essential services Life expectancy at birth (both sexes) 80 and benefit from New Zealand job markets and welfare systems. Under-five mortality rate (per 1,000 live births) 9.7 The average annual income of all Cook Islands residents is calculated by the 2021 census at NZ$19,249, Absolute number of maternal deaths 0 with incomes for males 15 years and older at NZ$20,209, and females in the same age group averaging NZ$18,348. Average annual income varied dramatically between island groups, with Northern Group average Maternal mortality ratio (per 100,000 live births) 0 annual income NZ$10,953, Southern Group average annual income NZ$11,956, and average annual Adult mortality rate from NCDs at ages 15-64 years (%) 23 income in Rarotonga NZ$21,863. Average national private household annual income was NZ$46,135. Number of suicides 2 Immunization coverage rate for diphtheria-tetanus-pertussis (4 doses by age 4) 86 (DTP4) (%) 7 Secretariat of the Pacific Regional Environment Programme (SPREP). 2023. “Population Projections for Pacific Island Countries and Territories from 1950 to 2050, by Sex and by 5-Years Age Groups.” Pacific Environment Data Portal. Apia. 8 Cook Islands Government. 2022. “Census of Population and Dwellings 2021.” Cook Islands Statistics Office. Rarotonga: GCI. p.27. 24 25 Immunization coverage rate for measles-mumps-rubella (MMR1 at 12 months) 2. Health Legislation 88 (%) Though this is not intended as an exhaustive list of legislation affecting TMO, the following acts, regulations Current tobacco smoking among persons 15 years of age and over (%) 30 and pieces of legislation are the primary sources of TMO legal authorities and responsibilities: 1 COVID-19 Act 2020 Population using improved drinking-water sources (%) >99 2 Ministry of Health Act 2013 Population using improved sanitation facilities (%) 85 a) Ministry of Health (Mental Health) Regulations 2013 Proportion of endemic NTDs having reached elimination goals envisaged in the Not b) Ministry of Health (Pharmacy and Therapeutic Products) Regulations 2013 global NTD roadmap to 2030 (%) - target 100% Available c) Ministry of Health (International Health Regulations Compliance) Regulations 2014 3 Tobacco Products Control Act 2007 a) Tobacco Products Control Regulations 2008

1. Health System 4 Public Health Act 2004 17 Through TMO, the Cook Islands government is the main provider of health care services in the country. Te a) Public Health (Sewage and Wastewater Treatment and Disposal) Regulations 2014 Marae Ora services are complemented by a range of Community-Based Organizations (CBOs) and NGOs, i) Approved Standards applicable to the Design and Construction of Sewage including CICWA, CIFWA, Punanga Tauturu, Red Cross Society, Creative Centre, Te Vaerua, Te Kainga, and Systems; Design and Construction Standards Te Punanga Ora’anga Matutu, et al. ii) Approved Standards and Codes of Practice applicable to the Registration of Apart from the direct and allied provision of health care services, the Ministry has statutory functions for at Designs and Personnel; Standards for Registration least 8 key pieces of legislations under its administration, and this landscape will be affected by the nascent iii) Approved Standards and Operating Procedures applicable to the Operation Public Health Bill, which has been under consultation in parliament since March 2021 (interrupted by the of Sewage systems; Operation, Testing and Reporting Standards COVID-19 pandemic) and for which passage is expected imminently.. The current Ministry of Health Act iv) Approved Sewage and Sanitation Forms 2013 is a principal act that provides for key areas and functions of the Ministry, and was bolstered by 5 Food Act 1992-93 numerous regulations, SOPs, acts, and other pieces of legislation or executive orders during the COVID pandemic.14,15,16 Te Marae Ora employs enforcement officers that are tasked with administering health laws a) Food Amendment Act 2005 and regulations, including those that pertain to tobacco, food, water, sanitation etc. b) Food (Fish Export Processing) Regulations 2006 Aligning TMO policies, plans and strategies with global health agendas and goals is also a key role of the Ministry. c) Food Regulations 2014 Requisite maintenance and construction of physical infrastructure for the delivery of healthcare services will 6 Nurses Act 1986 continue to be a core responsibility of the Ministry, in partnership with key stakeholders, including CIIC, ICI, 7 Medical and Dental Practices Act the private sector and development partners. TMO is also a core agency in the training of health personnel a) Medical and Dental Practices Amendment Act 1977 to address the staffing requirements of health institutions, along with the provision of pharmaceuticals and b) Medical and Dental Practices Amendment Act 1981 biomedical equipment. TMO is also involved in cross-cutting agendas such as disability, gender, the aged/ 8 Dental Act 1970-71 elderly, chronic illnesses, disaster management, pandemic and other emergent condition response, climate change, and other national interests as mandated by the Cook Islands government. 9 Narcotics and Misuse of Drugs Act 2004 10 Narcotics Regulations 1966 C. Organisational Structure The management and organizational structures of the Ministry of Health have been modified extensively since the previous NHSP was drafted, with the former three directorates expanded to five: Public Health, Oral Health, Primary Care, Hospital Health, and Planning and Funding. Though organizational structures are perpetually subject to change in accordance with shifting health, administrative and operational needs, it is proposed that the NHSP Key Result Areas (KRAs) and Target Indicators Monitoring Framework (TIMF) be structured to reflect these directorates for the 2023+ period. A TMO-wide functional structure chart, along with organisational structure diagrams for each of the five directorates, and an additional chart for the 9 Te Marae Ora Ministry of Health Cook Islands (TMO). (2023). National Health Information Bulletin 2021. Rarotonga: TMO. 10 United Nations Conference on TMO executive and managerial cadre, are included as an annex under the Appendix 2: TMO Organisational Trade and Development Statistics Office (UNCTADstat). (2022). General Profile: Cook Islands. Geneva: UNCTADstat Retrieved from https://unctadstat.unctad. org/countryprofile/generalprofile/en-gb/184/index.html. 11 World Health Organization (WHO). (2023). Global Tuberculosis Report. Geneva: WHO. Retrieved Structure heading. from https://www.who.int/teams/global-tuberculosis-programme/data. 12 Te Marae Ora Ministry of Health Cook Islands (TMO). (2023). Health Promotion. Rarotonga: GCI Retrieved from https://www.health.gov.ck/public-health/health-promotion/. 13 World Health Organization (WHO), & United Nations Children's Fund (UNICEF). (2023). Progress on Household Drinking Water, Sanitation and Hygiene 2000-2022: Special Focus on Gender (Launch Version). New York: United Nations Retrieved from https://cdn.who.int/media/docs/default-source/wash-documents/jmp-2023_layout_v3launch_5july_low-reswhowebsite.pdf?s- fvrsn=c52136f5_3&download=true. 14 Government of the Cook Islands. 2020. “COVID-19 Act.” 2. Parliament of the Cook Islands. Rarotonga: GCI. 15 Govern- ment of the Cook Islands. 2021. “Cook Islands Emergency Response Plan to Coronavirus Disease 2019 (COVID-19): April 2021, Version 2.” Rarotonga: GCI. 16 Williams, B. 2022. “Regulation 7 of the Ministry of aged/elderly, chronic illnesses, disaster management, pandemic and other emergent condition response, climate 17. Likely to be modified by the Public Health Bill/Act, expected to be passed during the current legislative session; cf. https://www.health.gov.ck/public-health/ change, and other national interests as mandated by the Cook Islands government. law-reform/ 26 27 CHILDREN FROM AITUTAKI SCHOOL 28 29 D. Health Services SITE SERVICES OFFERED TMO is the main healthcare provider in the Cook Islands, and is responsible for setting national health policy • Accidents & Emergency doctor and nursing staff on-site 24/7 including and managing the day-to-day delivery of health services. Health services range from public and population outpatient services (after hours) health, to primary care, with limited secondary care primarily provided via HSVs in the major population • On-site specialists (anaesthesia, O&G, internal medicine, paediatrics, centres on Aitutaki and Rarotonga. Compared to regional peers, the Cook Islands are well equipped to accidents & emergency, surgery and ophthalmology) at scheduled times, and on call at all times provide basic primary services, some secondary care (though this does require recourse to both overseas • Radiology (Ultrasound, X-ray, CT Scan) specialist visits and medical evacuations), and reasonably comprehensive tertiary care via its hospitals. The • Laboratory services including blood bank excluding histology services Cook Islands delivers a range of general clinical services in the core areas of surgery, medicine, anaesthesia, and cytology services obstetrics, gynaecology, ophthalmology and paediatrics18. There are a small number of private providers, all Rarotonga Hospital • Pharmacy (responsibility for both consumables and medicines provided located in the two main population centres. by two Pharmacists, one Pharmacy Technician, and one Pharmacy Assistant: clinical, dispensing, impresting, limited compounding, and stock management services A table of current health facilities and health services is as follows: • Ambulance services • Physiotherapy services • Dietary services SITE SERVICES OFFERED • General and specialist inpatient services • NP or RN on-site during normal working hours, and on call at all other • On-site GP(s) and nursing staff during normal working hours times • Minor surgical procedures • Provide basic health services including nursing care, ante natal care, baby checks, child immunization, family planning, wound dressings, • Medical screenings and reports medicine refills, home visits, post-natal check-up for mother and baby, • NCD consultations Pa Enua Clinics (Atiu, Mangaia, counselling, cervical cancer screening • Pharmacy services (providing by two Pharmacy Technicians: Tupapa Primary Health Care dispensing, limited clinical, and stock management services) Manihiki, Mauke, Mitiaro, Nassau, • General inpatient bed(s) on-site (except Palmerston) Centre (Rarotonga) Palmerston, Penrhyn, Pukapuka, • No laboratory services except for rapid antigen test for COVID • Dressings Rakahanga) • Telemedicine facilities for consultations with physicians in Rarotonga • Community health screenings • Limited general Oral Health services (tooth extraction, pain relief and • International medical exit screening consultation) • Follow up of discharged patients • Public health (health protection, health promotion, and community • Referrals to appropriate health services health services) • Provide basic health services including nursing care, baby checks, • On-site physician(s) and nursing staff during normal working hours, child immunization, wound dressings, home visits, palliative care visits, and on call at all other times post-natal check-up for mother and baby, counselling and physician • Limited radiology services consultations (NCDs) on allocated days Rarotonga Community Health • Limited secondary care (generally delivered via transfer to Rarotonga) • 10 clinics around Rarotonga (Ruaau, Pue, Ruatonga*, Takuvaine*, Clinics • Limited laboratory services Akaoa*, Titikaveka, Murienua*, Nikao, Ngatangiia*, Matavera), although the five asterisked community health clinics are closed at the • Pharmacy services (providing by one Pharmacy Technician and two time of writing Oral Health Centre (Tupapa) Aitutaki Hospital Pharmacy Assistants: dispensing and stock management services) • Provide basic oral • General inpatient beds • Minor surgical procedures • Provide basic oral health services for children and adults (consultation, • Obstetrics & Gyanaecology fillings, relief of pain) • Limited general oral health services (tooth extraction, pain relief and • Endodontics consultation) Oral Health Centre (Tupapa) • Prosthodontics • Public Health (health protection and community health services) • Orthodontics • Periodontology • Oral and maxillofacial surgery • Health Protection – communicable disease (CD) control, border, vector, food and liquor licensing, water and sanitation, environmental health • Community Health – child health, maternal & reproductive health, homes visits, rehabilitation and support • Health Promotion – CD & NCD risk factor interventions, family planning, injury & violence prevention Public Health (Tupapa) • Mental Health – assessment, counselling, community and inpatient admissions and treatment and referrals, training and promotion • Health Intelligence – enforcements, epidemiology, surveillance and response • International Workers medical entry screening 18 Te Marae Ora Ministry of Health Cook Islands (TMO). (2019). Takai'anga Angaanga Tutara a Te Marae Ora: Cook Islands National Health Strategic Plan | • Wound care (dressings) 2017-2021. Rarotonga: TMO. 30 31 JULY 2023 HEALTHY ISLANDS INITIATIVE, MANGAIA COLLEGE Students with their School Health Packs. 32 33

1. Hospital Services 4. Pa Enua Health Clinics a. Rarotonga Hospital Pa Enua health clinics provide basic services in primary healthcare. Patients with serious or complicated medical conditions that cannot be treated via telemedicine consultations are generally transferred to Rarotonga. The 80-bed Rarotonga Hospital is the country’s principal curative health facility, and also offers outpatient, general practice and emergency services. Since the COVID pandemic, the hospital has one negative pressure rooms covering 4 beds in total for infectious diseases since COVID was normalised in July 2022. Clinical

5. Referral Services, Secondary and Tertiary Care departments and services include: surgical, general medicine, accidents and emergency, paediatrics, ophthalmology, obstetrics and gynaecology, anaesthesia, and a high dependency unit (three beds). Clinical Rarotonga Hospital is the primary referral centre in the Cook Islands for further secondary care. Non-urgent support services include: radiology, laboratory, pharmacy, physiotherapy, and ambulance/paramedics. For cases requiring tertiary care or specialist consultations may be placed on a waiting list to be seen by an a hospital of this size in the Pacific, the hospital is well equipped. It additionally hosts training centres for the overseas visiting medical, surgical or other specialist. Patients with more serious conditions or requiring urgent nursing school and the POHLN facility. treatment not available in-country may be eligible for international referrals to New Zealand. TMO relies on its Patient Referral Policy 201519 to guide decisions on eligibility for government-funded international referrals. Domestic transfers from the Pa Enua are catered for in Rarotonga Hospital, and if needed referred b. Aitutaki Hospital onward to New Zealand following the updated Patient Referral Policy 2023. The Aitutaki Hospital is a 26-bed facility that provides primary and limited secondary health care. Clinical departments and services include GOPD, and ward areas for adults, paediatric and maternity patients. There

6. Private Health Providers are limited diagnostic (x-ray and laboratories), dental and ambulance/paramedic capabilities, and a full pharmacy. Private health providers in the Cook Islands are primarily located on Rarotonga. There are several such medical practices, as well as a small number of pharmaceutical outlets and a single privately-run dental clinic in operation at present. A limited range of medicines (General Sale medicine) are available in supermarkets

2. Primary Health Care Services and smaller convenience stores, including in the Pa Enua. The Ministry of Health (Pharmacy & Therapeutic Products) Regulation 2013 sets the requirements for premises, personnel and products with regard to a. Tupapa Primary Health Care Centre medicines. The Tupapa Primary Health Care Centre is a primary healthcare facility located in the main town area of Rarotonga, adjacent to TMO Headquarters. Planned renovations to TMO headquarters are intended to incorporate Tupapa facilities into a single campus, with both administrative and service delivery functions. E. Health Situation: Access, Morbidity, Mortality and Health Needs of the Current primary healthcare services at Tupapa include outpatient services, RMNCAH (reproductive, maternal, Population neonatal, child and adolescent health), Rheumatic Heart Disease screenings and treatment, mental health, an The Cook Islands enjoys a country health profile – and corresponding health indicators – analogous to NCD clinic and pharmacy. comparable countries in the region and/or with similar human development statuses. Among ADB’s ‘SIDS’ category, the Cook Islands is better than average on measures such as HIV incidence and prevalence,), b. Oral Health Services communicable diseases and maternal, prenatal and nutrition conditions mortality as a percent of total mortalities, immunizations, life expectancy at birth, and water, sanitation and hygiene measures. In Oral health services in Rarotonga are currently located within the Tupapa Primary Health Care Centre. Oral categories such as mortality from cardiovascular disease, cancer, diabetes, or chronic respiratory disease, health clinical services include the diagnosis of oral disease entities and the delivery of a broad range of tobacco use prevalence, and prevalence of overweight – both children and adults - and hypertension, the restorative care (e.g. fillings), minor oral surgery procedures such as simple tooth extractions, impacted Cook Islands is at orslightly worse than Pacific Small State averages 20. As with other countries that have third molar extractions, simple periodontal treatments and provision of removable prostheses. Though KRA undergone demographic transitions and development improvements in the 20th century, the triple burden of indicators for the Oral Health Division were not met during the NHSP 2017-21 period, prosthetic care, disease (communicable, non-communicable, and globalization-related health issues) has largely given way orthodontic, endodontic and less-complicated oral maxillofacial surgery services were expanded. The public to concerns around NCDs, pandemic and environmental-health issues, and health issues inherent to aging health arm of the service deals with preventative aspects of dental care in schools and the wider community, populations. Though communicable diseases cause a lower burden of morbidity and mortality in the Cook including primary school toothbrush programmes. Islands today than they did in the 20th century, STIs, TB, RHD, water-borne and vector-borne diseases can potentially resurge and therefore require constant vigilance, surveillance, and prophylaxis.

3. Other Health Services For 2021 – the last year for which a National Health Bulletin was issued as of the time of writing – a total of Other TMO-provided key services include school health programmes, health promotion, community health 35,274 outpatient consultations were reported, for an average of 2,940 such consultations per month. This services, food safety, water safety and quality, sewage and sanitation, pandemic response / surveillance figure represents an overall annual per capita health service utilization of 2.3 (compared to the 2015 total of / protection, border control, and vector-borne diseases. As the country’s health system moves towards 2.1). By way of comparison, studies assessing GP utilization in New Zealand have arrived at a range from a more preventative focus, the Community Health Services are intended to provide a greater share of 2.6 to 6.6 visits per person per year; in the OECD, most countries reported between 4 and 10 such visits preventive and primary care. Because of the high prevalence of (and heavy consequences from) NCDs, they per person per year, with an overall average of 6.8.22 remain a key area of concern and priority. 19 Te Marae Ora Ministry of Health Cook Islands (TMO). 2015. “Patient Referral Policy.” Rarotonga: TMO. 20 World Bank Group. 2020. “Health Nutrition and Popu- lation Statistics - Pacific Island Small States [PSS].” DataBank. Washington, D.C.: WB/IBRD/IDA. https://databank.worldbank.org/source/health-nutrition-and-pop- ulation-statistics#advancedDownloadOptions 21 Baldwin, J. N., et al. 2019. “Primary care doctor and nurse utilisation rates for billed consultations across the Com- prehensive Care Primary Health Organisation.” New Zealand Medical Journal 132(1498): 79-89. 22 Organization for Economic Cooperation and Development.

2021. Health at a Glance 2021: OECD Indicators. Paris: OECD. 34 35 For Hospital Health Services, patient admissions are accommodated in Rarotonga and Aitutaki Hospitals. Underlying causes of death for 2020-2021 are as follows: Pa Enua health clinics have a small number of beds mainly for maternity, day care observation and for patients awaiting emergency referrals. In 2021, Rarotonga Hospital admissions totalled 1,387 with 1,258 discharges. Bed days used equalled 6,332, while bed days available were 50,735 resulting in a 12.5% bed occupancy rate. In 2018-2021, the main causes of admissions were diseases of the circulatory system, pregnancy/childbirth, diseases of the respiratory system (spiking during the COVID pandemic and returning to average subsequently), diseases of the digestive system, and injuries. Non-communicable diseases, e.g. hypertension, diabetes, cancer, cardiovascular diseases and their risk factors, are major community health problems in the Cook Islands. Cardiovascular diseases (CVDs) are reported as the highest NCD condition in the Cook Islands with an average of over 460 cases a year (2018-2021). The majority of these cases also have co-morbidities, including other non-communicable diseases. The next highest prevalence NCDs were diabetes, COPD, and cancer. An NCD incidence rate of 21 per 1,000 persons was reported; over the four years preceding the 2021 National Health Bulletin, 72% of deaths that occurred in the Cook Islands were attributable to NCDs, with 25% of cases judged to have occurred prematurely. Among NCD risk factors, the 2022 STEPS survey preliminary results reported that in the adult population aged 18-69 years, the prevalence rate of obesity was 75.0%; raised blood pressure 50.3%; raised blood sugar 34.0%; and elevated blood cholesterol 53.2%, all of which have increased since the previous iterations of the NHSP and NCD STEPS Survey.23 As of the 2021 National Health Bulletin, there had been 25 people diagnosed with cancer per annum over the previous five-year period, with an increase in cancer prevalence of 30% since 2018. For males, prostate and skin cancers were the most common types of cancer reported; for females, breast, neoplasms of the genital organs, and skin cancers were the most common types of cancer reported. As of the 2022 NCD The overall crude death rate of 5.8 is recorded by TMO for 2021, and reflects a sharp decrease from the STEPS survey, only 67% of women aged 30-49 years had ever had a screening test for cervical cancer. previous five-year period average of 8.34. Sexually transmitted infections (STIs) experienced a ‘startlingly’ high increase in diagnosed cases between A functional and well-organized patient referral system is in use by Te Marae Ora. Domestic transfers from 2018 and 2021, with chlamydia up 90%, gonorrhoea up 67%, and high numbers of candida and syphilis.24 the Pa Enua to Rarotonga and international referrals from Rarotonga to New Zealand are governed by the There have been no recorded cases of HIV incidence in Cook Islands, although two historical positive tests Patient Referral policy 2015 and is managed by the Chief Medical Officer and the Referral Committee. were recorded in inbound migrants. In general, condom use rates are quite low for people engaging in high- In 2021, domestic patient transfers from the Pa Enua numbered ≈160, with just under 150 international risk sexual activity despite government and NGO efforts to raise awareness about their use. This creates a referrals. The number of domestic transfers has decreased over the previous decade (starting at just below potentially high-risk situation in the Cook Islands for the spread of HIV/AIDS and other STIs. 300 in 2012, and reaching a high of nearly 350 in 2019), whilst international referrals have been roughly There have been a relatively high number of motor vehicle accidents (MVAs) occurring in the Cook Islands, static over the previous decade (see figure, below). mainly from driving on motor bikes and as a result of speeding, reckless/careless driving, and driving under the influence of alcohol. In 2019, 2020 and 2021, the death rate to MVAs was 40.5, 47.3, and 33.4 per 100,000 (respectively); this latter figure is essentially unchanged from the previous NHSP. The percentages of MVAs linked to alcohol were 67%, 71% and 40% respectively over the most recently reported three- year period. Mortality classification by cause of death is reported using the WHO International classification of diseases (ICD-10). For the years 2016-2021, the maternal mortality ratio remained at zero, as there were no recorded maternal deaths during these years. The infant mortality rate was 2.0 in 2021, and U5MR was 9.7. The persistently low infant and maternal mortality rate is a major achievement for TMO. 23 Te Marae Ora Ministry of Health Cook Islands (TMO). 2023. “Cook Islands STEPS Survey: Preliminary Results.” Rarotonga: TMO. 24 Te Marae Ora Ministry of Health Cook Islands (TMO). 2023. “National Health Information Bulletin 2021.” Rarotonga: TMO. 25 Op. cit. p.39. 26 Op. cit. p.33. 36 37 MAY 2023 UNVEILING OF TE PUNA TIAKI WELLNESS UNIT SIGN BOARD. Crown Ministers, CIIC Board Members, Landowners, Secretary of Health with Mental Health Team. 38 39 The Mental Health (MH) service in the Cook Islands has grown considerably over the past four years. It Numbers and percentages of oral health procedures in 2021 are as follows: now employs 2 medical officers, one clinical psychologist, three nurses and a counsellor. This service is supplemented by a NGOs and annual visits of Mental Health specialists. The number of newly diagnosed mental health cases in the Cook Islands over the last two years indicated a slight increase over previous years, with an the incidence rate of 5.7 per 1,000 population. In 2021, a total of 7,615 appointments were conducted with total of 966 patients. Which is significantly higher than the 424 patients on the mental health register from 2015, although this increase is likely due at least in part to the strategic focus on improving data collection. The most common disorders were psychosocial issues and related disorders, anxiety and depression. There is a dedicated specialized facility for the treatment and care of persons, Te Puna Tiaki Wellness Unit. The 4 bed facility (2 high risk & 2 low risk rooms) was officially opened in May 2023. The number and proportion of mental and behavioural health diagnoses in 2021 was as follows: The 2021 health bulletin reported that 100% of pregnancies were in antenatal care through to delivery, and that 100% of deliveries were attended by trained personnel. Approximately 5% of live births were categorized as low birth weight (i.e. below 2,500 grams) in 2021, and over 90% of children born were exclusively breastfed for the first three months, although this figure declines steadily afterwards. Though the percentage of births attributable to adolescent mothers (defined as 14-19 years of age) has fluctuated over the previous decade, the most recent year had 206 such births, or 16%, which is unchanged from 2018, and only a modest decrease from the 2016 figure of 18%. A chart of adolescent births over the previous decade is as follows: There is continuing concern over levels of dependency and abuse of alcohol and other substances in the Cook Islands, as ‘addiction’ was the fifth-most common mental/behavioural diagnosis in 2021. Though the Mental Health and Wellbeing Action Plan is currently being revised, the most recently released version noted that a significant portion of mental health illnesses are due to problems associated with alcohol dependency and abuse, including the use of ‘homebrew’, tumunu or ‘bush beer’.28,29 Rheumatic Heart Disease (RHD) remains a neglected disease, correlated with poverty and overcrowding. A screening programme for RHD was initiated in 2016 and directed at children 5-15 years of age. Using echocardiography, the programme completed screenings in Rarotonga in 2016 and 2018, and the Northern Group Pa Enua in 2017, but was subsequently suspended for lack of trained staff, a circumstance which was compounded by COVID-related constraints. Plans to complete a new round of RHD screening in May of 2023 for 5-10 year-olds will hopefully serve to reinvigorate this important undertaking. In the Cook Islands, dental caries, periodontal disease and tooth loss is prevalent. Oral Health services over the three years preceding the 2021 National Health Bulletin had an average of 4,410 consults for patients aged two years and over. Some programming around the provision of toothbrushes in schools had been suspended during COVID owing to hygienic requirements and the need for dedicated washbasins in schools. Because oral health has been designated a directorate since the previous NHSP, it is that hoped there will be further impetus for preventive and therapeutic oral health programming, especially among the youth. 27 Op. cit. p.20 28 Nosa, V., et al. 2018. “The Use of Home Brew in Pacific Islands Countries and Territories.” Journal of Ethnicity in Substance Abuse 17(1): 7-15. 30 Op. cit, 31 Op. cit. 29 Deal, R. 2020. “Tumunu, the Bush Beer Bar Tradition of Atiu, Cook Islands.” The Geography of Beer: Culture and Economics: 35-45. 40 41 The total fertility rate (TFR) has seen a consistent decline over the years. For 2021, the TFR is reported at At present, the majority of Cook Islands practitioners are trained in New Zealand, Australia or Fiji, along with 2.1 births per woman. This places the Cook Islands under the classification of having moderate fertility levels, smaller proportions who received training in the Philippines and Myanmar. With the launch of the Bachelor of defined as a TFR less than 3 but greater than 2.1. Nursing Pacific Programme (delivered in the Cook Islands in cooperation with Whitireia Polytechnic in New Zealand and the University of the South Pacific in Fiji), and further remote trainings such as SPC’s Data for Adolescent health, particularly concerning births, is another area of focus. The data indicates that the highest Decision-Making course becoming more feasible, an increasing share of service providers will receive their number of births in 2021 occurred between the ages of 20-24. Furthermore, the Cook Islands have training in country. This need was reinforced during TMO staff and stakeholder consultations. maintained a low adolescent and under-five mortality rate. Over a five-year period, there was a peak in 2018, followed by a decline in 2020. On average, two infant deaths occur annually, with the highest number If CME funding is taken up at the level proposed, this would cost approximately NZ$1.6m in 2025. Funding of infant deaths being four in 2018. Additionally, three adolescent deaths were reported in the past two for human resource development is included in the current health strategy as a major cost component, but years, with motor vehicle accidents being a significant cause. recruiting and retaining staff is a perennial challenge given relatively low pay, high caseloads, and challenging practice environments. Over the last five years, there has been a slight increase in the number and proportion of women in the childbearing ages of 15-49 years in the Cook Islands reporting the utilization of a contraceptive method. Ophthalmological health is primarily provided via health specialist visits, although upskilling for existing staff

2. Health Financing in the diagnosis and treatment of diabetic retinopathy is planned, and TMO has included eye care visits/ Budget figures/estimates and projections for the 2022-2026 period, from MFEM’s 2022 Appropriation treatment for diabetes patients among their 129 national health indicators in the ‘Service Coverage’ category Estimates and Commentary are as follows: as a near term (<12 months) indicator. In the most recent year for which data are available (2019, prior to COVID-related border closures), health specialist visits completed 696 consultations and/or screenings TMO BUDGET CATEGORY 2022/23 2023/24 2024/25 2025/26 for ophthalmology or optometry, and a further 163 such encounters in the Pa Enua. A total of 60 cases received surgical intervention, primarily in the form of cataract operations. Personnel 12,833,011 13,133,011 13,172,011 13,172,011 The top five infectious diseases reported in the Cook Islands in 2021 were skin sepsis, dengue, gastroenteritis, Operating 3,648,951 3,598,951 3,598,951 3,598,951 pneumonia and scabies. Generally speaking, water-borne diseases are declining, largely due to improved water Administered Payments 2,536,870 2,536,870 2,536,870 2,536,870 and sanitation facilities.With respect to COVID-19, TMO (with the support of the New Zealand government), procured sufficient vaccines to provide full coverage for the entire resident population. Vaccination rollout for Depreciation 1,570,000 1,731,000 1,781,000 1,781,000 all people 16 years of age and older began in May of 2021, and in October of 2021 for 12-15 year-olds. Gross Appropriation 20,588,832 20,999,832 21,088,832 21,088,832 Third dose (booster) shots began in December of 2021 for people ≥18 years of age. As of the close of Trading Revenue 350,000 350,000 350,000 350,000 2021, a total of 95% of Cook Islanders were fully vaccinated (defined as having received both doses of the Pfizer–BioNTech [Comirnaty] COVID-19 vaccine)32. Net Appropriation 20,238,832 20,649,832 20,738,832 20,738,832 POBOC 0 0 0 0

1. Health Workforce Medium-Term Expenditure 20,588,832 20,649,832 20,738,832 20,738,832 Ceiling The Cook Islands currently has 1.46 physicians and 8.58 nurses per 1,000 population, or a total of ≈10 medical/nursing staff per 1,000 people. The OECD average for practising physicians is 2.7 per 1,000 TMO’s overall budget represents approximately 4.9% of the country’s GDP adjusted for purchasing power population (from an overall range of ≈2.5 to >5).33 Though the number of physicians is lower than high income parity. Historical health spend as a percentage of GDP, and as a percentage of overall government spending comparator countries (e.g. New Zealand, with 3.4), it does compare favourably to WHO recommendations is as follow: estimating at least 2.5 medical staff (physicians, nurses and midwives) per 1,000 people are necessary to provide adequate primary care coverage.34 HEALTH SPEND HEALTH SPEND It should be noted, however, that the distribution of physicians is heavily weighted towards Rarotonga (and FINANCIAL YEAR (% of GDP) (% of Govt Spending) to a lesser extent, Aitutaki), and the medical cadre is disproportionately dependent on registered nurses, 2013/14 3.3% 6.4% nurse practitioners, and general practitioners rather than employees at higher levels of practice. The Cook 2014/15 3.7% 6.0% Islands Health Workforce Plan (2016-2025) is in operation and highlighted the need for Continuing Medical Education strengthening for all levels of practice within the health workforce. The Plan states that the focus 2015/16 3.9% 6.4% of staff development should be on the expansion of the number of specialists in most disciplines including 2016/17 3.4% 6.1% paediatrics, building nurse practitioner workforce on all islands, and increasing the number of nursing, dental 2017/18 3.7% 7.1% and clinical support workforce. 2018/19 3.1% 6.5% 2019/20 3.4% 5.4% 2020/21 6.3% 6.4% 2021/22 5.5% 7.3% 32 Op. cit. p.36. 33 Organization for Economic Cooperation and Development. 2021. Op cit. 34 World Bank Group. 2022. “Physicians (Per 1,000 People) [SH. 2022/23 4.50% 7.0% MED.PHYS.ZS].” DataBank. Washington, D.C.: WB/IBRD/IDA. 42 43 Total Resourcing: Government and ODA, Health (NZ$) Administered Payments, Health (NZ$) 2022/23 2022/23 2023/24 2024/25 2025/26 Administered 2023/24 2024/25 2025/26 TMO Budget Category Budget Output Budget Projection Projection Projection Payment Projection Projection Projection Estimate Estimate Net Appropriation 20,238,832 20,649,832 20,738,832 20,738,832 1 NCD Fund 90,000 90,000 90,000 90,000 Trading Revenue 350,000 3,598,951 3,598,951 3,598,951 Law and Order Clinical 1 195,000 195,000 195,000 195,000 Psychologist Official Development Assistance 200,000 2,536,870 2,536,870 2,536,870 Output 1 Total Resourcing 20,788,832 1,731,000 1,781,000 1,781,000 285,000 285,000 285,000 285,000 Administered Funding Output Funding for 2022/23, Health (NZ$) 4 Patient Referrals 850,000 850,000 850,000 850,000 OUTPUT OUTPUT 1 OUTPUT 2 OUTPUT 3 OUTPUT 4 OUTPUT 5 TOTAL Pharmaceuticals & 4 1,167,800 1,167,800 1,167,800 1,167,800 consumables Personnel 2, 569,173 906,411 2,001,281 6,258,357 1,062,089 12,797,311 Output 4 Operating 265,000 210,000 623,600 1,673,000 877,351 3,648,951 Administered Funding 2,017,800 2,017,800 2,017,800 2,017,800 Administered 285,000 0 0 2,017,800 234,070 2,536,870 Workforce Funding 5 234,070 234,070 234,070 234,070 Development Depreciation 90,000 35,000 135,000 1,120,000 190,000 1,570,000 Gross Operating 3,209,173 1,151,411 2,759,881 11,069,157 2,363,510 20,588,832 Output 5 Appropriation 234,070 234,070 234,070 234,070 Administered Funding Trading Revenue 10,000 70,000 50,000 220,000 0 350,000 Net Operating Total Health 20,238,832 20,649,832 1,081,411 10,909,157 2,363,510 20,238,832 2,536,870 2,536,870 2,536,870 2,536,870 Appropriation Administered Funding In terms of Out-of-Pocket (OOP) expenditures, the most recent Cook Islands Household Income and It should be noted that, though ODA is zeroed out in the above budget tables from MFEM, funding support Expenditure Survey notes that the national average annual household expenditure on the ‘health’ category from development partners is extant, and is generally apportioned on a programmatic rather than overall was NZ$90 per annum, with urban/Rarotonga households spending an average of NZ$110/annum, and budgetary level. rural/Pa Enua households spending an average of NZ$60/annum. The default payment mechanism for

3. Funding Support from Development Partners clinical health services is governmental expenditure. New Zealand For eligible patients (Cook Islands citizens, permanent residents, and the children/partners of same), most Since 1994, the New Zealand Government has funded and initially managed medical specialist visits to consultations do not incur part-charges, or only nominal fees (e.g. NZ$5 for a consultation for 16-59 the Cook Islands. Patient referral and case management through contracted agencies in New Zealand is year-olds at Rarotonga hospital). For visitors and other ineligible populations, fees are generally pegged also an important component of assistance. Between 2004 and 2008, these visits took place under the to TMO costs35. With the 2021 census reporting a national average household size of 3.2 persons, and Medical Specialists Visits (MSV) scheme and from 2008 to current, under the Health Specialist Visits (HSV) the 2021 National Health Information Bulletin reporting an average of 4.5 outpatient consultations per programme. The programme aims to improve the health status of Cook Islanders through equitable access person per annum, this suggests an average of 14.4 outpatient consultations per household per annum. to specialists’ health services. The average annual household ‘health’ category totals from the Household Income and Expenditure Survey includes all health expenditures, including inpatient encounters, outpatient consultations, pharmaceuticals and World Health Organization consumables, oral and mental health visits, over-the-counter medicines, and ancillary supplies (e.g. plasters, The Cook Islands TMO also has a long-standing partnership with the World Health Organization, which first-aid materials), accounting for the total average household OOP spending tallies above. provides technical assistance, support for human resource development and supplementary funding for in-country implementation of priority TMO activities through a biennial budget process that allows TMO N.B. The TMO budgetary figures identified do not correspond exactly with the NHSP 2023+ KRAs; rather, they are delineated as follows: considerable latitude in addressing national priorities. Special emphasis has been given to accelerating “For Output 1: Public Health the Future: Towards the Healthiest and Safest Region” vision in the thematic priority areas such as health Output 2: Oral Health Services security including AMR, NCDs & aging, climate change and universal health coverage and health systems Output 3: Primary Care strengthening, Output 4: Hospital Health Output 5: Planning and Funding 36 Brown, H. M. 2022. “Cook Islands Government Budget Estimates 2022/23: Book 1 - Appropriation Estimates and Commentary.” Rarotonga: Ministry of 35 Te Marae Ora Ministry of Health Cook Islands (TMO). (2015). National Health Services Fee Schedule. Rarotonga: TMO. Finance. 44 45 UNFPA ii. Community-Based Follow-Up and Care The United Nations Population Fund (UNFPA) is committed to ensuring that reproductive health and Community-based follow-up of chronic cases (including palliative care) will require strengthening, as poor women's empowerment are central to development plans, health sector reforms and programming efforts patient adherence to treatment and follow-up is a major cause of disease complications. The use of to reduce inequities and to achieving universal access to quality reproductive health services, commodities community health clinics should help ameliorate this situation somewhat. and information. c. Clinical Care UNICEF UNICEF Programme of Cooperation 2023-27 of UNITED NATIONS CHILDREN’S FUND (UNICEF) provides i. Specialized Clinical Services the framework for its ongoing programme and technical assistance to TMO in relation to newborn, child Diagnostic and therapeutic capabilities, including keeping up with advances in medicines and consumables and maternal health, infant nutrition, emergency preparedness & response. The Expanded Program on technology are a continuing challenge and will need to be continually upgraded to meet requirements for Immunisation (EPI) and the cold chain are major areas of technical assistance along with breastfeeding appropriate patient management. promotion, the Baby Friendly Hospital Initiative and strengthening primary health care services. UNICEF also ii. Specialized Diagnostic Services provides assistance to other government ministries particularly Education. Diagnostic capabilities for radiology and screening purposes - particularly echocardiography – will need Secretariat of Pacific Community (SPC) strengthening, especially in the form of investments in equipment and staff training to improve services. The SPC technical support to the Cook Islands is identified in the joint country strategy. nascent agreement for radiology support from overseas should help somewhat, but local echocardiography UNDP (Global Funds) capability will be vital to achieve RHD screening goals. The Global Fund is a 21st-century partnership organization designed to accelerate the end of AIDS, tuberculosis and malaria as epidemics. Separately, SPC previously administered the Global Fund projects on HIV and TB, the HIV/STI Response Fund and small grants schemes under the regional NCD Framework. Current financial management arrangements for Global Funds have shifted to UNDP. Asian Development Bank (ADB) The Pacific Approach, 2021–2025, is ADB’s 5-year country partnership strategy for the 12 smallest Pacific members of ADB, including the Cook Islands. Focused technical assistance, aimed at building capacity and strengthening governance and public sector management, remains an integral part of ADB’s support to the Cook Islands. The ADB is a recent development partner of TMO in strengthening resilience against climate and economic shocks and in its recovery from the COVID-19 pandemic.

4. Gap Analysis of the Health System a. Governance i. Health Systems / Strategic Planning Capacity for strategic planning remains a challenge within the current workforce, especially given the recent flux induced by the COVID-19 pandemic. Bolstering capacity in this area will ensure that strategic objectives outlined in the various health programmes and plans are operationalized. ii. Human Resources for Health The Cook Islands health services will continue to depend on expatriate specialized doctors for the foreseeable future. Recruitment and retention of this specialized workforce, both in the clinical and allied health domains, is a perpetual challenge. Specialized training of the local workforce can help ameliorate shortages, and is planned for in the NHSP. b. Community Health Services i. NCD Prevention and Treatment Given the primacy of NCDs as the main contributor to morbidity and mortality in the country, funding allocations from the Cook Islands government – to TMO and other government ministries - should be maximized. JULY 2024 HEALTH Strengthened infrastructure, staffing, and supplies and equipment will be required for improved outcomes. EXPO AT THE NATIONAL AUDITORIUM. Biomedical Manager, Earnswell Tuazon demonstrates how to check the battery voltage of medical equipment. 46 47 III. MY HEALTH, MY FUTURE TMO Essay Competition Winner Year 9-11 Category BAN VAPES in the Cook Islands By Anne Browne, Year 11, Level 1 student, Tereora College Think about the amount of nicotine inhaled into addicted lungs every hour of the day. Scented flavoured air as you walk past a group of 12 year olds. Let alone, adults having an effect on younger children into using vapes. But would that be the same if vapes were not here in the first place? The saying goes “It’s never too late” but it is too late to educate addicted students about the disadvantages of vapes. They will not care. Take it from a minor's perspective. Vapes are becoming mandatory to young adults, and minors are already influence and peer pressured. I go into public bathrooms and run into young girls sharing a bathroom stall, for “vape breaks” as it has become an addiction. What if that was your child? Imagine every single person risking their lives, taking puffs one after another as a daily pill. Whether they are 10 years old or whether they are 50, is that what you want? Vapes should be banned in the Cook Islands. YOUNG PEOPLE ACCESS TO VAPES Vapes should not be sold in the Cook Islands, let alone to minors. Convenience stores and online sellers think they are not causing problem with investing in vapes to ages 18+ but what does “18+” actually restrict? I can say that the majority of these vapes being sold to/for ages 18+ and all handed down to minors. How do I know? Because I am a minor myself. People who surround me often engage in conversations like “Damn, I just need $5 to afford a vape” or “yeah my sisters going to buy me one, I can give your money to her to get yours since she’s 19” All I do is sit there and reminisce when vapes weren’t prioritised back then and there were less “addicted lungs” in minors everywhere. Do vapes being on our island benefit us? Many teenagers say “It relieves stress” but it would not have been a “Go-to stress reliever” if it was never originally here. A friend of mine said to me “If you give me a good reason to stop vaping, then the wish is yours”, my response was not convincing enough. So what would have been? VAPES ARE UNHEALTHY Would “because it’s bad for you” be good enough? I claim that it is too late to persuade people to stop but what would have been convincing? Yes, vaping is extremely unhealthy for us. But why? “This is it!” Vapes contain dangerous substances that are prone to damage the health of your body. In addition to nicotine, vapes also contain other harmful substances such as acrolein which is a chemical used to control plants and fungi, formaldehyde which is a fluid that is used to embalm dead bodies and acetaldehyde. These substances are dangerous because they are known to induce cancer, shortness of breath, unconsciousness, and reduction in lifespan. Is this convincing enough? Some might disagree and believe that we are spreading incorrect information to discourage vaping. So why convince when we should put a stop to this permanently? So why not ban vapes from our island? You know it is bad for us. You know it does not benefit us. Vapes are irrelevant here. Why maintain a dangerous matter? Kids are out, smoking vapes every day and everywhere inhaling harmful substances that is extremely risky. These kids that we are talking about, kids– and prioritising vapes invented to help adults cut down on cigarettes. If you care about our people, our young and future generations, I know you will make the right decision. BAN VAPE NOW! 48 49 IV. Te Marae Ora Ara Tango The broader government Annual Business Plan is a budget-linked document that endeavours to operationalize sectoral strategic plans. TMO key planning documents and linkages are presented below. Anga'anga: LEGAL FRAMEWORK Constitution National Health Strategic Plan 2023 - 2027

1. Methodology The drafting of Te Marae Ora Ara Tango Anga’anga: National Health Strategic Plan 2023 – 2027 Health Laws followed the methodologies outlined in WHO’s ‘Strategizing National Health in the 21st Century: A GOVERNMENT PLAN & Regulations Handbook’,37 which outlines eight key national health planning processes (one of which overlaps with the JANS methodology utilized as part of the NHSP 2017-21 evaluation). These eight processes are: • Population consultation on needs and expectations TE MARAE ORA’S NSDA 2020+ • Situation analysis of the health sector (also covered by JANS) PLANS • Priority-setting for national health policies, strategies and plans • Strategic planning: transforming priorities into plans Health Road Map Goals 2017 - 37 • Operational planning: transforming plans into action • Estimating cost implications of a national health policy, strategy or plan Regional/International Commitments • Budgeting for health National Health • Monitoring, evaluation and review of national health policies, strategies and plans Strategies Strategic Plan 2023+ These processes were addressed via desk reviews of documents, numerous workshops and fora, Programme- extensive interviews with relevant TMO staff and administrators, and other key stakeholders throughout Specific Plans the Cook Islands. Targets Annual Business

2. Policy, Legal, and Strategic Plan Linkages Plan The Cook Islands constitution provides the legal basis and mandate for the establishment and provision of health services in the country. The mandate of the constitution is interpreted and operationalized by elected governments through legislation and the NSDA 2020+. Sector plans are formulated by government Departmental/Unit ministries for medium term periods of 5-10 years to prioritize and align with the NSDP. Activities Activities Plans (monthly) B. NSDA 2020+ 2021, Cook islands Prime Minister, Hon. Te Ara Akapapa’anga Nui – NSDA 2020+ is structured with an extended outlook, including overlapping Mark Brown awaiting medium- and long-term plans on a generational scale. The chosen planning periods align with the philosophy his COVID-19 Vaccination. and practice of ‘Akapapa‘anga: the use and importance of genealogical legacies to and for the Cook Islands and its people. Central to Te Ara Akapapa’anga Nui – NSDA 2020+ is the concept of ‘Turanga Memeitaki – Wellbeing for all’. Under this vision, each person in the Cook Islands attains a state of being comfortable, healthy, and happy. There is general agreement within the Cook Islands government that, at minimum, wellbeing includes the presence of positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety), and satisfaction with life, fulfilment and positive functioning.38 Under the NSDA 2020+, the first five-year period is marked by short-term targets on wellbeing, with indicators linked to many of TMOs core competencies. 37 World Health Organization (WHO). (2017). Strategizing National Health in the 21st Century: A Handbook. Geneva: WHO. 38 Government of the Cook Islands. 2021. “Te Ara Akapapa’anga Nui NSDA 2020+: Te Kaveinga Iti 5 Year Score Card.” Rarotonga: GCI. 50 51 C. Alignment of NSDA 2020+ to NHSP 2023+ The NSDA 2020+ is also noteworthy for its alignments with the SDGs, as well as the regional agenda SIDS Accelerated Modalities of Action (SAMOA) pathway. Broader goals around wellbeing for all (Goal 1), waste management (Goal 4), water and sanitation (Goal 5), ICT (Goal 6), education and innovation (Goal 8), inclusivity and care for the vulnerable (Goal 9), food These linkages are elucidated in the NSDA 2020+ and are reproduced below: security (Goal 10), environmental/ecological health (Goal 11), climate resilience (Goal 12), sustainability (Goal 14), and safety and security (Goal 15) all have relevance for the NHSP 2023+, either via general goals/objectives, or through specific indicators. However, Goal 7 (Health and Healthy Lifestyles) remains the single most significant linkage between the NSDA 2020+ and the NHSP, and is reproduced in graphic form, below: SAMOA GOAL 7. HEALTH AND HEALTHY LIFESTYLES Cook Islands NSDA Pathway priority areas Reduce non-communicable diseases—Note that health impacts require linger periods to see change (2021 - 2121) Indicator 7.1 Rage of premature deaths from non-communicable diseases. This indicator meaures the rate of premature deaths from non-communicable diseases, with the intent to reduce this rate over time. Non-communicable diseases or NCD’s are our largest health challenge with high rates of heart disease, diabetes and other lifestyle diseases affecting the lives of many Cook Islanders every year and putting a strain on our health system. Increase inveestment in health care—Indicator 7.2 Health spending as a percentage of government Sustainable, Inclusive and Equitable expenditure. Economic Growth This indicator looks at how much Government spends on health. As our health system is almost exclusively publicly funded, the amount of the Government spend is crucial for improving the health of our people. Promote sexual health—Indicator 7.3 Prevalence of sexually transmitted infections (STI’s) Sexually transmitted infections have become a significant health issue in the Cook Islands. A reduction in STI’s is a key priority for the Ministry of Health and serves as a key indicator of safer sexual practives and better Food Security / Nutrition sexual health and increased fertility rates. Promote healthier lifestyles through exercise and sports—Indicator 7.4 Youth engagement in physical activity and sports Exercise, sports and other physical activities are crucial for a healthy lifestyles. Lifestyle habits are usually engrained at an early age which is why it is crucial that we measure the extent to which children, young people, and adults engage in physical activities on a daily and weekly basis (the Ministry of Health recommends at Health and NCDs least half an hour per day for adults and an hour per day for young people). Achieve healthier longer lives—Indicator 7.5 Average life expectancy. Life expectancy is the most widely used measure of the general health of a society. Health care spending, standards of livign, environmental improvements, lifestyle changes, public health, disease prevention, and education all contribute to improved life expectancy and quality of life. Improve mental health care—Indicator 7.6 Mental health index Social Development: Education This indicator looks at diagnosis, access to services and suspected suicide as a measure towards improving mental health care. • Number of people with mental health diagnosis in the past 12 months (moderate-severe mental illness) • Percentage of people accessing mental health services • Suspected suicide or completed suicide per year Gender Equality and Women’s Empowerment 39 Ibidem. p.11 52 53 Sustainable consumption and Production management of chemicals Water and Sanitation and waste, including hazardous waste Climate Change Sustainable Energy Oceans and Seas Sustainable, Inclusive and Equitable Economic Growth Biodiversity (Desertification, land degradation and drought; Forests) / Invasive Alien Species Sustainable, Inclusive and Equitable Economic Growth/Sustainable Transport Social Developmement: Promoting peaceful societies and safe communities Social Development Means of Implementation / Partnerships, Financing, Trade, Capacity Building, Data­—Statistics, Technology Social Development Culture and Sport/Disaster Most notably, Goal 7 of the NSDA 2020+ is linked to SDG 3 (Good Health and Well-Being), as well as the Risk Reduction ‘Health and NCDs’ SAMOA Pathway priority area. 40 Ibidem. pp.22-24 54 55 V. NHSP 2023+ GUIDING PRINCIPLES

1. Vision All people living in the Cook Islands living healthier lives and achieving their aspirations

2. Mission To provide accessible, affordable health care and equitable health services of the highest quality, by and for all in order to improve the health status of people living in the Cook Islands

3. Values - EQUIPPER E—Equity - Promoting human rights principles and providing timely and equitable access to quality, affordable healthcare services for all people in the Cook Islands; Q—Quality & Innovation – Embracing leading-edge, evidence-based best practice and excellence in all aspects of our work. Client-focused, delivering safe, responsive, sensitive, sustainable, well resourced, data-driven healthcare services provided by a qualified and competent workforce, including carers and advocates; U—Unity – Creating a spirit of cooperation and a sense of belonging; increasing enthusiasm for requisite tasks and fostering an empowering work environment; I—Integrity & Accountability - Maintaining professionalism, honesty, respect and confidentiality; ensuring that our systems are transparent and reflect responsible governance and management, ensure gender equality, non-discrimination and the participation of men and women in decision-making at all levels P—People centred - Ensuring that the welfare of men and women, boys and girls remains our priority, guided by the human rights principles of empowerment, gender equality, non- discrimination, participation and accountability; P—Passionate - Maintaining a persistent, determined and caring attitude in pursuit of goals E—Empower - Creating a spirit of appreciation, supporting, motivating and encouraging colleagues and clients R—Respect - Acknowledging a person’s inherent dignity, integrity and rights with compassion, trust, privacy and confidentiality

4. Policy Goals The following policy goals are reflected under the KRAs in the NHSP 2023+

1. Support and develop our workforce to provide quality service delivery, good governance, information and financial systems for a sustainable future.

2. To strengthen and improve community health services under the principles of Primary Health Care and Healthy Islands context.

3. To ensure universal access to quality healthcare services, strengthen health system and address key health determinants.

4. To provide quality pharmacy, diagnostics, and clinical support services to meet client clinical needs in line with evidence-based best practice and TMO policies, and within the limitations of the resources of the Ministry. JULY 2024 HEALTH EXPO AT THE NATIONAL

5. To work collaboratively, complement and support health partners in the implementation of agreed health AUDITORIUM, Tereora related interventions and activities. College Student participating in a media survey. 56 57 VI. KEY RESULT AREAS (KRAS) ii. Sectoral Policies and Planning Strategies Linked to KRA For the sake of continuity and coherence, the KRAs from the previous permutations of the NHSP serve as the starting point for the NHSP 2023+. Necessary revisions – to reflect new and/or changed divisions/ • Te Papa Tutara A Te Marae Ora: Cook Islands National Health Road Map | 2017-2036 departments/directorates, as well as evolving health system functions and national/regional/international • Cook Islands Road Safety Strategy 2016-2020: Keep Me Safe expectations and guidelines – have been undertaken. Following extensive consultation with TMO staff, • Sanitation (Wastewater Management) Policy 2016 governmental and NGO/CBO stakeholders, and the wider Cook Islands community, and reflecting the expressed preferences and hopes of participants, the NHSP 2023+ is intended as an evolutionary (rather • National Water Policy 2016 than revolutionary) document, serving as an update to the NHSP 2017-21. Lastly, it should be noted that • Cook Islands Government Financial Policies and Procedures Manual: April, 2020 only those targets that are codified in the TIMF serve as a basis for formal monitoring and evaluation. • Te Ara Akapapa’anga Nui: National Sustainable Development Agenda (NSDA) 2020+: 2021– 2121 A. KEY RESULT AREA 1: HEALTH ADMINISTRATION AND MANAGEMENT • Climate Change and Health Adaptation Plan for the Cook Islands a. Policy Goal Support and develop our workforce to provide quality service delivery, good governance, information and • Cook Islands Government Public Financial Management Roadmap financial systems for a sustainable future. • Ngaki’anga Kapiti Ora’anga Meitaki: The Cook Islands Strategic Action plan to prevent and control b. Delivery Areas Non-communicable diseases 2021-2025 DA 1: Leadership, Governance and Policy • Cook Islands National Infrastructure Investment Plan DA 2: Health Finance • Te Kavaeinga Tupu- ‘anga iti Tangata: Cook Islands Population Policy 2022-2032 DA 3: Human Resources for Health iii. Regional / Global Strategies DA 4: Health Information Systems • Framework of Action for Revitalization of Healthy Islands in the Pacific DA 5: Health Research DA 6: Health Infrastructure • Western Pacific Regional Action Plan for Noncommunicable Diseases: A Region Free of Avoidable NCD Deaths and Disability DA 7: Public Relations • International Health Regulations 2005: Guidance for National Policy-Makers and Partners DA 8: Information and Technologies (IT) DA 9: Monitoring and Evaluation • SIDS Accelerated Modalities Of Action (S.A.M.O.A.) Pathway • Transforming Our World: The 2030 Agenda for Sustainable Development c. Policies and Planning Strategies Linked to KRA • Pacific Health Information Network Vision and Strategy The following specific, extant plans have been considered in the planning process of the KRA: • Western Pacific Regional Framework for Action for Disaster Risk Management for Health i. Programme-Specific Strategies and Plans related to KRA • Cook Islands Health Workforce Plan 2016-2025 • WHO Strategic Communications Framework for Effective Communications • Te Rito O Te Papa’anga Ora: National Health Information Strategy 2015-2019 • 2050 Blue Ocean Pacific Island Forum • The Ministry of Health and Health Research in the Cook Islands: Policy and Procedures (2019) • Regional Innovation Strategy in the Western Pacific • Information & Communications Technology (ICT) Policy & Procedures (revised May 2017) • WHO Western Pacific Framework to shape the health workforce of the western pacific region • National Service Fee Schedule 2015 (revised March 2022) for future • Finance Policy and Procedures (revised May 2017) • WHO Western Pacific Regional Action Framework on Communications for Health • Cook Islands Government Financial Policies & Procedures Manual • The Pacific Approach, 2021–2025, ADB • Personnel Policies and Procedures Manual (revised July 2017) • Ministry of Health and Health Research in the Cook Islands: Policy and Procedures (2019) 58 59

1. KRA 1 Objectives • Formulation and maintenance of a research plan that identifies and prioritizes necessary health research for TMO and partners. DA 1. Leadership, Governance and Policy • Enforce, support and strengthen TMO’s health mandate, including core roles and functions. DA 6. Health Infrastructure • Provide support to strengthen general administrative and management responsibilities of hospital • Bolster climate resilience of health facilities, particularly on the Pa Enua. and community health services. • Increase the use of Renewable Energy Technologies (RETs) in TMO facilities. • Provide support to strengthen general administration and management responsibilities for support • Improved and safer working conditions, healthier and sustainable work environments. services areas, particularly kitchen, laundry, and maintenance to ensure ease and efficiency of DA 7. Public Relations operations. • Promote public health initiatives and raise awareness about various health issues within the • Strengthening capabilities for health strategy development, policy reviews and formulation. population. • Formulate and review legislation to address and anticipate health service needs, demand and • Develop and implement communication strategies to educate the public about preventive responsibilities. measures of health. • Strengthen and support enforcement of and adherence to health laws and regulations. • Effectively disseminate accurate and timely information to encourage positive health behaviours and empower individuals to make informed decisions regarding their well-being. DA 2. Health Finance • Strengthen financial control, coordination and monitoring of all health funding sources according • DA 8. Information Technologies (IT) to TMO and GCI standards. • Improve data collection, analysis and dissemination through capacity building activities and • Advocate for improved funding and budget allocations for TMO. supervision mechanisms. • Support and facilitate annual budget planning and auditing processes. • Enhance data management through written procedures and utilization of a metadata dictionary and/or MedTech Evolution templates. • Obtain and maintain unqualified audit opinions on TMO annual financial reports. • Improve quality of health information products through accessible and improved dissemination • Support and facilitate ongoing studies on feasible financing options for health services. of information on various electronic platforms (including public-facing websites where feasible/ DA 3. Human Resources for Health appropriate). • Support and facilitate staff development as outlined in the Cook Islands Health Workforce Plan • Strengthen the application of information and communication technologies (ICT) including the 2016-2025, and update policy prior to expiry. use of telehealth/telemedicine in all Pa Enua health clinics. • Facilitate specialist training of staff, especially paediatrics, general medicine and Pharmacy DA 9. Monitoring and Evaluation Technicians. • Assess and improve the effectiveness of all TMO’s health programmes and interventions. • Support training in echocardiogram diagnostic capability and ultrasound training for general • Conduct rigorous evaluations of all action plans, programmes and initiatives to determine their medicine and radiology service staff. impact, efficiency, and alignment with relevant strategic plans, business plans, policies and • Support in-service training for Pa Enua nurses in Primary Care, oral health, leadership and procedures. management. • Collect and analyse relevant data, assess the outcomes and outputs of programmes, identify areas • Provide and support training for nursing and Allied Health professionals for improvement, and provide evidence-based recommendations to enhance the effectiveness • Ensure Human Resources for Health policies are relevant, producing and maintaining quality and and efficiency of TMO administrative operations. equitable distribution and productive workforce. a. KRA 1 Targets DA 4. Health Information Systems DA1: Leadership and Governance • Strengthen resources, including legislative, regulatory and planning frameworks required for • Review of Legislation, particularly Tobacco Products & Control Act. an efficient health information system, including requisite inputs for Health Information Unit • Review and develop new Regulations as necessary under the new Public Health Act. forecasting and modelling. • Performance excellence recognized and rewarded by PSC. • Strengthen and support enhanced institutional capacity and workforce development for sustainable infrastructure. • New Public Health Act Implementation Plan approved and operationalized. • Provide accurate and comprehensive health information to support evidence-based decision • Develop TMO Occupational Safety & Health (OSH) Policy. making at all levels of the healthcare system. • National Health Service Fee Scheduled policy reviewed. DA 5. Health Research • Rebranding of the Mental Health Unit • Strengthen TMO health research capabilities through appropriate institutional capacity-building • Maintain existing cooperation of health arrangements with core partners. (both HRH and financial). DA2: Health Finance 60 61 PROMOTING WATER— Promoting water intake over the preference of fizzy drinks—TMO in partnership with APII AVARUA 62 63 • Maintain performance indicators specified under Public Expenditure and Financial Accountability DA6: Health Infrastructure (PEFA) framework. • Vulnerability assessments (i.e. mapping) for TMO buildings completed. • Maintain unqualified audit opinion. • Disability Access for entries into all TMO buildings. • 80%-100% implementation of the GCF Funding programme (contingent on approval/ • Scoping works to the activities identified in the National Health Infrastructure Programme disbursement). • Hospital redevelopment scoping plan completed • Health expenditure increase as a proportion of GDP/capita. • Scoping of prioritized areas of health for privatization. DA7: Public Relations • Development of Health Communications / PR 5-year Action Plan (CI population policy 7.6). DA3: Human Resources for Health • Continue NP training programme. • All registered complaints acknowledged within 24 hours. • Continue Nursing Bachelor Nursing Pacific Program. • All registered complaints responded to within 14 days. • Upskilling Health Protection Officers/Assistants. • Official Information Requests responded within 20 days. • Upskilling Pharmacy Technicians/Assistants. • Restructure Primary Health Care Directorate. DA8: Information Technologies (IT) • ManageMyHealth or similar Patient Management Portal fully implemented. • Annual Mid-Level Management Training program carried out. • Mid Term Review of the National Health Workforce Plan 2020-2025. • Arrangement of Health Co-operation (AoC) development for all private practitioners’ access to MedTech Evolution. • Develop National Health Workforce Plan 2025+. • Human Resources Information Management System (HRIMS) developed. • Wireless internet access rolled out in all TMO buildings in Rarotonga. • Annual general health check-up for all TMO staff mandatory. • Public Health Information System (PHIS) Developed (contingent on GCF project approval/ • Incentive scheme to attract and retain medical personnel explored. disbursement). • Dental Officers, Dental Therapists, Dental Technician, Dental Assistants, Health Care and/or • 80%-100% implementation of Digital Health and Information Action Plan. Caregiver training continued in collaboration with service providers. • Annual MedTech Evolution training for relevant TMO staff and/or private practitioners. DA4: Health Information Systems • Development of the Digital Health Information and Transformation Action Plan. • DA9: Monitoring & Evaluation • Biennial training on death certification for all Medical Officers and Nurse Practitioners. • M&E framework developed. • Biennial ICD coding for relevant HIS staff. • NHSP 2023+ midterm evaluation completed. • Annual Health Bulletin published. • Quarterly update on NCD published. B. KEY RESULT AREA 2: PUBLIC HEALTH • Comparative analysis of cause-specific death rates among males and females every 5 years. a. Policy Goal • Implement recommendations made in Vital Statistics Report of 2015 and CVRS report (2021). To strengthen and improve public/population health, under the principles of UHC, within the • Maintain prioritized Health Registers. context of the Healthy Islands Vision b. Delivery Areas DA5: Health Research • Annual health conference. DA 1: Health Protection • Develop data bank for all health-related research. DA 2: Health Promotion • Research food choices and preferences and reasons for sedentary behaviour (CI population policy 6.5). DA 3: Mental Health • Prepare TOR for research on social determinants of health. DA 4: Health Intelligence Unit (HIU) 64 65 C. POLICIES AND PLANNING STRATEGIES LINKED TO KRA • Regional Agenda for Implementing the Mental Health Action Plan 2013–2020 in the Western The following specific, extant plans have been considered in the planning process of the KRA: Pacific • SIDS Commitment Portal for NCDs and Mental Health i. Programme-Specific Strategies and Plans related to KRA

1. KRA 2 Objectives • Public Health Act • Integrated National Strategic Plan for Sexual and Reproductive Health 2014 - 2018 DA 1: Health Protection • Implement regulations in relation to the enforcement of health legislation. • Ngaki’anga Kapiti Ora’anga Meitaki: The Cook Islands Strategic Action Plan to Prevent and Control Non-Communicable Diseases 2021-2025 • Enforce food safety and tobacco control regulations. • Cook Islands Tobacco Control Action Plan 2023-2031 • Improve and strengthen vector control. • National Immunisation Policy • Enforce sewage and sanitation regulations. • Mental Health and Wellbeing Policy • Strengthen food safety and food standards. • Cook Islands National Suicide Prevention Strategy • Maintain and strengthen pollution control measures especially sewage and medical waste • IMS – Health Operations Water and Sanitation Standard Operating Procedure management. • Public Health Sanitation Unit – European Union (EU) Project Report: Ensure that the treatment • Maintain and strengthen water standards through monitoring, analysis and treatment of water and disposal of sewage and wastewater is in compliance with the Public Health (Sewage & storage. Wastewater Treatment and Disposal) Regulations 2014 • Maintain and strengthen quarantine and border control support services at ports of entry. • Sanitation (Wastewater Management) Policy 2016 • Sanitation (Wastewater Management) Policy 2016 • Cook Islands Emergency Response Plan to Coronavirus Disease 2019 (COVID-19): April 2021, • Cook Islands Emergency Response Plan to Coronavirus Disease 2019 (COVID-19): April 2021, • COVID-19 (Public Health Measures) Regulations • COVID-19 (Public Health Measures) Regulations • Cook Islands Health Workforce Plan 2016-2025 • Cook Islands Health Workforce Plan 2016-2025 • Cook Islands National Disaster Risk Management Arrangements • Cook Islands National Disaster Risk Management Arrangements • Cook Islands Pandemic Preparedness Plan (2023) • Cook Islands Pandemic Preparedness Plan (2023) • Cook Islands National Cancer Control Plan 2022-2027 ii. Sectoral Policies and Planning Strategies Linked to KRA • Cook Islands National Cancer Control Plan 2022-2027 • Cook Islands Road Safety Strategy 2016-2020: Keep Me Safe (revised June 2020) • WHO Regional Framework for the Future of Mental Health in the Western Pacific 2023–2030 • Sanitation (Wastewater Management) Policy 2016 • Regional Agenda for Implementing the Mental Health Action Plan 2013–2020 in the Western Pacific • National Water Policy 2016 • SIDS Commitment Portal for NCDs and Mental Health • Cook Islands Disability Inclusive Development Policy: Rights / Responsibilities / Action - 2020- 2025 (Tikaanga / Taau Tuanga / Rave’anga), 4th Edition • Maintain and strengthen the International Health Regulations framework, ESR, Public Health Surveillance Network, climate change impacts, and DRM. iii. Regional / Global Strategies • Facilitate and support WASH initiative activities in the Cook Islands. • Framework of Action for Revitalization of Healthy Islands in the Pacific • Support the implementation of the new Public Health Act. • Western Pacific Regional Action Plan for Noncommunicable Diseases: A Region Free of Avoidable NCD Deaths and Disability • Review and update HPO work manual. • International Health Regulations 2005: Guidance for National Policy-Makers and Partners • Develop a National Food Safety guideline. • Convention on the Rights of Persons with Disabilities (CRPD) and Optional Protocol • Support the implementation of the Cook Islands Healthy Island Initiative • Convention on the Rights of the Child DA 2: Health Promotion • Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) • NCD premature mortality reduction in line with regional standards and/or appropriate comparator country/ies (per CI Population Policy). • Community-Based Rehabilitation: CBR Guidelines • Support and strengthen prevention and management services for overweight/obesity, diabetes, • WHO Framework Convention on Tobacco Control hypertension and cardiovascular diseases. • WHO Regional Framework for the Future of Mental Health in the Western Pacific 2023–2030 • Support and strengthen ongoing prophylaxis against NCDs and their risk factors. 66 67 JULY 2023 HEALTHY ISLANDS INITIATIVE. Health promotion officer, Oropai Mataora delivering education program and raising awareness to Mauke School students 68 69 DA 2: Health Promotion cont... A. KRA 2 TARGETS • Strengthen and support health communication strategies covering key risk factors. DA1: Health Protection • Support research activities into NCDs and their risk factors. • Annual training in compliance and enforcement for HPOs. • Support prevention of childhood obesity through nutrition programmes utilizing school-based • Less than 10 non-compliance complaints / food and drinking water incidents per annum. approaches. • Twice-yearly Tutaka programme. • Promote healthier lifestyles through exercise and sports • 100% monitoring of mosquito breeding sites. • Support the Baby Friendly Hospital initiative. • 100% of new private and commercial buildings meeting approved standards for Rarotonga and • Advocate for household food security and good nutrition through home/school gardening and Aitutaki. healthy food preparation. • At least 80% of food premises inspected and registered annually. • Develop a nutrient intake profile for Cook Islanders using import data and household expenditure • Maintain 80% compliance with international border regulations (IHR). survey data. • Reduce the prevalence of STIs. • At least 2 HPOs attain formal qualifications from an accredited institute (in alignment with Workforce Plan). • Support national and regional efforts to prevent the spread and minimize the impact of HIV/STIs on individuals, families and communities. • Establishment of Public Health Mini Lab (contingent on GCF project approval/disbursement). • Strengthen the early detection of HIV and other STIs to reduce further infections and facilitate • Development of Rarotonga minimum water standards. timely management and treatment. • Development of prioritised Pa Enua minimum water standards. • Support local TB control programme via Global Fund strategies. • 100% outstanding non-compliant notices referred for prosecution • Strengthen and support TB awareness activities and management of TB in the community. • SOPs reviewed and completed, aligned to new Public Health Act. • Implement and strengthen Tobacco Control measures as outlined in the Cook Islands Tobacco Control Action Plan 2023-2031 and Ngaki’anga Kapiti Ora’anga Meitaki: The Cook Islands DA2: Health Promotion Strategic Action Plan to Prevent and Control Non-Communicable Diseases 2021-2025. • NCD premature mortality reduction in line with regional standards and/or appropriate comparator country/ies (per CI Population Policy). DA 3: Mental Health • Improve mental healthcare services • Increase of consumption of ≥5 serves of fruit and vegetables per day in line with regional standards and/or appropriate comparator country/ies. • Creation of mental health service infrastructure and governance. • Aggregate total of 5,000 followers across TMO health promotion social media platforms. • Provision of quality evidence-based equitable mental health services. • Implementation of 30 awareness activities, events, campaigns, initiatives or programmes by • Prevention of mental illness through collaborative health promotion and education. 2025 (per CI Population Policy Goal 7). • Effective data collection and quality improvement processes implemented. • Increase of physical activity by islands through strategic partnership development with fitness • Reviewing local social determinants of mental health. programmes. DA 4: Health Intelligence Unit (HIU) • Review and revise NCD strategy 2021-2025. • Improve public health surveillance systems by developing and implementing advanced data • Launch of ‘Healthy and Smoke Free Islands’ programme. collection and analysis methods to monitor and detect health trends, disease outbreaks, and public health emergencies in real-time. • Operationalize Healthy Meal Policy for Rarotonga primary and secondary schools, in conjunction with the development partners. • Establish robust information-sharing mechanisms with EMCI, and other relevant stakeholders to ensure timely reporting and response to health threats. • School Health literacy programme established. • Enhance data collection/collation within Public Health Management System. • Conduct ≥500 individual HIV tests per annum. • Maintain and strengthen Events Surveillance and Response focusing on International Health • Revise Integrated National Strategic Sexual and Reproductive Health (SRH) Plan (per CI Population Regulations, NCDs, climate change, and emerging Health Risks. Policy). • Develop a ‘One Health’ model that unifies and strengthens a multi sectorial approach towards • Achieve 100% DOTS coverage for TB. populations, animals and environment health. • Smoking rate reduction of 10% by 2025 in line with regional standards and/or appropriate • Operationalise New Public Health Act. comparator country/ies (per CI Population Policy). • Redefine functions and responsibilities post-COVID 19 incorporating aspects of regulatory • Dietary guidelines developed. compliance and enforcement to the Public Health Act. • Enrolment of 50 participants per annum in smoking cessation programmes. • Redefined functions and responsibilities completed and operationalized. • Biannual ‘Making Sense of Data’ workshops. 70 71 DA3: Mental Health • National Service Fee Schedule 2015 (revised March 2022) • Number of people with mental health diagnosis reported annually (moderate –severe mental • Antibiotic Guidelines - Cook Islands 2018: Guidelines for Empiric and Targeted Antibiotic illness). Treatment, Prophylaxis, Dosing and Allergies • Drafting of systematic review and/or position paper on locally specific social determinants of • Cook Islands Antimicrobial Resistance National Action Plan: Akono Meitaki mental health completed. • Cook Islands Population Policy 2022-2032 • 20% continued increased in number of objectives delivered and/or activities implemented each year, per the CI Mental Health Work plan. ii. Sectoral Policies and Planning Strategies Linked to KRA • Workforce is maintained above 80% of the work plan. • National Policy on Gender Equality and Women’s Empowerment and Action Plan 2019-2024 • Increase percentage of population accessing mental health services. • Reduction of suicide mortality rate (aggregated over 4-year period) in line with regional standards iii. Regional / Global Strategies and/or appropriate comparator country/ies. • Framework of Action for Revitalization of Healthy Islands in the Pacific • Patient satisfaction baseline established. • Western Pacific Regional Action Plan for Noncommunicable Diseases: A Region Free of Avoidable NCD Deaths and Disability • 80% patient satisfaction rate met biennially. DA4: Health Intelligence • Convention on the Rights of the Child • 6-monthly risk modelling reporting on notifiable diseases and emerging health risks. • Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) • 100% of non-compliance to the Public Health Act are addressed within 14 working days of • Pacific Regional Blindness Prevention Programme receipt. • ‘One Health’ framework developed and implemented. 1. KRA 3 Objectives • Case investigations of non-compliance under Public Health Act registered and reported annually. DA1: Clinical Patient Care Services • Strengthen triaging of patients for early and urgent care of very sick patients. • ≥5 staff undertake and complete Pacific Data for Decision Making (DDM) training programme. • Strengthen and embed Package of Essential Noncommunicable (PEN) disease management for • Completion of 3 Inter-Agency mock exercises focused around International Health Regulations. NCD control into patient consultation process. • Redefined functions and responsibilities completed. • Support and strengthen existing surgical and anaesthetic services. C. KEY RESULT AREA 3: HOSPITAL HEALTH • Strengthening laparoscopy procedures. a. Policy Goal • Strengthening orthopaedic procedures relating to fracture management. • Continue to support critical care nursing for High Dependency Unit staff. To provide quality clinical hospital care and services to meet the needs and expectations of patients, in line with the policies and resources of TMO. • Maintain and strengthen current services in obstetrics care and Safe Motherhood. b. Delivery Areas • Strengthen ante-natal screening services. DA 1: Clinical Patient Care Services • Support and promote family planning services and counselling to all eligible women especially to women who have NCDs such as diabetes and hypertension. DA 2: Referral Services (both Domestic and International) • Support and strengthen current multidisciplinary clinical services. DA 3: Specialist Care • Strengthen cardiac assessment and diagnostic capabilities such as echocardiogram services. c. Policies and Planning Strategies Linked to KRA • Strengthen diagnostic capability through modern medical technology (e.g. CT scanning), including The following specific, extant plans have been considered in the planning process of the KRA: securing requisite radiology services. i. Programme-Specific Strategies and Plans related to KRA • Strengthen paediatrics inpatient and outpatient services, including neonatal care and services. • Ngaki’anga Kapiti Ora’anga Meitaki: The Cook Islands Strategic Action Plan to Prevent and • Initiate and support Baby Friendly Hospital Initiative programme and secure status recognition. Control Non-Communicable Diseases 2021-2025 • Strengthen current services provided in eye care, including refraction. • Patient Referral Policy 2019 • Support awareness and interventions on preventable causes of blindness. • Te Rito O Te Papa’anga Ora: National Health Information Strategy 2015-2019 (revised June • Provide treatment services for diabetic eye complications. 2020) • Support retinal mapping training for relevant staff. • The Ministry of Health and Health Research in the Cook Islands: Policy and Procedures (2019) • Strengthen and expand cancer screening services. • Information & Communications Technology (ICT) Policy & Procedures (revised May 2017) • Improve average life expectancy 72 73 DA 2: Referral Services (both Domestic and International) DA2: Referral Services • Support and facilitate cost-effective evacuation and referral of patients for overseas medical • Patient satisfaction baseline established. treatment, commensurate with Patient Referral policy. • 80% patient satisfaction rate met biennially. • Support treatment and management of Pa Enua-referred patients through timely interventions. • Review and update patient referral policy. • Support ongoing treatment and review of overseas treated patients. DA3: Specialist Care DA 3: Specialist Care • ≥12 health specialist visits per annum • Support the development of local staff as specialists, as outlined in the Cook Islands Health • ≥2 community and/or Pa Enua outreach programmes implemented per annum. Workforce Plan (2016-2025). • Coordinate and facilitate the scheduled visits of relevant specialists. D. KEY RESULT AREA 4: PRIMARY CARE • Advocate for clinical and technical service support in relevant disciplines, including diagnostic and • a. Policy Goal biomedical services. • To foster and accelerate integrated primary healthcare as the main vehicle for achieving universal • Coordinate with partner agencies and island governments on specialist visits and services for the health coverage and national health goals. Pa Enua. b. Delivery Areas • Continue funding support for high-risk surgical referral cases in New Zealand in circumstances of DA 1: Primary Care long waiting times. • Support clinical services for visiting specialists. c. Policies and Planning Strategies Linked to KRA The following specific, extant plans have been considered in the planning process of the KRA: A. KRA 3 TARGETS DA1: Clinical Patient Care Services i. Programme-Specific Strategies and Plans related to KRA • Two ED protocols updated every year for best practice. • Primary Healthcare Development Strategy 2021 • 50% of emergency ambulance call outs in Rarotonga leave the hospital within three minutes in • Antibiotic Guidelines - Cook Islands 2018: Guidelines for Empiric and Targeted Antibiotic Rarotonga. Treatment, Prophylaxis, Dosing and Allergies • 50% of adult patients presenting with chest pain have ECG started within 10 minutes from 2023, increasing by 5% by each year. ii. Sectoral Policies and Planning Strategies Linked to KRA • Cook Islands Disability Inclusive Development Policy: Rights / Responsibilities / Action - 2020- • Increase cervical cancer screening rate by 5% each year from 2022 baseline of 55%. 2025 (Tikaanga / Taau Tuanga / Rave’anga), 4th Edition • 100% coverage of antenatal and obstetrics care. • Cook Islands Road Safety Strategy 2016-2020: Keep Me Safe (revised June 2020) • 100% of neonates from hepatitis-positive mothers are given a hepatitis B immunization and • Ngaki’anga Kapiti Ora’anga Meitaki: The Cook Islands Strategic Action Plan to Prevent and immunoglobulin within 72 hours, and followed up at nine months. Control Non-Communicable Diseases 2021-2025 • A reduction in the absolute number of post-operative infections by one annually. • Cook Islands Antimicrobial Resistance National Action Plan: Akono Meitaki • Develop Cook Islands National Infection Prevention Control Action Plan. • Cook Islands Health Workforce Plan 2016-2025 • Develop CI MOH Palliative Care guidelines and SOPs completed and updated. • Cook Islands National Policy on Positive Ageing 2024-2028. • Primary and secondary school student obesity rate reduced in line with regional standards. • iii. Regional / Global Strategies • Increase mammogram screening follow up of all eligible women (40 to 75 years of age) by 1% biennially (every 2 years) from the current 2022 level. • Framework of Action for Revitalization of Healthy Islands in the Pacific • Produce prostate cancer screening protocol to strengthen prostate cancer screening. • Western Pacific Regional Action Plan for Non-communicable Diseases: A Region Free of • Scope bowel cancer screening services. Avoidable NCD Deaths and Disability • NCD premature mortality reduction in line with regional standards and/or appropriate comparator • International Health Regulations 2005: Guidance for National Policy-Makers and Partners country/ies (per CI Population Policy). • Convention on the Rights of the Child • Maintain or increase average life expectancy • Regional Framework on the Future of Primary Health Care in the Western Pacific • Maintain nil maternal and low neonatal and child mortality rate. 74 75 AUGUST 2023, HEALTHY ISLANDS INITIATIVE, APII AVARUA Students enjoying Fruit Day. 76 77

1. KRA 4 Objectives DA1: Primary Care cont... DA 1: Primary Care • Palliative care database reviewed and maintained, and reported annually to HIS. • Support and strengthen primary healthcare services through integrated, multi-sectoral policy and • Nil stock-outs of oral, injectable and barrier contraceptives at community clinics. action, and empowered people including the elderlies and communities to meet basic primary • Scoping review of implementation of UN Health Aging Action Plan (per CI Population Policy care needs and UHC goals. Objective 5.3 and 5.4). • Sustain and provide continuing medical education for staff upskilling to bolster primary care • Compile and collate data on service provision to disabled and elderly patients. service delivery. • Monthly treatment for identified adolescent RHD cases reported. • Ensure digital technologies are operational on the Pa Enua to support telemedicine / telehealth • Maintain percentage of elderlies accessing health services. care and clinical support. • One NCD targeted training/upskilling conducted biennially. • Reorienting primary healthcare for improved accessibility, availability, and quality care. • Implementation of a structured patient appointment system. • Integrate other clinical support services appropriate at PHC. • Maintain or reduce patient waiting time to <99 minutes. • Strengthening of Primary Care specialist capability and capacity across the Cook Islands. • At least 90% of PHC to ED transfers deemed ‘Appropriate’ as measured by patient disposition at • Support and strengthen safe motherhood initiatives and programmes. ED (admission or discharge), investigations (e.g. labs, radiology), or specialist review. • Raise awareness of family planning resources and initiatives. • Establish PHC to ED transfer baseline by end of 2024. • Support and strengthen cancer screening and prevention programmes, especially Pap smear and • Establish SOPS for transfer of patients to appropriate specialised clinical area. breast examination / screening. • Minimum health practitioners allocated for each health centre / clinic. • Support the maintenance of a strong Expanded Programme on Immunization (EPI), including cold • Establishment of a paediatric clinic in PHC centre. chain management best practices to ensure high vaccine antigen coverage. • Establishment of ENT/eye clinic in PHC centre. • Support EPI disease surveillance and research. • RHD screening of children completed for >90% of persons in eligible age groups. • Promote exclusive breastfeeding up to 6 months of age. • RHD repeat screening for ≥90% of designated high-risk children. • Maintain and strengthen maternal & child health clinics for care and follow-ups of children. • RHD database updated and maintained. • Maintain and strengthen school health programmes and services. • RHD prophylaxis adherence ≥90% for all diagnosed patients. • Early Identification of developmental problems in children under 5, including appropriate referrals. • Primary and secondary school student obesity rate reduced in line with regional standards. • Support RHD screening programmes, treatment, referral and follow-up treatment for RHD cases. • Formal Agreements established with private practitioners and stakeholders. • Strengthen home visits to provide support for ongoing care of patients discharged from hospital • 6 monthly Professional Development calendar developed and distributed to Pa Enua Health Clinics. to prevent readmissions. • Reduce incidence of NCD in line with Regional standards. • Strengthen palliative care services. • Reduce inappropriate urgent referrals from PHC to ED. • Support the achievement of Baby Friendly Hospital Initiative certification. • Reduce transfer time of emergency cases from PHC clinics to Hospital. • Enable via training and supportive supervision of staff to undertake mobile utilization of digital • Training of staff to carry out thorough health screenings within community clinics using a screening templates to strengthen data collection for quality improvement. multidisciplinary approach. • Support community clinic practitioners. • Establishment of PHC Nursing service. • Assessment of adequacy of health services available to older people per the Cook Islands • Increased contraceptive prevalence rate in line with regional standards. Population Policy completed. A. KRA 4 TARGETS • Routine mobile doctors’ programme established for all islands. DA1: Primary Care • Establish minimum Rapid Test Kit for all Pa Enua health clinics. • Minimum 2 trainings in mobile utilization of digital screening templates to strengthen data collection for quality improvement. E. KEY RESULT AREA 5: ALLIED HEALTH AND CLINICAL SUPPORT SERVICES • Biennial school health check reports published. a. Policy Goal • Maintain ≥95% immunisation coverage. To strengthen service availability and readiness of allied health and clinical support services (e.g. • Maintain 100% post-natal checks. pharmaceutical services and diagnostics) to improve quality of life of patients and communities. • 100% home visits after hospital discharge. 78 79 b. Delivery Areas DA 1: Pharmacy cont... DA 1: Pharmacy • Support and strengthen pharmaceutical services through the provision of resources (human, financial and equipment) to meet basic pharmaceutical needs and store management. DA 2: Laboratory • Ensure availability of medicines supply at favorable prices and that meets recognized standards DA 3: Radiology of quality. • Review and update existing treatment guidelines, essential medicine list and national medicine DA 4: Physiotherapy and Occupational Therapy policy. DA 5: Biomedical • Strengthen optimal use of medicines through improved clinical support. DA 2: Laboratory DA 6: General Support (Food and nutrition, maintenance and Infection Prevention & • Support and strengthen laboratory quality management systems. Control [IPC]) • Maintain and strengthen current services in haematology, biochemistry, microbiology, blood c. Policies and Planning Strategies Linked to KRA bank, overseas lab tests referrals and related services in the laboratory. The following specific, extant plans have been considered in the planning process of the KRA: • Capacity building and institutional strengthening to full ISO standard. i. Programme-Specific Strategies and Plans related to KRA • Strengthen electronic laboratory information system through scoping of relevant system and • Primary Healthcare Development Strategy 2021 training of staff for improved surveillance and reporting • National Health Laboratory Policy DA 3: Radiology • Antibiotic Guidelines - Cook Islands 2018: Guidelines for Empiric and Targeted Antibiotic • Maintain and strengthen current radiology diagnostic services. Treatment, Prophylaxis, Dosing and Allergies • Support human resource development for upgraded services. ii. Sectoral Policies and Planning Strategies Linked to KRA • Strengthen radiology and scanning services to also cater for outreach services to Aitutaki • Cook Islands Disability Inclusive Development Policy: Rights / Responsibilities / Action - 2020- 2025 (Tikaanga / Taau Tuanga / Rave’anga), 4th Edition DA 4: Physiotherapy and Occupational Therapy • Cook Islands Road Safety Strategy 2016-2020: Keep Me Safe (revised June 2020) • Maintain and strengthen use of therapeutic ultrasound. • Ministry of Health (Pharmacy and Therapeutic Products) Regulations • Provide and strengthen physiotherapy services to cater for expanding patient health care needs. • Ngaki’anga Kapiti Ora’anga Meitaki: The Cook Islands Strategic Action Plan to Prevent and • Strengthen rehabilitation Program including training and networking. Control Non-Communicable Diseases 2021-2025 • Cook Islands Antimicrobial Resistance National Action Plan: Akono Meitaki DA 5: Biomedical • Cook Islands Health Workforce Plan 2016-2025 • Update baseline minimum medical equipment requirement in all health facilities. • Mental Health and Wellbeing Policy • Strengthen management of medical equipment especially the identification, verification, iii. Regional / Global Strategies procurement, servicing and disposal. • Framework of Action for Revitalization of Healthy Islands in the Pacific • Undertake standards and policy formulation to address biomedical equipment management (including the oxygen plant) • Western Pacific Regional Action Plan for Noncommunicable Diseases: A Region Free of Avoidable NCD Deaths and Disability DA 6: General Support (Food and nutrition, maintenance and Infection Prevention & Control • International Health Regulations 2005: Guidance for National Policy-Makers and Partners [IPC]) • Ensure access to nutritious food for hospitalized patients. • Convention on the Rights of the Child • Promote food safety and hygiene within hospital facilities. • APEC Guideline to Tackle Antimicrobial Resistance in the Asia-Pacific Region • Ensure safe and functional healthcare facilities.

1. KRA 5 Objectives • Promote hand hygiene and vaccination practices. DA 1: Pharmacy • Strengthening provision of special diets with a focus on diabetes. • Operate Pharmacy Information Management System (PIMS) to optimize service delivery. • Maintain availability of NCD (Diabetes, Hypertension) medications. 80 81 A. KRA 5 TARGETS DA5: Biomedical • 100% adherence to preventive maintenance schedule for biomedical equipment. DA1: Pharmacy • Completion of National Medicines Policy review. • Review and update Medical Equipment Donation Policy. • Review of Antimicrobial Action Plan. • Review Asset Management Policy. • Revision of TMO Pharmacy Warehouse SOPs. • Review Oxygen Management Plan. • Minimum medical equipment requirements for all health facilities maintained. • Revision of TMO Pharmacy Services Standards. DA 6: General Support (Food and nutrition, maintenance and Infection Prevention • Cold chain systems and processes meet best practise and acceptable standards on Rarotonga and Aitutaki by end of 2025, and other Pa Enua sites by end of 2027. & Control [IPC]) • Registration/licencing of medicines importers and distributors/suppliers (including requisite • TMO-approved national IPC guidelines translated to SOPs at the facility level and reviewed at auditing processes). least every five years. • Establish database for medicines importers and distributors/suppliers. • Audit of hand hygiene compliance to establish baseline. • 100% of Maintenance request forms attended to within a week. • Development of in-house Pharmacy Assistant training curriculum, and course delivery. • Biohazard waste collected and incinerated daily. • mSupply rollout to Pa Enua by end of 2025. • Rarotonga hospital kitchen inspected annually by HPOs. • Nil stock-outs of NCD (diabetes & hypertension) medications. • Develop infection control policies and guidelines. • Drug and therapeutic committee quarterly meetings maintained and reported. • Conduct surveillance and outbreak response. • Essential Medicine list reviewed every two years and align to Anti-Microbial Resistance Action Plan and Antibiotic guidelines. F. KEY RESULT AREA 6: ORAL HEALTH DA2: Laboratory a. Policy Goal • 90% of all non-urgent laboratory results processed and reported within 24 hours from the time To promote oral health, reduce oral diseases and other conditions for all individuals and communities. specimen received in laboratory (except microbiology results). b. Delivery Areas • 100% of urgent laboratory results processed and reported within three hours from the time DA 1: Child Oral Health specimen received in laboratory. DA 2: Adult Oral Health • Annual external audit report is generated on the progress of ISO 15189 certification. DA 3: Community Oral Health • Laboratory SOP and policies reviewed annually. c. Policies and Planning Strategies Linked to KRA • Monthly stock report submitted to Planning & Funding department to ensure nil stock outs. The following specific, extant plans have been considered in the planning process of the KRA: • Operationalize Laboratory Information Management System (LIMS). i. Programme-Specific Strategies and Plans related to KRA • Maintain unmodified audit report for laboratory inventory yearly. • Situational Analysis: Cook Islands Maternal and Child Oral Health National Policy and Guideline DA3: Radiology • The Cook Islands National Oral Health Strategy 2014-2018 • Development of radiology service plan with focus on local mammography service delivery. • WFPHA Maternal and Child Oral Health Initiative Endorsement Statement • One female staff member trained to conduct mammography screening. • Oral Health Services Plan 2019-23 • Full-time mammography screening available. • School Dental Program: Guidance Document • Review and update Radiology Equipment and Management policy annually. ii. Sectoral Policies and Planning Strategies Linked to KRA • Radiology Service Plan formulated and agreements executed. • Dental Act 1970-71 • Radiology scoping study for Aitutaki Hospital completed. • Medical and Dental Practices Act DA4: Physiotherapy and Occupational Therapy • Medical and Dental Practices Amendment Act • 100% of patients with musculoskeletal injuries are provided with therapeutic ultrasound. iii. Regional / Global Strategies • All disabled ward patients reviewed by physiotherapy department during admission. • Suva Declaration on Improving Oral Health in the Pacific Islands Region • Develop and review two guidelines and protocols annually for best practice. • Rethinking and Establishing a Dental Collaboration in the Pacific Region • Regional Oral Health Strategy 2016–2025: Addressing Oral Diseases As Part of Noncommunicable Diseases 82 83 JULY 2023, MITIARO PRIMARY SCHOOL, Physical Activity 84 85

1. KRA 6 Objectives DA2: Adult Oral Health DA 1: Child Oral Health • Acquire new digital imaging technologies (OPG, Intra-Oral). • Strengthen current child oral health services in schools. • Acquire digital prosthesis technologies (CAD-CAM). • Collaborate with other stakeholders in the delivery of effective maternal/child oral healthcare • Acquire dental laboratory equipment (furnaces and laboratory accessory equipment). services. • Renovate and upgrade Tupapa Clinic facility. • Establish integrated maternal/child oral health services. • Establish a dedicated oral surgery unit. • Re-introducing of fluoride varnish and rinse in schools. • Acquire and install dedicated oral health information system. DA 2: Adult Oral Health • Facilitate equipment and infrastructure procurement and development. • Enhance surveillance and health information systems to provide timely and relevant feedback on • Develop specialist oral healthcare services. oral health to decision-makers for evidence-based policy-making. • Implement oral health-specific health information system. • Strengthen preventive oral health programs, clinical health services (including Health Specialist • Implementation of a structured patient appointment system by end of 2024. Visit program) and patients receive quality care in timely manner. • Establish oral health disease profile. • Integrate essential oral health care and essential equipment and supplies in primary oral health care. • Improve natural teeth retention (baseline 2022 STEPS survey result: 78.3%) DA 3: Community Oral Health • Establish baseline for unmet denture treatment needs (18 to 69 years old) • Develop innovative workforce models and revise and expand competency-based education to respond to population oral health needs. DA3: Community Oral Health • Create and continuously update context and needs-specific research that is focused on the public • Review and update existing clinical guidelines by 2024. health aspects of oral health. • Implement Cook Islands National Oral Health Survey by 2025 and/or ensure oral health-relevant • Strengthen collaboration with other stakeholders (internal/external) to support the delivery of questions are on future NCD STEPS, DHS, and/or census. oral health services in the Cook Islands. • Develop 5-year oral health action plan. • Strengthen oral health promotion and oral disease prevention programs. • Routine mobile dental programme for all islands established. A. KRA 6 TARGETS • Number of new arrangement of cooperation established with oral health partners. DA1: Child Oral Health • Develop maternal and child oral health integrated policy. G. KEY RESULT AREA 7: PA ENUA a. Policy Goal • Implement school screening and delivery of oral health services for schoolchildren biennially for the next 5 years. To strengthen Pa Enua Health Services and improve participation in national health care service agenda especially on primary health care and healthy islands initiatives. • Conduct child oral health survey – including <5 year-olds - in the Cook Islands by the end of 2025. b. Delivery Areas • Mobile Dental programme established and operationalized for all islands. DA 1: Aitutaki • Implementation of ‘Baby Teeth Matters Programme’. DA 2: Atiu • Establish baseline attendance rate of pregnant mothers for oral health check-up. DA 3: Mangaia • Establish baseline attendance rate for oral health check-up of babies by their first birthday (early DA 4: Manihiki visits to the dentist). DA 5: Mauke • Establish database for special needs children. DA 6: Mitiaro • Number of primary schools with toothbrush programme. DA 7: Palmerston • Achieve WFPHA Maternal and Child Oral Health Initiative Endorsement. DA 8: Penrhyn • Number of schools with fluoride varnish and rinse program implemented. DA 9: Pukupuka and Nassau • Number of schools with fissure sealant programmes implemented. DA 10: Rakahanga • Consultation on water fluoridation in schools undertaken. • Reduce dental caries by 15% amongst schoolchildren. 86 87 JULY 2024 HEALTH EXPO, Senior Laboratory Scientist, Theresa Tatuava demonstrating use of Laboratory Equipment. 88 89 c. Policies and Planning Strategies Linked to KRA • Support health promotion and health protection activities at the Pa Enua level. The following specific, extant plans have been considered in the planning process of the KRA: • Strengthen disease surveillance and health service monitoring and reporting. i. Programme-Specific Strategies and Plans related to KRA • Strengthen domiciliary and chronic disease screening, as well as case follow up and management. • Island-specific Strategic Plans • Strengthen environmental health monitoring, especially relating to vector control, water safety, sanitation and waste management. • Integrated National Strategic Plan for Sexual and Reproductive Health 2014 - 2018 • Strengthen and support implementation of oral health preventative and specialist services. • Ngaki’anga Kapiti Ora’anga Meitaki: The Cook Islands Strategic Action plan to prevent and control Non-communicable diseases 2021-2025 • Strengthen PEN management for NCD control. • Cook Islands Tobacco Control Action Plan 2023-2031 • Support and strengthen current medical and referral services. • Maintain and strengthen current services in obstetrics care and Safe Motherhood. • National Immunization Policy • Strengthen antenatal screening services, especially for STIs, and Pap smears. • Oral Health Services Plan 2019-23 • Support awareness and intervention activities on preventable causes of blindness. • Mental Health and Wellbeing Policy • Support and strengthen ongoing clinical services in Pa Enua hospitals and health clinics. • Cook Islands National Suicide Prevention Strategy 2016-2020 • Introduce the Baby Friendly Hospital Initiative for Aitutaki. ii. Sectoral Policies and Planning Strategies Linked to KRA • Support continuing medical/professional education for all clinical staff. • Island-specific DRM Plans • Coordinate and facilitate health specialist visits. • Cook Islands Road Safety Strategy 2016-2020: Keep Me Safe (revised June 2020) • Strategic Roadmap for Emergency Management in Cook Islands 2018-2023: Cook Islands A. KRA 7 TARGETS Emergency Management Sector’s Contribution to Support the Cook Islands Joint Implementation DA 1: AITUTAKI Plan (JNAP) • Achievement of BFHI accreditation. • Sanitation (Wastewater Management) Policy 2016 • Inauguration of blood bank services. • National Water Policy 2016 • Implementation of ultrasound services. • Cook Islands Antimicrobial Resistance National Action Plan: Akono Meitaki. • Upskilling of nurses with NCD training. • Cook Islands Disability Inclusive Development Policy: Rights / Responsibilities / Action - 2020- 2025 (Tikaanga / Taau Tuanga / Rave’anga), 4th Edition • Water/Sanitation improvements at hospital (2027, contingent on GCF project approval/ disbursement). iii. Regional / Global Strategies • Support healthy island and smoke-free island initiatives via delivery of at least an annual community • Framework of Action for Revitalization of Healthy Islands in the Pacific classes. • Western Pacific Regional Action Plan for Noncommunicable Diseases: A Region Free of Avoidable • Attendance of continuing professional development programming for staff. NCD Deaths and Disability • Biennial school health check completed. • International Health Regulations 2005: Guidance for National Policy-Makers and Partners DA 2: ATIU • Community-Based Rehabilitation: CBR Guidelines • Completion of health specialist visits. • Suva Declaration on Improving Oral Health in the Pacific Islands Region • Water/Sanitation improvements at clinic (2025, contingent on GCF project approval/ • SIDS Summit for Health: Outcome Statement - For a Healthy Resilient Future in Small Island disbursement). Developing States. • Support healthy island and smoke-free island initiatives via delivery of classes. • Convention on the Rights of the Child • Attendance of continuing professional development programming for staff. • Regional Framework on the Future of Primary Health Care in the Western Pacific • Biennial school health check reports completed.

1. KRA 7 Objectives DA 3: MANGAIA • Strengthen and support implementation of primary health care activities especially relating to • Attendance of continuing professional development programming for staff. disease prevention and control. • School oral health screening follow-ups completed. • Strengthen and support maternal and reproductive health services. • Water/Sanitation improvements at clinic (2028, contingent on GCF project approval/ • Strengthen child health services, especially relating to immunization and nutrition programmes. disbursement). 90 91 DA 3: MANGAIA cont... DA 8: PENRHYN • Support healthy island and smoke fee island initiatives via delivery of at least an annual community • Renovation of Omoka clinic, including water/sanitation improvements at clinic, air conditioning, classes. and vaccine refrigeration facilities (2027, contingent on GCF project approval/disbursement). • Biennial school health check reports completed. • Attendance of continuing professional development programming for staff, especially palliative care training. DA 4: MANIHIKI • Water/Sanitation improvements at Te Tautua clinic (2028, contingent on GCF project approval/ • Achieve/maintain 9255 disbursement). • disbursement). • Support healthy island and smoke fee island initiatives via delivery at least an annual community • Water/Sanitation improvements at Tukao clinic (2025, contingent on GCF project approval/ classes. disbursement). • Biennial school health check reports completed. • Support healthy island and smoke free island initiatives via delivery at least an annual community • Upgrade of sea ambulance completed. classes. • Attendance of continuing professional development programming for staff. DA 9: PUKAPUKA AND NASSAU • Biennial school health check reports completed. • Water/Sanitation improvements at Pukapuka and Nassau clinics (2028, contingent on GCF project approval/disbursement). DA 5: MAUKE • Attendance of continuing professional development programming for staff. • Renovation of Mauke clinic, including water/sanitation improvements at clinic, solar battery back-up, air conditioning, and vaccine refrigeration facilities (2024, contingent on GCF project • Support healthy island and smoke fee island initiatives via delivery at least an annual community approval/disbursement). classes. • Implementation of NCD prevention initiative. • Biennial school health check reports completed. • Support healthy island and smoke free island initiatives via delivery at least an annual community DA 10: RAKAHANGA classes. • Water/Sanitation improvements at Rakahanga clinic (2024, contingent on GCF project approval/ • Attendance of continuing professional development programming for staff. disbursement). • Biennial school health check reports completed. • Attendance of continuing professional development programming for staff, especially in service of achieving NP status. DA 6: MITIARO • Use of MedTech Evolution to capture HIS data. • Attendance of continuing professional development programming for staff. • Support healthy island and smoke fee island initiatives via delivery at least an annual community • Implementation of NCD programme for children in primary/secondary school. classes. • Renovation of Mitiaro clinic, including water/sanitation improvements at clinic, air conditioning, • Biennial school health check reports completed. and vaccine refrigeration facilities (2026, contingent on GCF project approval/disbursement). • Support healthy island and smoke fee island initiatives via delivery at least an annual community classes. • Partnerships with community groups for physical activity programme established. • Biennial school health check reports completed DA 7: PALMERSTON • Attendance of continuing professional development programming for staff, especially in public health and oral health skills. • Hiring of HPA. • Delivery of mental health services via telemedicine. • Achieve/maintain 95% vaccine coverage under EPI. • Water/Sanitation improvements at clinic (2027, contingent on GCF project approval/ disbursement). • Biennial school health check reports completed. • 92 93 MAY 2023: SIGNING OF MOU between TMO and CIIC. Minister of Health, Hon. Rose Vainetutai Brown, Secretary of Health­, Bob Williams, CIIC Board Chairman, Melvin Fletcher, CIIC CEO, Allan Jensen. 94 95 H. KEY RESULT AREA 8: PARTNERSHIPS PARTNERSHIP AREA PROPOSED TARGET Proposed 2023+ target: Coordinate with TMO in PARTNERSHIP AREA PROPOSED TARGET Justice: Support for highly aggressive and cases of highly aggressive and violent mental violent mental health cases Proposed 2023+ target: Collect and report health cases Education: Establishment of tertiary Nursing numbers of enrollees and numbers of graduates and Health Training School Crown Law: Providing legal opinion on health health-related study programmes Carry forward target issues • Proposed 2023+ target: Data-sharing arrangements between TMO and MoE (e.g. • Proposed 2023+ target: Integration / via TMO reporting of aggregate special needs digitization / e-forms of documentation under Education: Biennial school health reports, statistics re: new school entrants and other MFAI: Support with medical clearance processes immigration scheme collaboration with disability and mental health health statistics as specified by MoE) for contract workers • Proposed 2023+ target: Renewal of medical • Proposed additional target: Biennial school clearances at triennial renewal of residence health screenings completed. permit Internal Affairs: Register of certified trained Carry forward target on registration of certified/ Punanga Tauturu: Provide counselling and Care Givers trained caregivers Carry forward target support for victims Internal Affairs: Annual report received on the vulnerable groups youth, disabled (mental and Carry forward target CICWA: Service AoC established between TMO Proposed 2023+ target: continue care physical), elderly and CWA coordination under AoC • Proposed 2023+ target: TMO to provide health advice to teachers/students e.g. via healthy CICWA: Number of functioning maternal and Carry forward target lunch initiative child welfare clinics Agriculture: Register of schools with ‘home gardens’ • Proposed 2023+ target: advocacy activities Proposed 2023+ target as continuation, with PCIFWA: Contraceptive prevalence increased to based on health food initiatives (e.g. health amended percentage to be proposed by CIFWA 35% promoters attend sandwich day or healthy food (if desired) day in conjunction w/Agriculture) • Proposed 2023+ target as continuation, with Possible 2023+ target: data collected on home amended percentage to be proposed by Agriculture: Increased number of local farmers gardens initiated by students on basis of school CIFWA gardens CIFWA: Increase Pap smear screening to cover • Proposed additional 2023+ target/ indicators: 80% women in the reproductive age group sexual/ reproductive health & emergency PSC: Excellence award recipient Carry forward target programme - # of staff trained, emergency plans in place and addressed in strategy, MFEM: Support funding options for social providers identified, minimum initial services health insurance for all government employees Carry forward target quantified with possibility of extension to private sector employees Men’s Health: Support screening for prostate 2023+ indicator to be amended to address cancer undertaken annually changed name / broadened focus CI Audit Office: Carry out annual audit Carry forward target Men’s Health: Advocacy for male methods 2023+ indicator to be amended to address of FP (vasectomy) and improved coverage Police: No drop policy for domestic violence changed name / broadened focus Carry forward target overall enforced • Carry forward existing target Police: Improved enforcement of drink driving CI Red Cross: Number of trainings provided for Carry forward target testing / restriction disaster risk management and CBHFA • Proposed additional 2023+ target: continue blood donor recruitment programme Police: Enforcement of amendments to the Carry forward target Transport Act 1966 • Carry forward existing target. Te Vaerua: Number of rehabilitative cases by • Proposed additional 2023+ targets: number Justice: Register all births and deaths Carry forward target sex and age of caregivers trained; number of home visits performed Proposed 2023+ target: Annual workplan for law Development Partners: Health specific plans Justice: Support coroner investigations Carry forward existing target & order psychologist implemented 96 97 KRA 3: Hospital Health Projected Cost VII. IMPLEMENTATION STRUCTURE AND SCHEDULE A. Costing the Health Strategy DA 1: Clinical Patient Care Services $1,621,600 The following tabulation lists estimated budgetary requirements to support the implementation of Te Marae DA 2: Referral Services $295,000 Ora Ara Tango Anga’anga National Health Strategic Plan 2023-2027, at the KRA/DA level. (All sums in this table are in NZ$.) DA 3: Specialist Care $1,916,600 KRA 4: Primary Care Projected Cost DA 1: Primary Care $4,951,700 KRA 1: Health Administration and Management Projected Cost KRA 5: Allied Health Projected Cost DA 1: Leadership, Governance $756,000 DA 1: Pharmacy $7,901,750 DA 2: Health Finance $2,028,500 DA 4: Physiotherapy and Occupational Therapy $45,000 DA 5: Biomedical $1,546,000 DA 3: Human Resources for Health $1,100,070 DA 6: General Support (Reception, Food and nutrition, maintenance and $288,500 Infection Prevention & Control [IPC]) DA 4: Health Information Systems $435,000 KRA 6: Oral Health Projected Cost DA 5: Health Research $230,000 DA 1: Child Oral Health $308,000 DA 2: Adult Oral Health $760,000 DA 6: Health Infrastructure $465,000 DA 3: Community Oral Health $205,000 DA 7: Public Relations $830,000 KRA 7: Pa Enua Projected Cost DA 1: AITUTAKI $416,000 DA 8: Information Technologies (IT) $978,800 DA 2: ATIU $112,000 DA 9: Monitoring & Evaluation $95,000 DA 3: MANGAIA $162,000 KRA 2: Public Health Projected Cost DA 4: MANIHIKI $542,000 DA 5: MAUKE $392,000 DA 1: Health Protection $2,416,000 DA 6: MITIARO $542,000 DA 2: Health Promotion $1,725,000 DA 7: PALMERSTON $175,300 DA 8: PENRHYN $862,000 DA 3: Mental Health $600,000 DA 9: PUKAPUKA AND NASSAU $112,000 DA 4: Health Intelligence Unit $849,500 DA 10: RAKAHANGA $112,000 98 99 JULY 2024 WHO AND TMO SCHOOL VISIT, (From L to R): Secretary of Health, Mr Bob Williams, Associate Health Minister, Hon. Tehani Brown, Minister of Health, Hon.Rose Brown, WHO Regional Director for the Western Pacific, Dr Saia Ma’u Piukala and WHO Representative, Samoa, American Samoa, Cook Islands, Niue and Tokelau, Dr Kim Eva Dickson 100 101 VIII. MONITORING AND EVALUATION IX. TARGET INDICATORS MONITORING FRAMEWORK

1. Introduction 1. KRA 1 Targets The NHSP's monitoring and evaluation component utilizes a logical framework and focuses on a core set of indicators. It identifies data sources for each indicator and facilitates the analysis, communication, Indicator Definition/ Data Source/ and dissemination of results. The monitoring process collects data from relevant sources and employs Target Focus Type Description Verification the core indicators and targets to provide ministries, partners and stakeholders with timely and actionable information to inform operational and policy decisions. Concurrently, the evaluation process endeavours to delve deeper into monitoring data, accounting for contextual changes, addressing attribution/causality DA 1: Leadership, Governance questions, and examining counterfactual situations. Review report of The implementation of M&E in the NHSP operates in parallel to TMO's health information system, though it Review of Legislation, relevant legislation obtains information from the same sources. Te Marae Ora's health information system has also established particularly Tobacco completed; at Governance / Process TMO Report Products & Control minimum including Standards a core set of 129 health indicators, which include processes, outcomes, and impact indicators that are Act review of Tobacco & used or aligned with the NHSP's indicator set, arrayed across short-term (<12 months), medium-term Control Act (≥1 to <10 years), and long-term (≥10 years) time frames. The 129 set of health indicators will be Review and develop reviewed by 2028. Review report of new Regulations as Process/ regulations specified Governance / necessary under TMO Report Outcome under public health Standards

2. NHSP Indicators the Public Health act Act The pool of health indicators to choose from is voluminous, and can pose challenges in terms of collection, interpretation, and meeting quality criteria such as relevance, reliability, and validity. In the case of the Performance HAP, selecting a core set of indicators that can objectively and effectively monitor progress towards the excellence Receipt of ‘excellence Governance / Outcome PSC Award recognized and award’ by PSC Standards identified key objectives is a perpetual challenge. rewarded by PSC While there is no optimal number of core indicators, aligning NHSP indicators with what is currently available New Public Health TMO Public Health from TMO’s HIS – keeping in mind that quantitative indicators are meant to be representative of reality, Act Implementation Process/ Bill Implementation Governance / TMO Report serving as tracer indicators rather than describing the entirety of what is happening – will be the most Plan approved and Outcome Plan approved and Standards pragmatic choice. operationalized enacted Target-setting in the NHSP is associated with various programme-specific TMO strategies, in alignment National Health National Health Service Service Fee Governance / with international targets such as those in the SDGs, as well as regional targets under the Healthy Islands Process Fee review report TMO Report Scheduled policy Standards Vision and SAMOA Pathway. Thus, this permutation of the NHSP includes national, regional, and international drafted reviewed health targets, tailored to the particular requirements and capabilities of the Cook Islands in general and TMO in specific. For all process indicators, the end point of the NHSP (2027) is the expected point of Rebranding of the Organisational Process New name approved Governance Mental Health Unit Structure completion/fulfilment unless otherwise specified.

3. Disease / Programme-Specific Indicators and Targets DA 2: Health Finance In the past, multiple health directorates/departments/divisions and management units generated their own Receipt of unqualified Cook Islands Maintain unqualified Governance / strategic plans, development strategies, business plans, etc. The Mental Health and Wellbeing Strategy, Outcome audit from Cook Audit Office audit opinion Standards Islands Report Human Resource Workforce Plan, and HIS Strategies are examples of such plans. The profusion of such plans, along with disease-specific programmes, can lead to confusion, bureaucratic bloat, and administrative 80%-100% implementation of challenges, and can dilute the utility of an overarching NHSP. the GCF Funding Implementation and Governance / As such, this NHSP proposes that operations (and the indicators/targets selected to direct these operations) programme Process TMO Reports Budget Reports Standards (contingent at the directorate level and below, be promulgated solely via business plans rather than separate strategies on approval/ going forward. disbursement)

4. Measurement and Reporting Frequency Health expenditure increase as a The periodicity of data collection and reporting is dependent on the interval of the health indicator and Input Budget Reports TMO Reports Finance proportion of GDP/ should derive from the National Health Indicator Summary Table, below. capita

5. Health Information System / HIU Integration Scoping of TMO scoping report prioritized areas Governance / As with the previous NHSP, the NHSP M&E framework is aligned with HIS capabilities (especially the Process on health privatisation TMO Report of Health for Standards implementation of MedTech Evolution), as well as the inauguration of the HIU. The indicators in the drafted privatisation National Health Indicator Summary Table, below, will help inform the TIMF. 102 103 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 3: Human Resources for Health DA 4: Health Information Systems cont... NP training Biennial training on death Continue NP training programme Process programme TMO Report HRH Process / Attendance report certification for all Medical TMO Report HIS continued Outcome and/or training logs Officers and Nurse Practitioners Bachelor of Nursing Health Bulletin Continue NP training programme Process TMO Report HRH Annual Health Bulletin published Outcome NHIB HIS programme published annually continued Quarterly update on NCD Upskilling Health Protection Process Training reports TMO Reports HRH published Officers/Assistants Upskilling Pharmacy Technicians/ Comparative analysis of cause- Process Training reports TMO Report HRH specific death rates among Assistants Outcome Analysis report TMO Report HIS males and females every 5 years New Primary Care Directorate Restructure Primary Health Care Outcome organisational TMO Chart HRH Directorate structure chart Implement recommendations issued made in Vital Statistics Report of Outcome Manager’s Report TMO Report HIS 2015 and CVRS report (2021). Annual Mid-Level Management Outcome Training reports TMO Report HRH Training program carried out DA 5: Health Research Mid-Term Review of the National Mid-term Review TMO Review Health Workforce Plan 2020- Outcome HRH Develop data bank for all health Health report Report Outcome Databank Database sighted 2025 related research Research National Health Research food choices and Develop National Health preferences and reasons Health Outcome Workforce Plan TMO Plan HRH Process Research Report TMO Report Workforce Plan 2025+ for sedentary behaviour (CI Research 2025+ drafted population policy 6.5) Human Resources Information Prepare TOR for research on Health HRIMS HRH / Health Outcome TOR Drafted TMO TOR Management System (HRIMS) Outcome TMO Report social determinants of health Research implemented IT Developed DA 6: Health Infrastructure Develop National Health Incentive scheme Process TMO Report HRH Workforce Plan 2025+ scoping report Vulnerability assessments (i.e. Vulnerability Health CIIC / TMO Mapping) for TMO buildings Outcome assessment Reports Infrastructure completed reports DA 4: Health Information Systems Disability Access for entries into CIIC / TMO Health Outcome Mapping all TMO buildings Mapping Infrastructure Development of the Digital Health Digital Health Information and Transformation Outcome Information TMO Workplan HIS Health Hospital redevelopment scoping CIIC / TMO Action Plan Workplan drafted Outcome Scoping Plan plan completed Mapping Infrastructure 104 105 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 7: Public Relations DA 1: Health Protection cont... All new private Development of Health and commercial Communications / PR 5-year Health 100% of new private and Outcome Action Plan TMO Plan buildings in Action Plan (CI population policy Research commercial buildings meeting Health Process Rarotonga and Manager’s Report 7.6) approved standards for Protection Aitutaki compliant Rarotonga and Aitutaki with building standards All registered complaints Complaint Health Outcome TMO Report ≥80% of responded to within 14 days response report Research At least 80% of food premises food premises Health Process Manager’s Report inspected and registered annually inspected by Protection DA 8: Information Technologies (IT) TMO IHR border Maintain 80% compliance with ManageMyHealth or similar Patient requirement Health TMO international border regulations Process TMO Report Patient Management Portal fully Outcome Management Health IT indicators Protection Demonstration (IHR) implemented Portal achieved ≥80% Public Health Information System Establishment of Public Health Existence of mini Health (PHIS) Developed (contingent Mini Lab (contingent on GCF Outcome TMO Reports Outcome PHIS Developed TMO Report Health IT lab Protection on GCF project approval/ project approval/disbursement) disbursement) Issuance of Digital Health Development of Rarotonga minimum water TMO standard Health Outcome Information minimum water standards standards for issuance Protection 80%-100% implementation of Process / Action Plan Rarotonga Digital Health and Information TMO Report Health IT Outcome implemented with Action Plan ≥80% indicator Issuance of achievement Health minimum water Development of prioritized Pa TMO standard Protection Outcome standards for Relevant staff Enua minimum water standards issuance / Health Annual MedTech Evolution prioritised Pa Process / designated and Training logs / Infrastructure training for relevant TMO staff Health IT Enua Outcome attend MedTech reports and/or private practitioners Evolution Training HIU SOP review Manager’s SOPs reviewed and completed, Process / HIU / report completed Report, TMO aligned to new Public Health Act Outcome Governance

2. KRA 2 Targets per terms in PHA Report DA 1: Health Protection DA 2: Health Promotion Assessment of CI <10 food / NCD premature Less than 10 non-compliance drinking water NCD premature mortality HPO complaint Health mortality complaints / food and drinking Impact complaints reduction in line with regional log Protection reduction rate and NHIB, regional Health water incidents per annum registered per standards and/or appropriate Impact comparison with statistics Protection annum comparator country/ies (per CI regional average Population Policy) or comparator Tutaka country programme Health Twice-yearly Tutaka programme Outcome TMO Report Assessment of implemented Protection twice annually CI consumption Increase of consumption of ≥5 of serves of fruit serves of fruit and vegetables and vegetables STEPS Survey, Health Identified mosquito per day in line with regional Impact per day and NHIB (or similar), 100% monitoring of mosquito Health Protection Process breeding sites TMO Report standards and/or appropriate comparison with regional statistics breeding sites Protection comparator country/ies regional average logged or comparator country 106 107 MAY 2023 OPENING OF TE PUNA TIAKI WELLNESS UNIT. Secretary of Health, MR Bob Williams, CIIC CEO, MR Allan Jensen 108 109 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 2: Health Promotion cont... DA 2: Health Promotion cont... Aggregate number of followers across Health Aggregate total of 5,000 all TMO health Promotion / Achieve 100% DOTS coverage DOTS coverage for followers across TMO health promotion social Health Outcome TMO Report Community Outcome TMO assessment for TB. TB maintained promotion social media media platforms Protection Health / platforms. (e.g. Facebook, Primary Care Twitter, Instagram, TikTok, LinkedIn) Smoked tobacco Implementation of 30 awareness Number of TMO products use activities, events, campaigns, Process / health promotion Health rate decreased initiatives or programmes by TMO Report Smoking rate reduction of 10% Outcome activities, etc. Protection (defined as 2025 (per CI Population Policy by 2025 in line with regional STEPS Survey, implemented incinerated Health Goal 7) standards and/or appropriate Impact TMO Report or tobacco use Promotion Number of comparator country/ies (per CI similar – excluding partnerships Population Policy) Increase of physical activity electronic nicotine with fitness delivery devices / by islands through strategic Outcome Health programmes; TMO Report vaping) partnership development with / Process Protection amount of fitness programmes increase in physical activity Issuance of Health Dietary guidelines developed Outcome TMO guidelines dietary guidelines Promotion Review and revise NCD strategy Revised NCD Health Outcome TMO Strategy Smoking cessation 2021-2025 strategy released Protection Enrolment of 50 participants programmes enrol Health per annum in smoking cessation Outcome Manager’s report ≥50 participants Promotion Declaration of programmes. per annum Launch of ‘Healthy and Smoke Healthy / Smoke Health Outcome TMO Declaration Free Islands’ programme Free Islands on ≥5 Protection ‘Making Sense of Health Biannual ‘Making Sense of Data’ Pa Enua Outcome Data’ workshops Attendance logs Promotion / workshops Operationalise Healthy Meal conducted HIS / HIU Issuance of Policy for Rarotonga primary minimum water TMO standard Health and secondary schools by Outcome standards for issuance Protection DA 3: Mental Health 2025, in conjunction with the Rarotonga development partners Number of people with mental School health School Health literacy literacy Health health diagnosis annually Process / Baseline Manager’s Mental programme established Outcome programme TMO Report Promotion (moderate –severe mental Outcome established Report Health illness) established Review/position Drafting of systematic review ≥500 HIV paper drafted on TMO Review/ Health and/or position paper on locally Mental tests (antibody, Outcome CI-specific social position paper Promotion / specific social determinants of Health Conduct ≥500 individual HIV antibody/antigen, determinants of drafted Process TMO Report Community mental health completed tests per annum. or nucleic acid mental health Health / tests) performed Tally of objectives Primary Care annually achieved / activities 20% continued increase in implemented under Revise Integrated National number of objectives delivered Process / CI Mental Health Mental Health Strategic Sexual and Revised SRH Plan Health and/or activities implemented Manager’s Report Outcome TMO Plan Outcome Workforce Plan / HRH Reproductive Health (SRH) Plan Drafted Promotion each year, per the CI Mental – 20% increase (per CI Population Policy) Health Workforce plan by end of NHSP Strengthen the early detection 2023+ of HIV and other STIs to reduce Number of unique HIV/STI detection Increase percentage of Manager’s Report, further infections and facilitate Process TMO Report Primary Care mental health strengthened population accessing mental Process NHIB, TMO Report Mental Health timely management and patient encounters treatment health services is measured or similar logged 110 111 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 3: Mental Health cont... DA 4: Health Intelligence Unit cont... Suicide mortality Reduction of suicide mortality Inter-agency mock rate assessed for rate (aggregated over 4-year NHIB, regional exercises on IHR CI and compared Mental Completion of 3 Inter-Agency period) in line with regional Impact health statistics, performed ≥3 Manager’s HIU / to regional figures Health mock exercises focused around Process standards and/or appropriate NHIB or similar times before end Report Governance and/or comparator International Health Regulations. comparator country/ies of NHSP 2023+ country/ies period Mental health Manager’s Patient satisfaction baseline Mental Process patient satisfaction Report, TMO 3. KRA 3 Targets established Health figures measured Reports DA 1: Clinical Patient Care Services TMO mental health 80% patient satisfaction rate Mental Outcome patient satisfaction Manager’s Report met biennially Health 50% of emergency ambulance Ambulance callouts tallied at ≥80% call outs in Rarotonga leave the Process / leave Rarotonga Hospital / HHS hospital within three minutes in Outcome hospital in ≤3 ambulance logs Rarotonga minutes DA 4: Health Intelligence Unit From a baseline of 50% in 2023, Reporting on NCDs, patients presenting 6-monthly risk modelling 50% of adults patients notifiable diseases with chest pain reporting on NCDs, notifiable presenting with chest pain have TMO Report, Outcome and emerging health HIU Report HIU Process / will have an ECG diseases and emerging health ECG started within 10 minutes Manager’s HHS risks completed via Outcome started within risks. from 2023, increasing by 5% Report risk modelling 10 minutes of by each year admission to the hospital, increasing HIU enforcement of by 5% per annum food/water non- 100% of food/water non- HIU / Process / compliance issues Manager’s compliance issues are addressed Health Outcome at 100% within 48 Report within 48hrs of receipt Protection hours of complaint receipt From a baseline of 55% of eligible Increase cervical cancer Process / patients, cervical TMO OH TMO Report, screening rate by 5% each year TMO Reports HHS ‘One Health’ framework Process / Outcome cancer screening Framework drafted Manager’s HIU from 2022 baseline of 55% developed and implemented. Outcome rates will increase and operationalised Report by 5% per annum Case investigations of non- HIU to conduct HIU / Manager’s compliance under Public Health Outcome PHA non- Health Report Act compliance Protection 100% of pregnant women in CI ≥5 staff undertake and 100% coverage of antenatal receive antenatal ≥5 TMO staff Outcome TMO Reports HHS complete Pacific Data for Process / and obstetrics care and obstetrics care complete DDM Manager’s Report HRH / HIU Decision Making (DDM) training Outcome from a skilled birth training programme attendant 100% of neonates from HIU enforcement of hepatitis-positive mothers are food/water non- 100% of food/water non- HIU / given a hepatitis B immunisation Process / Process / compliance issues Manager’s Per indicator TMO Report HHS compliance issues are addressed Health and immunoglobulin within 72 Outcome Outcome at 100% within 48 Report within 48hrs of receipt Protection hours, and followed up at nine hours of complaint months receipt 112 113 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 1: Clinical Patient Care Services cont... DA 2: Referral Services Absolute numbers Patient satisfaction baseline Outcome Per indicator TMO Report HHS of post-operative established infections – defined A reduction in the absolute TMO Report, as infections number of post-operative Impact Manger’s HHS Patient satisfaction within 30 days infections by one annually Report measured of a surgery – decreasing by 1 80% patient satisfaction rate Process / biennially; ≥80% TMO Report HHS every year. met biennially Impact of patients report ‘satisfied’ or higher on patient surveys Develop Cook Islands National Infection Prevention Control Outcome Per indicator Action Plan HHS Action Plan Review and update patient Process / Per indicator TMO Policy HHS referral policy Outcome Develop CI MOH Palliative Care Palliative care guidelines and SOPs completed Outcome Per Indicator guidelines and HHS DA 3: Specialist Care and updated SOPs ≥12 health specialist visits per Process / Per indicator TMO Report HHS annum Outcome Number of Increase mammogram screening mammogram follow up of all eligible women screening follow up ≥2 community and/or Pa (40 to 75 years of age) by 1% Impact HSV Report HHS Process / of all eligible women Enua outreach programmes Per Indicator TMO Report HHS biennially from the current 2022 Outcome (40 to 75 years of implemented per annum level. age)

4. KRA 4 Targets Prostate cancer Produce prostate cancer Prostate cancer screening protocol screening protocol to strengthen Outcome screening HHS DA 1: Primary Care reviewed and prostate cancer screening protocol developed Minimum 2 trainings in mobile Trainings in mobile utilisation of digital screening Process / Scoping report on utilisation of digital Community templates to strengthen Outcome / Attendance Logs Scope bowel cancer screening feasibility of bowel screening templates Health Process Report HHS data collection for quality Impact services cancer screening conducted improvement services NCD premature mortality School health check Biennial school health check Community reduction in line with regional Outcome reports produced TMO Report reports published Health standards and/or appropriate Outcome Per indicator Report HHS and published comparator country/ies (per CI Population Policy) ≥95% coverage Maintain ≥95% immunisation for all standard Community Outcome TMO Reporting coverage childhood Health Maintain or increase average life Life expectancy NHIB or other immunisations Outcome HHS expectancy statistics TMO report Maintain 100% post-natal Process / 100% post-natal Manager’s Community Maintain nil maternal and checks Outcome checks completed Report Health Outcome Per indicator Report HHS neonatal and child mortality rate 114 115 2023 APII AVARUA 116 117 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 1: Primary Care cont... DA 1: Primary Care cont... 100% post-hospital 100% home visits after hospital Manager’s Community Dedicated ENT and Process discharge home visits Establishment of ENT/eye clinics Primary Care / discharge Report Health Outcome eye clinics in Tupapa Manager’s Report completed in PHC centre Specialist Care PHC centre Database review, Palliative care database reviewed Manger’s Process / updated, and Community RHD screening of children Echo screening of and maintained, and reported Report, TMO Process / Outcome annually reported Health, HIS completed for >90% of persons children in eligible RHD Report Primary Care annually to HIS Report Outcome to HIS in eligible age groups age groups Zero stock-outs Repeat echo of carried oral / RHD repeat screening for ≥90% screening for Nil stock-outs of oral, injectable Outcome RHD Report Primary Care injectable / barrier Community of designated high-risk children designated high- and barrier contraceptives at Process TMO Report contraceptives at Health risk children community clinics community clinics in Rarotonga RHD database updated and Outcome Per indicator RHD Report Primary Care maintained Scoping review of Scoping review of RHD prophylaxis adherence implementation of UN Healthy Outcome Per indicator RHD Report Primary Care TMO implementation TMO Review Community ≥90% for all diagnosed patients Aging Action Plan (per CI Outcome of UN Healthy Aging Report Health Population Policy Objective 5.3 Action Plan CI primary and and 5.4) secondary school obesity rate tallied and compared with Database on Compile and collate data on regional rates and/ Process / service provision to TMO Community Primary and secondary school HHS, Primary service provision to disabled and or comparator TMO Report, Outcome disabled and elderly database Health, HIS student obesity rate reduced in Impact Care, Public elderly patients country/ies; CI regional report patients created line with regional standards Health achieves reduction in line with regional rates and/ Wait time after or comparator Maintain or reduce patient Manager’s Primary Impact patient registers / country/ies rates waiting time to <99 minutes Report Care checks-in CI NCD incidence Measurement of tallied and transfer time and compared with appropriateness regional rates and/ Establish PHC to ED urgent baseline for patients or comparator HHS, Primary Manager’s Primary Care Reduce incidence of NCD in line TMO Report, transfer baseline data by end of Outcome transferred from Impact country/ies; CI Care, Public Report / HHS with Regional standards regional report 2023 primary care sites in achieves reduction Health Rarotonga to hospital in line with regional under urgent transfer rates and/ conditions or comparator country/ies rates At least 90% of PHC to ED Assessment of adequacy of Define ‘adequacy’ HHS, Primary transfers deemed ‘Appropriate’ health services available to older with recourse to Process TMO Report Care, Public as measured by patient people per the Cook Islands CIPP, and perform Manager’s Primary Care Health disposition at ED (admission or Impact Per indicator Population Policy completed assessment Report / HHS discharge), investigations (e.g. labs, radiology), or specialist Routine mobile doctors’ review. programme established for all Process Per Indicator TMO Report Primary Care islands Dedicated paediatric HHS, Primary Establishment of a paediatric Manager’s Primary Care / Establish minimum Rapid Test Kit Outcome clinic in Tupapa PHC Process Per Indicator TMO Report Care, Public clinic in PHC centre Report Specialist Care for all Pa Enua health clinics centre Health 118 119 Indicator Definition/ Data Source/

5. KRA 5 Targets Target Focus Type Description Verification Indicator Definition/ Data Source/ DA 2: Laboratory cont... Target Focus Type Description Verification 100% of urgent laboratory DA 1: Pharmacy results processed and reported Outcome Per indicator TMO Report Laboratory within three hours from the time National medicines specimen received in laboratory. Completion of National Medicines NMP Review Outcome policy review Pharmacy Policy review Report document created Annual external audit report is Laboratory, External audit External audit generated on the progress of Outcome Health report report Review of Antimicrobial Action Antimicrobial Action AAP Review ISO 15189 certification Infrastructure Outcome Pharmacy Plan Plan reviewed Report Operationalize Laboratory Process / Pharmacy Information Management Per Indicator TMO Report Laboratory TMO Pharmacy Outcome Revision of TMO Pharmacy Services System (LIMS). Outcome Services Standards Pharmacy Services Standards Standards Revised Revision Report DA 3: Radiology Cold chain systems and Radiology service processes meet NZ accreditation Development of radiology plan, including local standards on Rarotonga and Manager’s TMO Service Outcome Per indicator Pharmacy service plan with focus on local Outcome mammography Radiology Aitutaki by end of 2025, and Report Plan mammography service delivery service delivery other Pa Enua sites by end of plan 2027 One female staff member trained Manager’s Radiology / Registration/licencing of to conduct mammography Outcome Per indicator Registration of Report HRH medicines importers and Process / Manager’s screening medicines importers / Pharmacy distributors/suppliers (including Outcome Report distributors / suppliers requisite auditing processes) Full-time mammography Full-time mammography Outcome screening available Manager’s Report Radiology Database of screening available Establish database for medicines Database, in Rarotonga from medicines importers 2026 importers and distributors/ Outcome Manager’s Pharmacy / distributors / suppliers Report suppliers Review and update Radiology Annual policy Manager’s Equipment and Management Outcome Radiology review and update Report policy annually Nil stock-outs of NCD Impact Nil stock out TMO Report Pharmacy Radiology Service Plan medications Technical assistance formulated and agreements Outcome Manager’s Report Radiology source identified executed Quarterly Drug and therapeutic committee Meeting committee meetings Radiology scoping study for Scoping study quarterly meetings maintained Process minutes / TMO Pharmacy Outcome Study Report Radiology orchestrated and Aitutaki Hospital completed completed and reported Reports logged DA 4: Physiotherapy and Occupational Therapy Essential Medicine list reviewed EML review + every two years and align to alignment with Process TMO Reports Pharmacy Rarotonga HHS Anti-Microbial Resistance Action AMR Action Plan / 100% of patients with Physiotherapy Plan and Antibiotic guidelines Antibiotic Guidelines musculoskeletal musculoskeletal injuries are and Outcome injury patients are Manager’s Report provided with therapeutic Occupational offered therapeutic ultrasound Therapy DA 2: Laboratory ultrasound 90% of all non-urgent Development and laboratory results processed and review of two Physiotherapy Develop and review two reported within 24 hours from Outcome / Physiotherapy and/ Guidelines and and Outcome Per indicator TMO Report Laboratory guidelines and protocols annually the time specimen received in Impact or Occupational Protocols Occupational for best practice laboratory (except microbiology Therapy guidelines / Therapy results). protocols per annum 120 121 Indicator Definition/ Data Source/ Target Focus 6. KRA 6 Targets Type Description Verification DA 5: Biomedical Indicator Definition/ Data Source/ Target Focus Type Description Verification 100% adherence to preventive Manager’s maintenance schedule for Process Per indicator Biomedical DA 1: Child Oral Health Report biomedical equipment Maternal and Medical Develop maternal and child oral Development of child oral health Equipment Medical Process Oral Health Review and update Medical Process / Biomedical / health integrated policy relevant policy integrated Donation Policy Equipment Equipment Donation Policy Outcome Governance policy reviewed and Donation Policy updated Implement school screening and delivery of oral health services Process / Manager’ Oral Health / Asset Asset Per indicator Review Asset Management Process / for school children biennially for Outcome Report Paediatrics Management Management Biomedical the next 5 years Policy Outcome Policy Reviewed Policy Conduct child oral health survey – Oxygen Child oral health Oxygen including <5-yearolds - in the Process / Child Oral Health Oral Health / Review Oxygen Management Process / survey completion Management Plan Management Biomedical Cook Islands by the end Outcome Survey Report Paediatrics Plan Outcome by end of 2025 Reviewed of 2025 Plan Mobile Dental programme Process / Manager’ Oral Health / Minimum medical equipment Per Indicator Process / Manager’s established Outcome Report Paediatrics requirements for all health Per Indicator Biomedical Outcome Report facilities maintained Implementation of ‘Baby Teeth Manager’s Oral Health / Outcome Per Indicator Matters Programme’ Report Paediatrics DA 6: General Support (Reception, Food and nutrition, maintenance and Infection Prevention & Control [IPC]) Establish baseline attendance Process / Baseline Manager’s Oral Health / rate of pregnant mothers attendance rate Outcome Report Obs & Gynae TMO-approved for oral health check-up established national IPC guidelines translated to SOPs at Manager’s Establish baseline attendance Outcome Per indicator IPC the facility level and Report rate for oral health checkup Process / Baseline attendance Manager’s Oral Health / reviewed at least every of babies by their first birthday Outcome rate established Report Paediatrics five years (early visits to the dentist) Hand hygiene Audit of hand hygiene Establish data base for special Database Database, Oral Health / audit in Manager’s Outcome compliance to Outcome IPC / HHS needs children established Manager’s Report Paediatrics Rarotonga Report establish baseline hospital Number of primary schools with Process / Baseline Manager’s 100% of Maintenance Oral Health Manager’s Maintenance toothbrush programme Outcome established Report request forms attended Outcome Per indicator Report / HHS to within a week Achieve WFPHA Maternal and WFPHA Process / Endorsement Oral Health / Child Oral Health Initiative Initiative Food and Outcome achieved Paediatrics Endorsement Endorsement Rarotonga hospital nutrition / Manager’s kitchen inspected Outcome Per indicator Health Number of schools with fluoride Report Process / Baseline Manager’s annually by HPOs Protection / varnish and rinse program Oral Health HHS Outcome established Report implemented. Number of schools with Develop infection Development of IPC Process / Baseline Manager’s Process / fissure sealant programmes Oral Health control policies and IPC Policies/ Policies/ IPC / HHS Outcome established Report Outcome implemented guidelines Guidelines Guidelines Consultation on water Manager’s Outcome Per indicator Oral Health fluoridation in schools undertaken Report 6 Conduct surveillance Process / Establish baseline Per Indicator TMO Report IPC / HHS Reduce dental caries by 15% NHIB / TMO and outbreak response Outcome Outcome and generate Oral Health amongst school children Report assessment 122 123 JULY 2024 HEALTH EXPO, Theresa Tatuava demonstrating the use of Laboratory Equipment to students. 124 125 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 2: Adult Oral Health DA 3: Community Oral Health cont... Acquire new digital imaging Acquisition of technologies (e.g. ≥1 new dental Manager’s Oral Health / 5-year oral Manager’s Outcome Develop 5-year oral Orthopantomagram [OPG], laboratory Report Biomedical Process health action report / TMO Oral Health health action plan Intra-Oral) equipment plan developed report Acquire digital prosthesis technologies (e.g. Computer- Acquisition of ≥1 new Routine mobile dental Manager’s Manager’s Oral Health / Process / Aided Design/Computer- Outcome dental laboratory programme for all islands Per indicator report / TMO Oral Health Report Biomedical Outcome Aided Manufacturing equipment established report [CAD-CAM]) Acquire dental laboratory Acquisition of Oral Health / Manager’s 7. KRA 7 Targets equipment (e.g. furnaces and Outcome ≥1 new dental Health Report laboratory accessory equipment) laboratory equipment Infrastructure Oral Health / Renovate and upgrade Tupapa Manager’s DA 1: Aitutaki Outcome Per indicator Health Clinic facility Report, CIIC Infrastructure BFHI Declaration Oral Health / Achievement of BFHI Pa Enua / Establishment of Outcome for Aitutaki Plaque Establish a dedicated oral Manager’s Health accreditation HHS Outcome dedicated oral surgery Hospital surgery unit Report Infrastructure / unit HRH Implementation of Inauguration of blood Manager’s Acquisition and Outcome blood bank at Pa Enua bank services Report Acquire and install dedicated oral deployment of oral Manager’s Oral Health / Aitutaki Hospital Outcome health information system health information Report Health IT system Implementation of ultrasound Manager’s Outcome Per Indicator Pa Enua services Report Develop specialist oral healthcare Process / Designated Manager’s Oral Health At least one nurse services Outcome profile established Report Upskilling of nurses with NCD Manager’s Pa Enua / Outcome completes NCD training Report HRH related CME/CPE Implement oral health-specific Process / Designated Manager’s Oral Health Water/Sanitation improvements health information system Outcome profile established Report Pa Enua / at hospital (2027, Outcome Per indicator CIIC Report Health Implementation of a structured contingent on GCF project Process / Designated Manager’s Infrastructure patient appointment system by Oral Health approval/disbursement) Outcome profile established Report end of 2024 DA 2: Atiu Establish oral health disease Process / Designated Manager’s Oral Health profile Outcome profile established Report Completion of health Manager’s Pa Enua / Process Per indicator Improve natural teeth retention specialist visits Report HHS Assessment (baseline 2022 STEPS survey Outcome Per Indicator Oral Health report result: 78.3%) Water/Sanitation improvements Pa Enua / Establish baseline for unmet at clinic (2025, contingent on Baseline Manager’s Outcome Per indicator CIIC Report Health denture treatment needs (18 Outcome Oral Health GCF project approval/ established Report Infrastructure to 69 years old) disbursement) DA 3: Community Oral Health DA 3: Mangaia Update and review Review and update existing TMO Outcome of oral health clinical Oral Health Attendance of continuing clinical guidelines by 2024 Guidelines At least one staff Manager’s Pa Enua / guidelines professional development Outcome attends CME/CPE Report HHS programming for staff Implement Cook Islands Manager’s National Oral Health Survey Report / Water/Sanitation improvements by 2025 and/or ensure oral Pa Enua / Process Per indicator Survey Oral Health at clinic (2027, contingent on health relevant questions Outcome Per indicator CIIC Report Health Report / GCF project approval/ are on future NCD STEPS, Infrastructure Census disbursement) DHS, and/or census 126 127 Indicator Definition/ Data Source/ Indicator Definition/ Data Source/ Target Focus Target Focus Type Description Verification Type Description Verification DA 4: Manihiki DA 7: Palmerston Mental health ≥95% of coverage Pa Enua / services and/ TMO Report Delivery of mental health Pa Enua / Achieve/maintain 95% vaccine via childhood Primary Care / Process or consultations / Manager’s Impact TMO Report services via telemedicine Mental Health coverage under EPI immunisations Community delivered via Report under EPI Health telemedicine ≥95% of coverage Pa Enua / Achieve/maintain 95% vaccine via childhood Primary Care Renovation of Tauhunu clinic, Impact TMO Report coverage under EPI immunisations under / Community including water/sanitation EPI Health improvements at clinic, solar Pa Enua / battery back-up, air conditioning, Outcome Per indicator CIIC Report Health and vaccine refrigeration facilities Infrastructure Water/Sanitation improvements (2025, contingent on GCF Pa Enua at clinic (2027, contingent project approval/disbursement) Outcome Per indicator CIIC Report / Health on GCF project approval/ Infrastructure disbursement) Water/Sanitation improvements Pa Enua / at Tukao clinic (2025, Outcome Per indicator CIIC Report Health contingent on GCF project DA 8: Penrhyn Infrastructure approval/disbursement) Renovation of Omoka clinic, DA 5: Mauke including water/sanitation improvements at clinic, air Pa Enua Renovation of Mauke clinic, conditioning, and vaccine Outcome Per indicator CIIC Report / Health including water/sanitation refrigeration facilities (2027, Infrastructure improvements at clinic, solar Pa Enua / contingent on GCF project battery back-up, air conditioning, Outcome Per indicator CIIC Report Health approval/disbursement) and vaccine refrigeration Infrastructure facilities (2024, contingent on Water/Sanitation improvements GCF disbursement) Pa Enua at Te Tautua clinic (2027, Outcome Per indicator CIIC Report / Health NCD Prevention contingent on GCF project Implementation of NCD Manager’s Infrastructure Process Initiative activities Pa Enua approval/disbursement) prevention initiative Report completed Pa Enua Upgrade of sea ambulance Outcome Per Indicator TMO Report / Health DA 6: Mitiaro completed Infrastructure Attendance of continuing DA 9: Pukapuka and Nassau At least one staff Manager’s professional development Outcome Pa Enua / HRH attends CME/CPE Report programming for staff Water/Sanitation improvements Pa Enua at Pukapuka and Nassau clinics Implementation of NCD NCD programme Outcome Per indicator CIIC Report / Health (2027, contingent on GCF programme for children implemented for Manager’s Infrastructure Outcome Pa Enua project approval/ disbursement) in primary/secondary primary/secondary Report school school children DA 10: Rakahanga Renovation of Mitiaro clinic, including water/sanitation improvements at clinic, air Pa Enua / Water/Sanitation improvements conditioning, and vaccine Outcome Per indicator CIIC Report Health Pa Enua at Rakahanga clinic (2024, refrigeration facilities (2026, Infrastructure Outcome Per indicator CIIC Report / Health contingent on GCF project contingent on GCF project Infrastructure approval/ disbursement) approval/ disbursement) 128 129 X. COUNTRY COORDINATING MECHANISM 2. Data Sources NHSP implementation will be overseen and monitored by the NHSP Supervisory Committee (HSC), which To assess the progress and performance of the NHSP 2023+, it will be necessary to use the full complement will be led by TMO and bolstered via the participation of subnational stakeholders, other ministries, NGOs/ of available data, which will require a clear delineation of how data will be generated including a specification CBOs/CSOs, the private sector, academic institutions, and development partners. The TMO Planning Unit of inputs, processes, outputs, outcomes, and impact. The following are envisioned as primary data sources will serve as the focal point and chair for the coordinating committee (CC). Regular meetings will be held for M&E processes: at intervals deemed appropriate by TMO, informed by the above indicator periods. Minutes of CC meetings • The census of population and housing, which provides information on the size, distribution, and will be disseminated to all senior staff and partners for information and action. These minutes should also characteristics of the population. be collected to serve as input for M&E functions of the NHSP evaluation during mid-point and endpoint reviews. • Civil registration and vital statistics systems, which provide data on births, deaths, and causes of death. The NHSP therefore includes provisions for the use of vital statistics and plans to improve their

1. HAP Supervisory Committee availability and quality. The following structure and membership of the NHSP supervisory committee is proposed under the overall • Population-based health surveys, such as the STEPS NCD Survey and the Demographic Health Survey supervision of the Secretary of Health. (DHS), which focus on service coverage, equity, and population health outcomes. • Facility-generated data, including routine facility information systems (e.g. LMIS), health facility assessments, and surveys. HIS/HIU is the natural focal point for such statistics. Director Planning MFEM/OPM Director CHS • Health programme-generated data, which are specific to individual initiatives, and may be generated and Funding Representative by outreach programmes, special campaigns and drives (e.g. immunization campaigns), and/or other intervention activities. These data sources should be included in M&E and planning activities. • Administrative data sources, such as parliamentary briefs, financial resource flows, and expenditures at all levels, including major programmes. Manager Policy and Director HHS IntAff Planning (HSC Focal Point)

3. Dissemination and Communication M&E findings should guide the NHSP Supervisory Committee in designating analytical outputs that will inform decision-making, programme management, financial disbursements, and general reporting. HIS CSO Representative NGO Representative PSC Representative data products will serve as key outputs, and will form an important basis for M&E reporting, as outlined below: • Health Sector Progress and Performance Report: This report is a critical input for NHSP annual reviews, providing a systematic assessment of progress against specific objectives and goals in the national A. Country Progress and Performance Review Mechanism health strategy and disease-specific plans. This report will synthesize data from various sources, such The basis for progress and performance reviews lies in the target/indicator data collected through M&E as facility reporting systems, household surveys, administrative data, and research studies, to answer processes, and will necessitate institutional mechanisms (i.e. the HSC) that involve multiple stakeholders. key questions on progress and performance using the country’s core indicators and health goals. The current health-sector review procedures in the Cook Islands is an important M&E baseline, • Annual Health Statistical Report: Via TMO’s National Health Information Bulletin, these annual health and will optimally be used to inform priority-setting and resource allocation. These reviews should be information reports provide a comprehensive analysis of all health data derived from administrative systematically linked to actions in the Cook Islands and serve as the foundation for mutual accountability and health facility reporting, including the most relevant data by island. The NHIB report is cognizant of and transparency. data quality issues, such as timeliness, completeness, and accuracy of reporting, and will specify data adjustments and methods used, if applicable.

1. Schedule of Reviews • Policy Briefs: These briefs present actionable recommendations for decision-making in a short-form

1. Annual Reviews: at the end of each calendar year format. The format typically identifies a problem, proposes a solution, presents a compelling and

2. Mid-term Review: at the end of 2025 feasible recommendation, and highlights supporting evidence using non-academic language, images,

3. Final situation analysis and evaluation: June of 2027 or at the expiry of the HAP, quotes, photographs, and bullets. whichever comes later. • Colour Coding: This strategy groups data and suggests action using colours corresponding to a traffic Performance reviews will draw on data information obtained from the HIS/HIU teams, and from individual stop light. Each colour and indicator is given predetermined numerical ranges based on progress towards programmatic reviews and reports. Annual reviews are expected to feed into the Business Plan formulation a programmatic target. Decision-makers can quickly determine if action is required around a specific process for funding and resource allocation. indicator. This technique shares similarities with the grading found in health report cards. 130 131 2024 HEALTHY ISLANDS INITIATIVE ON AITUTAKI. 132 133 XI. MY HEALTH, MY FUTURE TMO ESSAY COMPETITION WINNER YEAR 12-13 CATEGORY A necessary step towards a BETTER FUTURE By Matamaru Tekoronga, Year 13, Level 3 student, Tereora College The Cook Islands, our island, our home, our beautiful paradise - but behind all that beauty, a troubling truth. The lack of mental health support in the Cook Islands is a crisis that could potentially tear our community apart if not dealt with. The Government’s lack of funding for resources and facilities. Without the funding people cannot get the help they need regarding mental illnesses such as anxiety and depression, especially for children and teenagers because they are the future of our country, their health is our future. The Mental Health support in the Cook Islands is quite appalling and we need funding for more mental health resources and facilities, these days young minds are being plagued by this issue, why is there nothing being done to help? Why is this basic human need being ignored? AWARENESS; COMMUNICATION, GENERATION TO GENERATION “Mental health? What a joke. Kids these days need to toughen up” said almost every old person on this island. Admit it, you have thought it at least once, “kids these days are getting soft” or “in my day we just had to deal with it”. Get with the times. Kids these days go through more damage that is psychological each day. I’ve heard it myself from the mamas and papas at church to the mamas and papas in public, almost every time a teenagers mental health was brought up, they treated it as if it was a second, third, fourth priority. If no one acknowledges this issue, nothing will be done to fix it. The fact that older people, the people that teach the younger ones, push this issue aside is quite sad, because if the younger people see it, chances are they will do the same. Older people influence the younger ones. SUICIDE PREVENTION; DO YOUR PART TO SAVE LIVES. “Not all people do that, I don’t do that” congratulations, do you want an award? If you do not Imagine losing a loved one to a form of mental illness, bi-polar disorder, alcoholism, suicide. project that stuff on to children, then great, but there are still so many people who do. “Children Approximately eight million people worldwide die each year and according to the World Health have minds of their own, they should use it”. So do you, still think it is okay to treat mental health Organization, “Suicide is the fourth leading cause of death among 15-29-year-olds. People with as a last resort of matter. As the older generation, it should not be acceptable to poison kids’ minds severe mental health conditions die prematurely as much as two decades early due to preventable with this “get over it” perspective, because the kids have been told this, are most at risking, then physical conditions”. Even WHO recognizes that this is an issue that must be dealt with. WHO the wish is yours”, my response was not convincing enough. So what would have been? identifies this issue as “preventable” and how do we prevent this in the Cook Islands? By supplying OUR KIDS, OUR FUTURE LEADERS more funding for mental health facilities, we can help these people with their mental stability so they Teenagers are the most at risk when it comes to mental illness diagnostics - and they are the do not hurt themselves or others. The evidence is plain and clear; the statistics are right there, a future of our island, if nothing is done now it will only get worse. Around the world one in every simple google search proves it. You cannot deny it. With more help, we can save more lives. seven teens suffer from mental illnesses and of the people I know, three out of five of my friends In conclusion, the Cook Islands Government needs more funding for mental health support. Mental suffer from the same illnesses, be it depression, anxiety etc. These statistics do not get lower as instability, it is real, it is here, and it is plaguing the minds of our young ones, our teens, the ones time goes on. Globally, there are less people but it adds up to 13% of the world - but based on more at risk and they are the future of our island. If we can prevent these people from feeling a personal anecdote the number is much higher locally. “But that is globally, nothing in their states this way, we can save more lives. So I am asking, pleading, begging, for the future of our beloved anything about the Cook Islands” and you’re right, it doesn’t, but if that’s happening in the whole islands, please, we need more funding for mental health support. world how would Cook Islands not be affected. If we can prevent teenagers from feeling as if their feelings do not matter, then maybe we can save some lives. HELP US HELP THE FUTURE OF OUR ISLAND. 134 135 XII. APPENDIX 1: NHSP CONSULTATION PROCESS 2. Consultations

1. Initial Programme – NHSP 2017-21 Evaluation and NHSP 2023+ Consultations NATIONAL HEALTH STRATEGIC EVALUATION FACE-TO-FACE MEETINGS MARCH 2023 Draft Programme – National Health Strategy 2023+ Consultations 13 - 24 MARCH 2023 MON 13 TUE 14 TUE14 PP Team to meet with David + M & E Hospital Services Public Health Mental Health TA 1st visit / EOC (Stocktake of the 2017-21 NHS) Directors Monday, 13 March 2023 9am - 1pm and Managers one on one consultations [Hospital Health] Dr May Metua Bates Dr Evangelene Wong Karen Ngamata Dr Koko Dr Rangi Fariu M & E (Stocktake of the 2017-21 NHS) Rangi Tairi TA 1st visit / ESR Acting Director / Managers / Staff one on Frances Akaruru Rufina Tutai Dr Philadelphia Ngarua Tuesday, 14 March 2023 9am - 1pm one consultations [Public Health & Mental Annaliese Copper Ngatamaine Rongo RN Anna Paniani Health] Roger Nehemia Maina Tairi RN Mamahotu Tararo M & E (Stocktake of the 2017-21 NHS) Oirua Tini TA 1st visit / ESR Helen Maunga Tania John Tansy Brown Wednesday, 15 March 2023 Directors and Managers one on one 9am - 12noon consultations [Oral Health] Tai Tommy RN Mereana Taikoko James Auora Maina Tairi M & E (Stocktake of the 2017-21 NHS) Moetuma Nicholas TA 1st visit / ESR Helen Maunga Thursday, 16 March 2023 Directors and Managers one on one 9am - 12noon consultations [Primary Health] Howard Tangimetua Nelson Ngaiorae M & E (Stocktake of the 2017-21 NHS) Paul Maaka Friday, 17 March 2023 TA 1st visit Directors and Managers one on one Mexico Jack consultations [PnF & Partners] Edwina Tangaroa Edith Tangaroa Saturday, 18 March 2023 FREE Maina Tairi Tereapii Tumutoa Briefing with the Secretary of Health and Oropai Mataroa Monday, 20 March 2023 ESR TMO Tupapa TMO Executive and ADB; Meet the Policy Helen Maunga and Planning Team; Update Maina Tairi Workshop with TMO Staff: Consultations on WED 15 THU 16 FRI 17 Tuesday, 21 March 2023 the New NHS 2023+ Oral Health Primary Health Planning & Funding Workshop with Stakeholders Partners Dr Danny Areai Dr Teariki Faireka (NGOs, Cabinet Ministers, Opposition, Jeremy Goodwin Workshop at ArePua RN Vainenooapii Mateariki Wednesday, 22 March 2023 MPs) : Consultations on the New NHS Dr Seema Community Hall Rangi Tairi Michaela Tangimetua 2023+ DTh Upokotea Unuia Rufina Tutai Howard Tangimentua Workshop with Stakeholders Partners DTh Ngametua Maina Tairi Helen Maunga (NGOs, Cabinet Ministers, Opposition, Moekapiti Helen Maunga Thursday, 23 March 2023 MPs) : Consultations on the New NHS Howard Tangimetua 2023+ Maina Tairi Primary Health Helen Maunga TA Final Briefing with SOH and Executives - Dr AU NG - RHD Friday, 24 March 2023 TMO Board Room Preparation for 2nd Visit: 22 May - 02 June Primary Health 2023 ICT Manager - Ralema Geno 136 137 TMO AND STAKEHOLDERS WORKSHOP— CONSULTATION ON THE NATIONAL HEALTH STRATEGY 2023+ DAY 1—21 MARCH 2023 DAY 2—22 MARCH 2023 NAME NAME MINISTRY

1. SoH Bob Williams TMO

1. Francis Akaruru 22. Michaela Tangimetua 43. Ligipati Dowling 2. David Angelson TMO

3. Rangi Tairi TMO

2. Andrew Orange 23. Howard Tangimetua 44. Paul Ongoua

4. Michaela Tangimetua TMO

3. Helen Sinclair 24. Dr Evangelene Wong 45. Hiawatha Tauia

5. Howard Tangimetua TMO

4. Douglas Tou 25. Dr Rangi Fariu 46. Ella Napara 6. Maina Tairi TMO

5. Metua Bates 26. Dr Philadelphia Ngarua 47. Roana Mataitini 7. Helen Maunga TMO

8. Grace Matenga TMO

6. Karen Ngamata 27. RN Anna Paniani 48. Nadave Tereapii

9. TMO Roana Mataitini TMO

7. Rangi Tairi 28. RN Mamahotu Tararo 49. Ralema Geno TMO

10. Rufina Tutai

8. Rufina Tutai 29. Tansy Brown 50. Munukoa Takai 11. Dr Seema Kumar TMO

12. Ngametua Moekapiti TMO

9. Ngatamaine Rongo 30. Tereapii Nimerota 51. Charlie Ave

13. Nga Manea TMO

10. Roger Nehemia 31. Tu-Te Maeva Poaru 52. Kati Blatner

14. Fraces AkarurU TMO

11. Oirua Tini 32. Dr Danny Areai 53. Nga Manea TMO

15. Douglas Tou

12. Tania John 33. Dr Seema Kumar 54. Moetuma Nicholas 16. Ralema Geno TMO

17. Dr Danny Areai TMO

13. Tangata Vaeau 34. DTh Upokotea Unuia 55. Theresa Tatuava EMCI/OPM

18. Stephano Rampling Tou

14. Edwina Tangaroa 35. DTh Ngametua Moekapiti 56. SoH Bob Williams EMCI/OPM/Tupapa Puna

19. Lydia Sijp-

15. Edith Tangaroa 36. Dr Tuaine Unuia 57. James Auora MoE

20. Anna Moesau Roumanu

16. Tereapii Tumutoa 37. Dr Kiriau Nio 58. Shaun Teaurima INTAFF

21. Pauline Rangi INTAFF

17. Oropai Mataroa 38. RN Vainenooapii Mateariki 59. Mokoroa Pepe (Ri) 22. Tuiane Jnr Manavaroa CIFWA

23. Dean Tangata

18. Vaine Ngatokorua 39. Norma Tairi 60. Paul Maaka CIFWA

24. Polly Tongia

19. Maina Tairi 40. Matavaine Numanga 61. Mexico Jack Te Kainga

25. Dr Maria Peach

20. Helen Maunga 41. Rongo Ingaua 62. Ina Tararo Te Kainga

26. Mereana Taikoko Chamber of Commerce

21. Grace Matenga 42. Jeremy Goodwin 63. Bernadett 27. Nganga Hosking Health Research-MoE

28. Teau Puna

64. David Angelson ADB

29. Lavinia Tama

30. George George 138 139 TMO Staff Workshop—Consultations on the FINAL Draft AITUTAKI School Children in their National Health Strategy 2023+ Physical Actiavity Program. Wednesday 21 June 2023, Rarotongan Beach Resort Conference Room TIME PRESENTATION RESPONSIBLE—MC HOWIE Policy and Planning: Michaela 8.30am Registration of participants Tangimetua 9am Opening Prayer TMO Rep 9.15am Welcome / Introductory remarks Secretary of Health 9.40am Presentation: Health Status Health Information System TMO Vision, Mission, & Values: 10am Presentation on New TMO Values Group Photo 10.20am Secretary of Health MORNING TEA Policy, Legal, and Strategic Plan 10.30am Director Planning & Funding Linkages Activity on Key Results Area One: Health Administration and 10.40am Acting Director Public Health Management (Planning & Funding) Activity on Key Results Area Two: Director Hospital Health 10.50am Public Health Services Activity on Key Results Area Three: 11am Director Primary Care Hospital Health Activity on Key Results Area Four: 11.10am Chief Medical Officer Primary Care Activity on Key Results Area Six: 11.20am Director Oral Health Oral Health Activity on Key Results Area 11.30am Director Primary Care Seven: Pa Enua Activity on Key Results Area 11.40am Eight: Partnerships and Monitoring Director Planning & Funding Framework 12pm PRESENTATION /Q & A All Group Leads 12.30pm FINAL REMARKS Secretary of Health 12.40pm CLOSING PRAYER 12.50pm LUNCH 140 141 RAROTONGA MINISTRY OF HEALTH PARTICIPANTS AITUTAKI TMO STAFF NHSP2023+ WORKSHOP DAY 1, TUES 29 MAY 2023 DAY 1 WEDNESDAY 24 MAY 2023 NAME MINISTRY/DEPARTMENT NAME MINISTRY/DEPARTMENT Ngapoko Ananas Infection Control/Hospital Health Celestine Mana-Vaikai Clinical Technician Memory Taputoa Food and Nutrition/Hospital Health Eteta Lockington Clinical Support Technician April Tamatoa Surgical Charge Nurse/Hospital Health Maiarii Paiti Administration Patricia Puna Medical Charge Nurse/Hospital Health Bolton P Tamu Ambulance Joyce Sakai RN Operating Theatre/Hospital Health Anthony Jessie Ambulance Tai Topa Maintenance/Hospital Health Lee Marie Charge Nurse Aitutaki Felix Leota Biomedical/Hospital Health Waisiki Lomalagi Radiology/Hospital Health Dr Helen Heimoana Glassie Medical Doctor Shane Marcus Physiotherapy/Hospital Health Kura Ioane Nursing Dr Kevin Basili OBGYN/Hospital Health Tuono Teaukura Nursing Dr Donna Pauu Paediatric/Hospital Health Manu Robert Nursing Teio Kea Paediatric/Hospital Health Maria Williams Nursing Lycee Teiotu Maternity/Hospital Health Metua Tuarae Nursing Helen Maunga Policy and Planning Angeline Magu Nursing Dr Seema Kumar Oral Health Metua Bates Public Health Mataiti Rave Health Protection Karen Ngamata Health Intelligence Unit/Public Health Benioni Blenkarn Health Protection Tangata Vaeau Health Protection/Public Health Tima Ngatuakana Groundsman Munokoa Takai Health Protection/Public Health Party Rave Kitchen Tereapii Nimerota Health Protection/Public Health Maria Tare Infection Control Oirua Tini Health Protection/Public Health Ngatokorua Vahua Maintenance Nelson Ngaiorae Health Protection/Public Health Mareta Mose-Paerau Aitutaki Hospital Manager Ngatamaine Rongo Health Intelligence Unit/Public Health Health Ella Napara Protection/Public Health Tepaeru Ngatuakana Dental Therapist Dr Phila Ngarua Mental Health/Public Health Samantha Taala Dental Therapist Assistant Rufina Tutai Public Health Nurse Nooroa Tuakeu Health Protection Monika Mafua Public Health Nurse Intern doctor Intern Doctor Jeremy Goodwin Health Promotion Intern Doctor Intern Doctor Paul Ongoua Human Resources/Planning and Funding Ligipati Dowling Human Resources/Planning and Funding MALE —8; FEMALE—17 TOTAL—25 Dr Danny Areai Oral Health Dr TeAriki Faireka Director of Primary Health Care / Glassie Utia Warehouse/Hospital Health Ministry of Health Rarotonga Howard Tangimetua Policy and Planning Helen Maunga Michaela Tangimetua Policy and Planning Policy & Planning / Ministry of Health Rarotonga Grace Matenga Policy and Planning Dr David Angelson TA NHSP 2023+ / Ministry of Health Dr Koko Lwin Hospital Health Service Vainenooapii Mateariki Primary Health Erenoa Rakanui Primary Health Dr Kati Blatner Primary Health Dr TeAriki Faireka Primary Health Douglas Tou Laboratory/Hospital Health Edwina Tangaroa Health Promotion/Public Health Maina Tairi Policy and Planning Ricky Boaza Primary Health Roana Mataitini Planning and Funding Dr Yin Yin May Hospital Health Services Dr Kirianu Nio Oral Health Tutai Mauke Pharmacy MALE—20; FEMALE—28 TOTAL—48 Dr David Angelson TA NHSP 2023+ / Ministry of Health 142 143 AITUTAKI STAKEHOLDERS NHSP2023+ WORKSHOP DAY 2, WED 30 MAY 2023 NAME MINISTRY/DEPARTMENT Paraia Toi Ministry of Health Aitutaki Joe Elia Non-Governmental Organisation Kura Tutai Ministry of Health Aitutaki Lee Marie Charge Nurse Aitutaki Dr Helen Heimoana Glassie Ministry of Health Aitutaki Kura Ioane Public Health Nurse Tekura Bishop Mayor / Island Council Local Government Ruautu Ngatokoa Vaipae Councillor / Local Government Pepe Tekii Raela Agriculture Tou Mose Non-Governmental Organisation Tangi Tapora Kitchen / Ministry of Health Aitutaki Tukoe Purenga Cleaner / Ministry of Health Aitutaki Grace Stusky Police Mereana Bishop Island Government Twin Ruarangi Island Government Alice Hoff Vodafone Rosa Henry Bank of South Pacific Marama Tini Carer Mary Tini Retired Registered Nurse Metuakore Strickland Clinical Nurse Mareta Mose-Paerau Aitutaki Hospital Manager Tepaeru Ngatuakana Dental Therapist Samantha Taala Dental Therapist Assistant Anthony Jessie Ministry of Health Aitutaki Benioni Blenkarn Ministry of Health Aitutaki Mataiti Rave Ministry of Health Aitutaki Mii Jacob Bank of Cook Islands MALE—8; FEMALE—19 TOTAL—27 Dr TeAriki Faireka Director of Primary Health Care / Ministry of Health NURSE PRACTITIONER PARAU Rarotonga NGAMATA conducting health physical examinations for APII Helen Maunga Policy & Planning / Ministry of Health Rarotonga NIKAO school children from the Dr David Angelson TA NHSP 2023+ / Ministry of Health TMO Mobile Bus. 144 145 Group photo taken during the 2024 TMO Health Conference. 146 147 XIII. APPENDIX 2: TMO ORGANIZATIONAL STRUCTURE DIAGRAMS TE MARAE ORA—COOK ISLANDS MINISTRY OF HEALTH CHART 1—TMO CORE FUNCTIONAL STRUCTURE FEBRUARY 2021 FUNCTIONS 148 149 TE MARAE ORA—COOK ISLANDS MINISTRY OF HEALTH CHART 2—PUBLIC HEALTH TE MARAE ORA—COOK ISLANDS MINISTRY OF HEALTH CHART 4—PRIMARY CARE FUNCTIONAL STRUCTURE FEBRUARY 2021 DIRECTORATE FUNCTIONAL STRUCTURE FEBRUARY 2021 DIRECTORATE TE MARAE ORA—COOK ISLANDS MINISTRY OF HEALTH CHART 3—ORAL HEALTH TE MARAE ORA—COOK ISLANDS MINISTRY OF HEALTH CHART 5—HOSPITAL HEALTH DIRECTORATE FUNCTIONAL STRUCTURE FEBRUARY 2021 DIRECTORATE FUNCTIONAL STRUCTURE FEBRUARY 2021 150 151 TE MARAE ORA—COOK ISLANDS MINISTRY OF HEALTH CHART 6—PLANNING AND FUNCTIONAL STRUCTURE FEBRUARY 2021 FUNDING DIRECTORATE 152 153 MAUKE school children on their way home from school: OUR FUTURE IS BRIGHT.