Kiribati Health Strategic Plan 2016-2019

Ministry of Health and Medical Services 2016 to 2019 MINISTRY STRATEGIC PLAN Contact Details: Dr. Teatao Tira Address: Naverevere, Ministry of Health and Medical Services Telephone: 686 28100 Website: www.health.gov.ki Date of Plan: 2015 PREFACE: The Ministry Strategic Plan 2016-2019 is an extension of the 2013–2015 Plan which was an outcome of strategic thinking and collective work of the senior management team and all individual heads of department (HODs) within the Ministry of Health and supported through a Health Needs Assessment supported by WHO. The key areas addressed and content in this plan will remain from the last strategic plan that includes the following:- Non-communicable diseases (NCDs) Population growth Maternal morbidity and mortality Child morbidity and mortality Health service delivery Gender-based violence (GBV) and youth health The plan is a good guiding framework with an inclusive approach that focuses on the technical, administrative and operational strategic issues and extending it as far as possible to look into other factors that have a major impact on the efficiency of the service. Of critical importance this time are:-  Expansion of the current hospitals  Maintenance of existing equipment and buildings/affordable new equipment  Affordable source of renewable energy  Strengthening hospital and Public health services We encourage high commitments from all staff of the Ministry to fully participate in the implementation of the plan. We invite our development partners to work in good partnership with us to achieve our mission for better health for all. ............................... Dr. Kautu. Tenaua Honourable Minister Ministry of Health and Medical Services 1 Table of Contents PREFACE: .................................................................................................................................... 1 Acronyms .................................................................................................................................... 3 Executive Summary .................................................................................................................... 5 Ministry of Health & Medical Services Structure: ...................................................................... 6 VISION ........................................................................................................................................ 7 MISSION ..................................................................................................................................... 7 GUIDING PRINCIPLES ................................................................................................................ 7 Recent Ministry History .............................................................................................................. 8 STRATEGIC CONTEXT .............................................................................................................. 10 Situation Analysis...................................................................................................................... 11 Goals, Objectives, Strategies .................................................................................................... 15 STRATEGIC ACTIONS, INDICATORS AND TARGETS .............................................................. 15 Key Performance Indicators ..................................................................................................... 18 Budget....................................................................................................................................... 45 Ministry Operational Plan......................................................................................................... 56

Results management ................................................................................................................ 58 MONITORING .......................................................................................................................... 60 2 Acronyms ADB Asian Development Bank AGI Adolescent Girls Initiative AHD Adolescent Heath and Development CoC Continuity of Care DOTS Directly Observed Treatment Short course DRR Disaster Risk Reduction EHU Environmental Health Unit [in MHMS] EmOC Emergency Obstetrics Care EPI Expanded Program on Immunization ESGBV Eliminating Sexual and Gender Based Violence FBOs Faith Based Organisations GBV Gender Based Violence GOK Government of Kiribati HIU Health Information Unit [in MHMS] HSCC Health Sector Coordinating Committee [comprising the MHMS and development partners] ICD International Classification of Diseases IEC Information, Education and Communication IMCI Integrated Management of Childhood Illness KDP Kiribati Development Plan KFHA Kiribati Family Health Association KHSP Kiribati Health Strategic Plan [this plan] KPA Key Policy Area KPS Kiribati Police Service KSoN Kiribati School of Nursing MA Medical Assistant MDGs Millennium Development Goals MELAD Ministry of Environment, Land and Agricultural Development MFED Ministry of Finance and Economic Development MH Mental Health MHMS Ministry of Health and Medical Services, Ministry MISA Ministry of Internal and Social Affairs MPWU Ministry of Public Works and Utilities MS-1 The MHMS Monthly Consolidated Statistical Report form NCDs Non-Communicable Diseases NGOs Non-government Organisations NSO National Statistics Office OI Outer Islands PEN Package of Essential NCD interventions PH Public Health PNO Principal Nursing Officer 3 PSO Public Service Office RH Reproductive Health SA Strategic Action [within this Strategic Plan] SDPs Service Delivery Points SMC Senior Management Committee [of the MHMS, comprising the Permanent Secretary, Deputy Secretary, and Directors of Public Health, Health Services, and Nursing] SOP Standard Operating Procedures TB Tuberculosis TBAs Traditional Birth Attendants TCH Tungaru Central Hospital [main referral hospital, located in South Tarawa] tbd/c To be determined/confirmed UNICEF United Nations Children’s Fund WHO World Health Organization YFHS Youth Friendly Health Services 4 Executive Summary The Ministry felt that most of the health issues and health indicators for 2016-2019 will remain the same from the 2013-2015 strategic plan. Therefore most of the content and strategies in this plan are the same with the Health Strategic Plan 2013-2015. The Kiribati Health Strategic Plan sets the direction for the Ministry of Health and Medical Services action on health over the next four years. It identifies a Vision, Goal, Guiding Principles and Strategic Objectives describing what the Ministry expects to achieve, and Strategic Actions and Indicative Activities for implementation in order to get there. It includes Indicators and Targets as a basis for monitoring progress towards the Strategic Objectives. It also signals the need for strong multi-sector coordination in order to effectively implement the Strategic Plan. The initial sections of the Strategic Plan outline its scope, provide some strategic context (in particular its relationship to the Kiribati Development Plan), and summarise population health needs in Kiribati. A Vision and Goal for the Strategic Plan are then defined, as well as a set of Guiding Principles to guide decisions on implementation priorities.

The six Strategic Objectives and their associated Strategic Actions, Indicators and Targets form the core of the Strategic Plan and are outlined over pages 13–21. Taken together, these describe what the Ministry wants to do (or the results we want), how we will do it (or the activities we will implement), and how we will know if we have succeeded (or how we will monitor progress). Further details on how we will do it are set out as Indicative Activities in an Implementation Plan in Annex A. The Implementation Plan can be used as a basis for annual Ministry operational plans. The Strategic Plan emphasises the importance of relationships, partnerships and inter-sectoral coordination and collaboration to the effective delivery of the plan. This includes relationships with domestic partners, including other Kiribati government departments and agencies, and NGOs and community-based groups. It also includes relationships with numerous bi-lateral and international development partners. The Strategic Plan notes specific initiatives on which the Ministry needs to work with domestic partners and development partners. It also promotes the use of the Health Sector Coordinating Committee as a specific mechanism for supporting the implementation of this Strategic Plan. 5 Ministry of Health & Medical Services Structure: Minister Secretary Director Public Director Director Health Hospital Nursing Deputy Director Deputy Deputy Director Deputy Director Secretary Public health Hospital Senior Midwifery DPNO Public SAS Consultants/Sp Consultants/Sp DPNO hospital Accountant School Health ecialists ecialist TCH, Betio, Public health Pop & FP MCH Dental Hospitals Outer Island AS Accountant Xmas doctors School Medical OM EPI NCD Pharmacy laboratory Assitsnt School Account STI/HIV TB Radiology Rehabilitation Registry Support services ICT Health Nutrition Biomedical KITP Transport promotion Kitchen Mechanics Leprosy Env Health Tradesmen Plumbing Security Outer Island Filariasis clinics

6 VISION The vision for the Kiribati Health Strategic Plan is: Akea Tokin Te Tamaroa towards “healthy population that is well supported by quality health services” MISSION To deliver a safe quality service through hospital, public health and nursing services. GUIDING PRINCIPLES The Kiribati Health Strategic Plan is based on nine underlying principles (Table 2). These principles need to be reflected in all strategic actions and activities developed and implemented. The principles can also be used to guide decisions on implementation priorities. Table 2: Guiding principles for the Kiribati Health Strategic Plan Principle Explanation Relevant and appropriate Does the proposed action reflect the core issues and strategies in the KDP and the local population’s health needs? Is the proposed action responsive to the needs of the health system, and/or the needs of specific health programmes/interventions? Equity and pro-poor Does the proposed action meet the rights and needs of the poor? Effective Is the proposed action like to be effective in the Kiribati setting? Efficient Is the proposed action likely to lead to more efficient and cost-effective service delivery? Outcome-focused Does the proposed action have a clear link to an improved health outcome or improved quality in health service delivery? Evidence-based Does the proposed action have a robust evidence base? Realistic Is the proposed action likely to succeed? Are the proposed indicators and targets realistic? Coordinated Is the proposed action well-coordinated or integrated with actions taken elsewhere by the Ministry (eg, existing Ministry strategies, policies and plans for specific programme or health service areas)? Is the proposed action well-coordinated with the plans of multi-sectoral partners, including other government agencies, NGOs and development partners? Sustainable Is the proposed action sustainable in Kiribati? 7 Recent Ministry History The 2016-2019 Kiribati Health Strategic Plan is an extension of the 2013-2015 Plan and sets the direction for the Ministry of Health and Medical Services action on health. It identifies the results the Ministry wants to achieve in four years (strategic objectives), what needs to happen in order to achieve these results (strategic actions), and how progress will be measured (indicators and targets). The Strategic Plan has been informed by a Health Needs Assessment, which examined the health needs of the I-Kiribati population and the ability of the health system to respond to these needs. The different elements of the Strategic Plan are shown in Figure 1. Figure 1: Elements of the Kiribati Health Strategic Plan Kiribati Health Strategic Plan (Monitor progress) (c) Indicators and targets (a) Strategic objectives/outcomes (The results sought) What do we want to see in four years? How do we know when we have (b) Strategic actions

succeeded? (The health system activities) What do we need to do? What needs to happen? Health Needs Assessment (The needs/problems) What are the needs of I-Kiribati? What are the challenges for the health system in meeting those needs? Ministry staff from all levels has participated in the development of the Strategic Plan. External health sector experts and partners have also provided input into its development. 8 The Kiribati Health Strategic Plan sits alongside the Health Needs Assessment, which has been developed at the same time. The Strategic Plan sets the overall framework for action on health. It is intended as a living strategy that may be further developed and refined over its lifetime to reflect changing conditions, including emerging priorities and needs, and the further development or modification of Ministry strategies, policies and plans and for specific programme or health service areas. 9 This document begins with a summary of the strategic context for the Strategic Plan and of the priority issues identified in the Health Needs Assessment. It then covers the vision, goal and principles that underpin the work of the Ministry of Health and Medical Services. The core of the Strategic Plan includes the strategic objectives, strategic actions, and indicators and targets. Tables in Annex 1 provide, for each strategic action, the indicative actions or steps that need to be undertaken, potential funding sources, and an indicative sequence for implementation. STRATEGIC CONTEXT The plan will link with the Kiribati Development Plan 2016–2019. The previous KPAs reflect international and regional conventions, such as the Millennium Declaration, and government policies. The Kiribati Development Plan (KDP) includes a set of indicators to enable progress in each KPA to be monitored and evaluated. KPA 3 sets out six core issues and 12 strategies for health (Table 1). There is a strong desire to align the Kiribati Health Strategic Plan with the priority issues and strategies in the new KDP. Table 1: Issues and strategies identified in the Kiribati Development Plan (2012–2015) Issues Strategies 1. High burden and incidence of Non- 1. Improve outreach of NCD services through HOPE communicable diseases 2. Improve and expand coverage on awareness of the root causes of NCD (prevention) 3. Improved screening, detection and access to treatment services for all NCDs through Package of Essential NCD services (PEN) 2. Reproductive health, Maternal, Neonatal, 4. Promote Healthy Family concept Child, Adolescent health issues. (RMNCAH) 5. Strengthen partnerships with community, NGOs and Faith Base Organizations through Health Outreach Programme for Equity (HOPE) 6. Improve delivery of emergency and obstetric care services 7. Improve access to antenatal and post natal care 8. Expand and Increase EPI coverage and IMCI services for children at risk 3. High burden & incidence of communicable 9. Strengthen DOTS services and existing diseases diseases (TB, leprosy, lymphatic filariasis, surveillance and outbreak response for TB, leprosy, STIs and HIV/AIDS) lymphatic filariasis, STIs and HIV/AIDS 4. Apparent gaps in health service delivery 10. Re-assess human resources needs and address gaps/issues 11. Strengthen post and basic training amongst service providers 12. Provide equipment and maintenance including training on how to operate complex health machines

10 Situation Analysis The Health Needs Assessment describes the demographic and socio-economic factors that provide a general context for health service demand in Kiribati. It also provides evidence of the need for action, as well as the main challenges for the health system in meeting these needs, in seven priority areas: Non-communicable diseases (NCDs) Population growth Maternal morbidity and mortality Child morbidity and mortality Communicable diseases Health service delivery Gender-based violence (GBV) and youth issues Data on progress to achieving the health-related Millennium Development Goals (MDGs) in Kiribati shows a mixed picture. Figure 2 shows under-five and infant mortality rates dropped significantly over 1990–2010, completing 68 percent and 60 percent of the respective 2015 targets. However, this still leaves Kiribati with the fourth highest under-five mortality rate and fourth highest infant mortality rate in the region, in both cases only ahead of Lao, Cambodia and Papua New Guinea. Figure 2: Infant and Under 5 Mortality Rates, Kiribati 11 Infant and Under 5 Mortality Rates 200.00 180.00 160.00 140.00 120.00 100.00 80.00 60.00 40.00 20.00 0.00 1 - 4 yrs Mortality Rate Under 1 Mortality Rate Kiribati has reasonably high levels of immunisation with 89 percent of one-year-old children immunised against measles in 2010, and 91 percent having had the combined DIP-HepB-Hib vaccine. In 2005, the antenatal care coverage rate (the proportion of pregnant women who had at least one visit) was 100 percent. In 2010, 98 percent of births were attended by skilled health personnel. The adolescent fertility rate, at 39 per 1000 women aged 15–19 years over 2005–2010, is around the median for the region and reflects a low contraceptive prevalence rate of 36 percent of women of reproductive age in 2000. There is a high prevalence of STIs, with a study in 2004 showing around 15 percent of pregnant women were infected. At the end of 2010, Kiribati had a cumulative total of 54 HIV/AIDS cases, of which 24 were known to have died. Table 4: Summary of Selected Health Indicators, Kiribati Latest KDP data target Neonatal, infant and child health Immunization, measles (% of children aged 12-23 months) (2013) 91% >90% Infant mortality rate (2013) 26.2 22 Mortality rate, under-5 (per 1,000 live births) (2013) 52.9 30 Fertility rate (2012) 2.7 <3.5 Antenatal care from a skilled provider (doctor, nurse, and/or 88% 100% midwife) % with at least one visit (2007-12) Incidence of tuberculosis (per 100,000 people) (2013) 497 Declining In 2009, the estimated incidence and prevalence of tuberculosis was high, at 351 per 100,000 population and 288 per 100,000 respectively. The incidence rate was second highest in the region and the prevalence rate was higher than other similar sized countries in the region. In 2010, there were 182 reported new cases of leprosy in Kiribati making Kiribati one of three countries in the Pacific where leprosy elimination status is not yet achieved. At the same time as a number of communicable diseases are not under control, Kiribati is facing an increasing burden from NCDs. Figure 3 shows the recent increase in rates of reported NCDs and nutrition and related diseases as the leading causes of morbidity. The rate of reported NCDs increased more than three-fold over 2005–2010 while the rate of reported nutrition and related diseased increased more than eight-fold.1 The number of new cases of diabetes was also up, from

1 There are likely to be high numbers of unreported NCDs and nutrition and related diseases. 12 248 in 2005 to 842 in 2010, while the 2004–2006 STEPs survey showed around 28 percent of the adult population had diabetes. Table 5: NCDs Kiribati 2008 NCDs as a proportion of total deaths, all ages 69.0% Proportion of population who are overweight (BMI ≥ 25 kg/m2) 81.5% Proportion of population aged 25-64 years with ≥ 3 NCD risk factors 72.7% Proportion of population with elevated fasting blood glucose (≥ 6.1 28.1% mmol/L) or currently on diabetes medication Nutrition is a significant risk factor, with 38 percent of males and 54 percent of females aged 20 years or over being classified as obese in 2008. Increased consumption of imported, cheap and low quality food products high in salt, sugar and fat contributes to this problem. Under-nutrition is a significant problem in children; the 2009 DHS found that close to one quarter of children are underweight or severely underweight, while in 2010 the percentage of newborn infants weighing less than 2500 grams at birth was 22 percent. Other risk factors for NCDs include smoking and alcohol consumption. In the 2005 Census, almost 70 percent of the males aged 30–54 years said that they were regular smokers, compared to less than 50 percent of females aged 30–54 years. The proportion of 15–19 year old smokers was 32 percent for males and 8 percent for females. There has been a steady improvement in life expectancy at birth over the last two decades, from an estimated 63 years in 1990, to 66 years in 2000 and 68 years in 2009. The rate of improvement in life expectancy has been greater for females than males. Life expectancy for females increased from 64 years in 1990 to 70 years in 2010, while for males it increased from 62 years to 65 years over the same period. It is worth noting that a rise in NCDs is likely to impact on life expectancy; either slowing or halting the rate of increase, or perhaps even reversing the trend of increasing life expectancy. In 2010 the leading causes of death were disease of the circulatory system, infectious and parasitic diseases, and diseases of the digestive system. Leading causes of morbidity were acute respiratory infections, diarrhoeal diseases and eye diseases. In 2010, in children under 5 years of age the main causes of death were pneumonia, prematurity and birth asphyxia. The publicly funded health system in Kiribati is well established, and includes a national referral hospital in South Tarawa, two hospitals in the Outer Islands and another small hospital providing basic medical services in South Tarawa. Primary care services are provided through 92 health centres. The Ministry had around 740 permanent staff. This included around 405 professional/technical roles, including approximately 375 nurses and 30 doctors. 13 Figure 6: Doctor-Patient Ratio, Kiribati, 2010-20 A workforce plan is underway. The proportion of doctors to patients has declined from a high level of 4,242 in 2011 to 2,453 in 2013 and an estimated 1,918 in 2014. Hindrances to quality medical services include a limited budget to meet the demand. A qualified biomedical engineer is required to assist in

Source: MHMS Priority issues for the Kiribati health system are identified above in Table 1. The system faces a number of challenges in addressing these issues, including in relation to: The quality of health service delivery The availability of essential medicines and supplies The availability and maintenance of equipment The reliance on support from development partners, including challenges in coordinating and prioritising this support An ageing health workforce A shortage of paramedical and support staff. A lack of qualified staff, particularly in laboratory and radiography services, health promotion, environmental health and health information. A lack of systematic processes to ensure the ongoing competency of health workers No routine clinical supervision or support. A lack of accurate, timely and relevant health information to inform planning, policy development and monitoring of health sector performance 14 Goals, Objectives, Strategies The primary goal for the Kiribati Health Strategic Plan for the period 2016–2019 is: To improve population health and health equity through continuous improvement in the quality and responsiveness of health services, and by making the most effective and efficient use of available resources The six strategic objectives of the Kiribati Health Strategic Plan for the period 2016–2019 are: Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs. Increase access to and use of high quality, comprehensive family planning services, particularly for vulnerable populations including women whose health and wellbeing will be at risk if they become pregnant. Improve maternal, newborn and child health. Prevent the introduction and spread of communicable diseases, strengthen existing control programmes and ensure Kiribati is prepared for any future outbreaks. Address gaps in health service delivery and strengthen the pillars of the health system. Improve access to high quality and appropriate health care services for victims of gender based violence, and services that specifically address the needs of youth. Note: The order of the objectives does not reflect their priority. The first five of these objectives are consistent with the core issues and strategies for health in the Kiribati Development Plan 2016–2019. The issues and strategies in the KDP on maternal and child health have been combined into a single objective in this Strategic Plan. This is intended to improve coordination between maternal and child health and reflects a key result area in the Kiribati Child Survival Strategy 2008–2012 to integrate the maternal and child health programmes. The sixth objective was identified by the Ministry of Health and Medical Services as a priority issue for the next four years. Strategies relating to gender equality are included in the KDP under KPA 5 on governance, and gender based violence is considered in the results matrix for this KPA. The needs of youth are considered in various places in the KDP including in relation to health (STIs and HIV) and governance (empowerment, involvement and participation). STRATEGIC ACTIONS, INDICATORS AND TARGETS This section includes the strategic actions, along with associated indicators and targets. Activities to guide the implementation of these strategic actions are included in the implementation plan in Annex A. A separate strategic action relating to strengthening the implementation and monitoring of this Strategic Plan, through improved coordination between the MHMS and development partners, is included after the strategic actions, indicators and targets for strategic objective 6 (below). 15 Strategic objective 1. Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs and complications

Strategic actions 1.1 Improve data monitoring and strengthen the integration of NCD interventions into primary health care. 1.2 Strengthen initiatives around tobacco control and alcohol misuse. 1.3 Strengthen initiatives around healthy eating. 1.4 Strengthen initiatives around physical activity. 1.5 Strengthen initiatives around prevention, detection and management of diabetes and its complications. 1.6 Strengthen initiatives around road safety 1.7 Promote prevention, detection and early treatment in relation to cervical cancer, hypertension, heart disease, chronic lung disease, and their complications. 1.8 Improve mental health services. 1.9 Improve oral health services Strategic objective 2. Increase access to and use of high quality, comprehensive family planning services, particularly for vulnerable populations including women whose health and wellbeing will be at risk if they become pregnant Strategic actions 2.1 Improve skills, quality of services and access to family planning drugs and commodities for rural and urban islands. 2.2 Reinvigorate national Reproductive Health committee to proactively monitor & evaluate the data input towards Family Planning services 2.3 Engage with development partners around support for initial implementation of the RH strategy, and initiate work to identify a sustainable funding mechanism. 2.4 Strengthen partnership with KFHA, FBOs, youth groups and other non-government organisations to expand Family Planning services and increase involvement of men. 2.5 Engage with other GOK ministries departments to coordinate and integrate resources & approaches to managing population growth to benefit the aspirations of all sectors. Strategic objective 3. Improve maternal, newborn and child health Strategic actions 3.1 Improve the quality of services and care procedures during pregnancy, delivery and the immediate postpartum and for the newborn 16 3.2 Improve the skills and capacity of maternal care attendants. 3.3 Improve maternal and child health facilities and equipment. 3.4 Collect quality health information and data and use to improve MNC health care practice. 3.5 Strengthen community-based and outreach maternal and child health services. 3.6 develop and implement set of guidelines for MNCH (treatment and referral) 3.7 development of mother and baby friendly settings – workplace, institutions 3.8 Scale up MNC programs through inter-sectoral policies and legislations 3.9 Integrate Child eye health into Child health programs Strategic objective 4. Prevent the introduction and spread of communicable diseases through strengthening existing control programmes and ensure Kiribati is prepared for any future outbreaks. Strategic actions 4.1 Strengthen the ongoing delivery and sustainability of the TB Control Programme. 4.2 Strengthen the ongoing delivery of the Leprosy Control Programme. 4.3 Implement the ongoing National Plan for Lymphatic Filariasis and manage morbidity caused by the disease. 4.4 Revise the National HIV and STI Strategic Plan 2012–2015 with a focus on reversing the spread of STIs through improving prevention, increased testing capacity, and improved treatment services. 4.5 Improve preparedness for disease outbreaks through strengthening multi-sectoral surveillance and response systems, including in the Outer Islands. 4.6 Undertake initiatives and support multi-sectoral and coordinated approaches to increase access to, and use of, safe water and basic sanitation services, and promote improved hygiene. 4.7 Strengthen the implementation of the National Environmental Health Action Plan, 2015-2020 4.8 Strengthened activities to reduce antimicrobial resistance Strategic objective 5. Address gaps in health service delivery and strengthen the pillars of the health system Strategic actions 5.1 Improve the effectiveness and efficiency of health service delivery, focusing on addressing gaps in healthcare system and referral services. 5.2 Strengthen leadership and governance of health within and beyond the Ministry of Health and Medical Services. 5.3 Strengthen systematic and strategic (long term) workforce plans and systems. 5.4 Implement annual analysis of National Health account and secure sustainable health financing to ensure cost-effective and efficient delivery of services.

17 5.5 Develop and implement a formal asset maintenance and replacement programme for infrastructure and equipment. 5.6 Improve systems to ensure equitable and ready access to essential medical products, vaccines and technologies. 5.7 Improve systems for the collection, analysis, reporting and use of health information/data. 5.8 Improve and expand hospitals and clinics to meet the health need of the community 5.9 Strengthen KITP to ensure sustainability and quality of the program. Strategic objective 6. Improve access to high quality and appropriate health care services for victims of gender based violence and services that specifically address the needs of youth. Strategic actions 6.1 MHMS to implement Standard Operating Procedure of Eliminating Sexual and Gender Based Violence (ESGBV) policy in line with the national policy taking into account constant reviews and updates 6.2 Improve health care facilities and systems or management, treatment and care of victims of GBV. 6.3 Build the capability and capacity of the health workforce so that it is better able to meet the health care needs of victims of GBV 6.4 Strengthen GBV task force activities in terms of meetings, auditing of cases, awareness, data recording and improving service delivery points. 6.5 Strengthen MHMS GBV coordination with national GBV stakeholders 6.6 MHMS to finalize and implement national operational guidelines for Youth Friendly Health Services and implement in coordination with multi sectors initiatives. 6.7 MHMS to improve planning of and expand access to YFHS. 6.8 Strengthen MHMS coordination on YFHS with national youth stakeholders Key Performance Indicators Strategic objective 1 Indicators and targets Health indicator 2019 target Baseline Number of clinics implementing Package of Essential NCDs 103 6 (2015) Tobacco smoking prevalence (population aged 25–64 years) (a)  Female 29% 34% (2010) (a)  Male 52% 61% (2010) Tobacco smoking prevalence (population aged 15–24 years) (a)  Female 11% 13% (2010) (a)  Male 33% 39% (2010) 18 Health indicator 2019 target Baseline Obesity rate (population aged 25–64 years) (b)  Female 44% 59% (2006) (b)  Male 31% 42% (2006) Prevalence of diabetes (c)  Female 20% 27% (2006) (c)  Male 22% 30% (2006) (c) Number of diabetic-related amputations 68 90 (2011) Number of treated diabetic retinopathy cases (complication) 80 NA Number of cases caused by road safety a. Injury 69 178 (2013) b. Deaths 0 3 (2013) Number of active partnerships between NCD team and groups focused on addressing four NCD risk factors  Maneaba 200 58 (2011)  Workplaces 50 40 (2011)  Schools 50 10 (2011)  Homes tbc tbc Number of cervical smear tests, HPV tests and percentage of cases 760/20% 760/9% (2011) (confirmed by cytology and rapid test) Number of hypertension cases detected and treated >750 734 (2011) Setting up of Mental Health Rehabilitation Centre To be completed 2014 by 2016 Prevalence of Dental caries (5-6 yrs. old) 65% 70% (2012) Number of Decayed Missing Filled Teeth level (5-6 yrs old) <3 4 (2012) (a) Target is a 15% reduction on a 2010 baseline. The target is informed by the voluntary targets for NCDs agreed by WHO in 2012, including a 30% relative reduction in prevalence of current tobacco smoking among persons aged 15+ years by 2025. Prevalence rate calculated on those who smoke ‘regularly’; excludes those who smoke ‘sometimes’. (b) Target is a 25% reduction of baseline. In November 2012, WHO agreed voluntary targets for NCDs, including no increase in obesity prevalence in adults aged 18+ years. The targets in this Strategic Plan are, therefore, ambitious and should be reviewed once more recent data is available. (c) Target is a 25% reduction of baseline.

Strategic Objective 2: Indicators and targets Health indicator 2019 target Baseline 100% 85% (2010) SDPs offer at least three contraceptive methods (a) (c) Contraceptive prevalence rate (population aged 15–49 years) (b) 36% (2000) 45% 18% 2010 SDPs reporting stock-outs of family planning drugs and commodities in last 0% 21% (2009) 12 months (d) Fertility rate (women aged 15–49 years) <3.5 4.1 (2010) Number of teenage pregnancy 100 120 (2014) Revised National SRH policy 2008 Number of islands 12 3 Number of communities visited for Family Planning awareness 30 8 (2015) 19 Increase partnership with churches All in 2016 2 (a) MDG Indicator. (b) Target represents a 25 percent increase from the baseline. (c) Data for sexually active women of reproductive age. There is no regular measure of contraceptive prevalence rate and the requirements to report against this indicator will need to be reviewed. An alternative indicator could be ‘number of patients provided with contraceptives’ and perhaps broken down by pill, injections, implants, condoms. (d) Target represents the fertility rate in 2005. Replacement fertility rate is 2.1. Strategic objective 3: Indicators and targets Health indicator 2019 target Baseline (a) Maternal mortality <2 deaths 3 deaths (2010) (a) Births attended by skilled health personnel >95% 98% (2010) Antenatal care coverage (at least 2 visit) 100% 100% (2005) Access to EmOC:  SDPs meeting standards for basic EmOC functions 20% 1.8% (2009)  Hospitals meeting standards for comprehensive EmOC 3 1 (2010) functions (a) (b) Under-five mortality (per 1000 live births) 30 46 (2009) (a) (b) Infant mortality (per 1000 live births) 22 37 (2009) (d) Newborn infants weighing less than 2500 g at birth 30% reduction 22% (2010) (a) One-year-old children immunised against measles >90% 89% (2010) Newborn receiving Hepatitis B birth dose (<24hrs) >90% NA Number of active, trained community IMCI groups in Kiribati 6 2 (2012) (d) Percentage of anaemia in pregnant women 50% reduction by NA 2025 Number of cases of pneumonia (children aged <5 years) <3568(c) 4756 (2011) Number of cases of severe diarrhoea (children aged <5 years) <10 289 (2011) Number of cases of malnutrition (LWA, VLWA,Bilateral 25% reduction 320 (2014) (d) Edema)(children aged <5 years) (d) Number of cases of stunting (children aged <5 years) 40% Reduction by NA 2025 (d) Number of cases of overweight (children aged <5 years) No increase NA (d) percentage of wasting (children aged <5 years) Reduce or maintain NA to less than 5% by 2025 (d) Rates of exclusive breastfeeding at birth 50% increase by 79% (2009) 2025 (d) Rates of exclusive breastfeeding 50% increase 23%(2009) By 2025 Number of communities using SODIS 80 1(2014) Percentage of pre-schools enforcing school food policy 50 NA Number of schools having hand washing facilities 93 TBC Number of maternal and child health services focusing on oral TBC TBC health (a) MDG Indicator. (b) MDG Target.

20 (c) Target is a 25% reduction of baseline. Strategic objective 4: Indicators and targets Health indicator 2019 target Baseline (a) 1. TB case notification rate (all forms, per 100,000 population) 315 287 (2010) (a) (b) TB cases cured under DOTS ≥95% 97% (2010) Leprosy prevalence (per 10,000 population) <1 20 (2010) Lymphatic filariasis prevalence (total population) Eliminated 1.5% (2007– 2008) Number of tests conducted for STIs and percentage of positive cases 27,084/30% 27,084/5% (2011) Number of tests conducted for Hepatitis B and percentage of positive 10,266/40% 10,266/9% cases (2011) Comprehensive correct knowledge of HIV/AIDS (among population 15– (a)(c) 24 years)  Female >55% (d) 44.4% (2009)  Male >60% (d) 48.6% (2009) (a) (e) (f) Population using improved drinking water source 74% 48% (1990) (a) (e) (g) Population using improved sanitation facility 63% 26% (1990) Trachoma(Trachoma Folliculitis <10% 21.3%(2013) Soil Transmitted Helminthiasis >75% 94.9%(2002) Number antimicrobial resistance infections cases reported 0 1 (a) MDG Indicator. (b) Align with year 3 targets in Towards TB Elimination in Kiribati Project. (c) The baseline result comes from the Kiribati Demographic and Health Survey (DHS). A similar survey would not to be repeated to measure progress against this indicator. (d) Target is a 25% increase on baseline. (e) MDG Target. (f) In 2010, 64% of the population had access to an improved drinking water source. (g) In 2010, 49% of the population used an improved sanitation facility. Strategic objective 5: Indicators and targets Health indicator Target Health service delivery 2. Health service plans reviewed  1 revised per annum – end of 3. Number of Hospital Improvement Projects or reforms July each year  2 new improvement reforms 4. Developed sector plan per annum  End of 2015 and annual 5. Customer service charter advocated and implemented revision 6. Number of Curative Programs review meeting  Jan 2016 and revised annually 7. Number of Public Health Programs review meeting  Biannual  Biannual

21 Health indicator Target Leadership and governance 8. KHSP implementation and progress reports against indicators and  Quarterly targets 9. Number of health legislation/regulation reviewed 1 per annum 10. Number of meetings of the MHMS Senior Management Committee 11. Number of meetings of the Health Sector Coordinating Committee  6 per annum  Quarterly (refer to TOR) Workforce 12. Revised and finalization of workforce plan  Jan 2016 and annually 13. Number of health staff completing specialized trainings  Sectoral plan target Health financing Completed and implemented National Health Accounts  Annually Provided financial report  Monthly Infrastructure and equipment Infrastructure and Equipment management plan developed and  Developed by first quarter implemented 2016 Complete Kiribati Essential Equipment List and management and  Complete end of July 2015 replacement plan Reviewed and implemented KNEEL  First Quarter 2016 Developed Special funds for health equipment sustainability  Mid 2016 Medical products, vaccines and technologies Revised essential drugs list  By March 2016 and annually Updated treatment guideline  By June 2016 and annually Health information/data Monitor and report on major health indicators and targets in the KHSP and  Quarterly reports in the KDP Nursing reporting  100% MS1 reporting  100% Census reporting  100% motorcycle reporting Expansion of hospital and clinics TCH expansion  End of 2016 Betio hospital Expansion  End of 2016  End of 2016 New Kiritimati hospital  End of 2016 Buota, Betio, Teraina and Tabuaeran clinics KITP Well established KITP structure  By 2016 Assessment report from trainers  % of local supervisors Strategic objective 6: Indicators and targets Health indicator 2019 Target Baseline By December - Review of GBV SOP 2016 Healthy Family clinic By June 2016 - SDP staff to receive basic specialized training on the management and 90% by - 22 care of GBV victims December 2017 GBV task force commitment Quarterly every - year Number of GBV cases treated for PEP, STI and pregnancy prevention 50% of the MS1 - reported cases Number of YFHS clinics in school and community setting 8 4 (a) MDG Indicator. (b) Target is a 25% reduction of baseline.

23 IMPLEMENTATION PLAN FOR STRATEGIC ACTIONS Strategic objective 1: Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs and complications Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 1.1 Improve data monitoring and strengthen the integration of NCD interventions into primary health care. 1.1.1 Review, update and implement the Kiribati NCD work plan, ensuring it is consistent with (but adapted to suit the local Kiribati context) implementing the WHO Package of Essential NCD interventions (PEN) to all health clinics 1.1.2 Develop and provide a core set of interventions for detection, prevention, treatment and care of cancer, hypertension, heart disease and chronic lung disease, based on the WHO PEN 1.1.3 Maintain and strengthen outreach activities in workplaces, schools and community maneaba targeting NCD risk factors in an integrated way 1.1.4 Design and implement a comprehensive Recurrent budget, WHO public awareness programme targeting 2016 and ongoing behavioural change to reduce the prevalence of NCD risk factors 1.1.5 Ensure access to the essential DPHS technologies and tools, and to a core list of medicines, for implementing essential NCD interventions in all health clinics 1.1.6 Strengthen multi-sectoral mechanisms to coordinate and support implementation of NCD activities 1.1.7 Investigate sources of revenue for ensuring the sustainability of the NCD programme, including instigating formal engagement with development partners to discuss options for long term funding 1.1.8 Monitor the implementation of the NCD work plan, and undertake regular surveillance to identify progress and future areas of priority (including implement a STEPS survey at midway point (2013) and at end (2015)) 1.1.9 Over time, consider expanding on the core set of interventions based on local requirements and available resources 24 Strategic objective 1: Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs and complications Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 1.2 Strengthen initiatives around tobacco control and alcohol misuse 1.2.1 Activate the Tobacco Bill and Regulation 1.2.2 Review the adequacy of legislation relating to alcohol Recurrent budget, WHO 2016 and ongoing 1.2.3 Investigate the costs and benefits of implementing services to support people to quit smoking, including counselling and pharmacological support (eg, NRT) DPHS 1.2.4 Collaborate with KPS with regards to compliance with smoke-free public places, liquor licensing and selling tobacco and alcohol to underage children

1.2.5 Monitor misuse of other drugs and substances, such as benzene and chewing of dry tobacco 1.3 Strengthen initiatives around healthy eating. 1.3.1 Promote food and nutrition guidelines supported by other communication methods and messages about healthy eating, including messages about the link between diet, obesity and disease Recurrent budget, WHO 1.3.2 Strengthen and extend outreach activities 2016 and ongoing around community gardening and cooking demonstrations 1.3.3 In collaboration with the Ministry of DPHS Commerce, Industry and Cooperatives, investigate the feasibility and value of introducing requirements for food fortification 1.3.4 In collaboration with the Ministry of Commerce, Industry and Cooperatives, investigate the public health value of greater disclosure of food ingredients and nutritional information 25 Strategic objective 1: Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs and complications Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 1.4 Strengthen initiatives around physical activity. 1.4.1 Promote physical activities such as YOGA, etc. Recurrent budget, WHO 1.4.2 Collaborate with Ministry of 2016 and ongoing Education and MISA, councils, NGOs working in sport/recreation, and DPHS others to identify land appropriate for developing sports grounds and play facilities 1.4.3 In collaboration with the Ministry of Commerce, Industry and Cooperatives, investigate the feasibility and value of decreasing the tax on sport and exercise equipment 1.5 Strengthen initiatives around prevention, detection and management of diabetes and its complications. 1.5.1 Strengthen coordination and continuity of care across clinics (diabetes clinics and PH clinics) and outreach services Recurrent budget 2016 and ongoing 1.5.2 Provide specific training to MAs and DPHS PH nurses on early detection and intervention measures for diabetes, including to support secondary prevention 1.5.3 Support patients with disabilities to access medical services, as required in the National Policy and Action Plan on Disability 1.6 Strengthen initiatives around road safety 2016 and ongoing 1.6.1 Develop strong community Recurrent and awareness on road accident 1.6.2 Strengthen links with other DPHS Police WHO stakeholders in the implementation of road safety. 1.7 Promote prevention, detection and early treatment in relation to cervical cancer, hypertension, heart disease, chronic lung disease, and their complications.

26 Strategic objective 1: Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs and complications Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 1.7.1 Investigate the development and implementation of a national HPV vaccine programme, including cost and funding options. Recurrent budget, WHO 1.7.2 Promote early diagnosis and guidelines for treatment of breast 2016, ongoing cancer, including strengthening self- examination programmes 1.7.3 Investigate other screening options, DPHS including mammography, for viability, cost and potential for improved population health 1.7.4 Promote early detection of Diabetic Retinopathy 1.7.5 Strengthen PH approaches to other NCDs, focusing on raising awareness, prevention and early intervention 27 Strategic objective 1: Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs and complications Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 1.8 Improve mental health services 1.8.1 Provide specialised mental health training for nurses in the MH Unit to improve patient care and management of illnesses 1.8.2 Provide post-graduate training to a nurse in the MH Unit in psychiatric nursing 1.8.3 Develop and implement a long term plan for ongoing specialist support from a psychiatrist, or a plan to recruit a psychiatrist to the MH Unit 1.8.4 Investigate the need for specialist child psychiatry services (trained counsellor(s) and facilities) to meet the needs of children and young people 1.8.5 Provide training and supervision to orderlies to ensure MH patients have MISA, KHSP (SA5.4 & 5.6), KPS access to proper patient care and to Recurrent budget 2016 and ongoing promote patient safety DHS/DNS 1.8.6 Identify and review existing international guidelines for providing mental health services in primary care, adapt to fit local Kiribati context and implement, including by training staff in OI in the use of the guidelines 1.8.7 Promote greater public awareness around MH illnesses, including prevention and detection 1.8.8 Implement a plan to upgrade the bathroom and toilet facilities, and the water supply system, at the MH Unit 1.8.9 Improve the medication supply chain, especially to OI, to ensure better stock control 1.8.10 Investigate the feasibility and value of establishing a rehabilitation house for outpatients 1.8.11 Strengthen relationships with external organisations and other units within the MHMS 1.9 Improve oral health services 28

Strategic objective 1: Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce morbidity, disability and mortality from NCDs and complications Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe MISA, KHSP Recurrent DHS/DNS 2016 and 1.9.1 Strengthen services and awareness on oral health (SA5.4 & 5.6), budget ongoing 1.9.2 Strengthen outreach programs on oral KPS health (a) Including to other strategic actions in the KHSP, other strategies and plans (including for programmes), and other agencies. Strategic objective 2: Increase access to and use of high quality, comprehensive family planning services, particularly for vulnerable populations including women whose health and wellbeing will be at risk if they become pregnant Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 2.1 Improve skills, quality of services and access to family planning drugs and commodities for rural and urban islands. Recurrent 2.1.1 Support and strengthen staff training, stock management 2016, DPHS budget, activities, and increasing the supply of commodities UNFPA ongoing WHO 2.2 Reinvigorate national RH committee to proactively monitor & evaluate the data input towards FP services 2.2.1 Facilitate the development of RMNACAH committee to UNFPA, NZ Aid UNFPA, monitor and evaluate the program 2016 and DPHS Recurrent Programme, 2.2.2 Secure funding and support from UNFPA budget ongoing KFHA, UNICEF 2.2.3 Improve data collection on all RMNACAH programs 2.3 Engage with development partners around support for initial implementation of the RH strategy, and initiate work to identify a sustainable funding mechanism.

UNFPA, 2.3.1 Investigate future funding from UNFPA 2016, KFHA, DPHS FBOs, 2.3.2 Facilitate greater coordination of approaches to family Recurrent other ongoing NGOs, planning and delivery through the HSCC budget UNICEF 2.4 Strengthen partnership with KFHA, FBOs and other non-government organisations 29 Strategic objective 2: Increase access to and use of high quality, comprehensive family planning services, particularly for vulnerable populations including women whose health and wellbeing will be at risk if they become pregnant Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 2.4.1 Review Memorandum of Understanding with KFHA 2.4.2 Investigate the expansion of services provided by KFHA that KFHA, FBOs, other NGOs, UNFPA,UNICEF target the RH needs of young people and other vulnerable groups UNFPA, Recurrent budget 2.4.3 Inform and educate religious leaders, including in health and economic considerations relating to population control 2016, ongoing DPHS 2.4.4 Engage with religious leaders in finding common ground on family planning and planned parenting 2.4.5 Support those who may be willing to advocate for family planning and informed parenting 2.4.6 Support the delivery of the CycleBeads Program 2.4.7 Strengthen Partnership with KFHA, FBOs in outreach programs 30 Strategic objective 2: Increase access to and use of high quality, comprehensive family planning services, particularly for vulnerable populations including women whose health and wellbeing will be at risk if they become pregnant Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 2.5 Engage with other GOK ministries departments to coordinate and integrate resources & approaches to managing population growth to benefit the aspirations of all sectors. 2.4.1 Promote completion of whole-of- 2016, ongoing government implementation strategy UNFPA, GOK DPHS to support the GOK Population Policy Recurrent Population 2.4.2 Contribute to activities in implementation strategy around budget Policy informed parenting (a) Including to other strategic actions in the KHSP, other strategies and plans (including for programmes), and other agencies.

31 Strategic objective 3: Improve maternal, newborn and child health Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 3.1 Improve the quality of services and care procedures during pregnancy, delivery and the immediate postpartum and for the newborn Reproductive 3.1.1 Promote at least four antenatal Health Policy care visits and postnatal and Strategy, care/clinics to all pregnant women Child Survival and mothers of newborn Committee, Safe 3.1.2 Take a systematic and syndromic Motherhood approach to the management and care of women and their newborn 3.1.3 Implement emergency management of childbirth protocols and referral guidelines for EmOC consistently and timely 3.1.4 Develop robust communication protocols around referral Recurrent budget, pathways 2016, ongoing 3.1.5 Establish continuity of care by DPHS, skilled professionals for the first six DHS UNFPA weeks following delivery (with a focus on the first 28 days of life) 3.1.6 Strengthen engagement with TBAs and investigate ways to work in partnership, including for allowing TBAs to play a greater role in providing care and support in hospitals 3.1.7 Promote the involvement of men in maternity care, from antenatal through to postnatal care 3.1.8 Coordinate work across the MHMS to prevent parent to mother to child transmission of STIs/HIV 3.2 Improve the skills and capacity of maternal care attendants. 32 Strategic objective 3: Improve maternal, newborn and child health Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe Reproductive 3.2.1 Review basic midwifery curricula Health Policy and consider adopting a syndromic and Strategy, approach to training and inclusion Child Survival of basic training in EmOC to all Committee, trainee midwives/nurses/MAs Safe Motherhood 3.2.2 Provide ongoing in-service training of midwives/nurses/MAs on Recurrent budget, comprehensive obstetric skills

2016, ongoing 3.2.3 Investigate further training for DPHS TBAs DHS 3.2.4 Consider options for increasing UNFPA capacity in advanced obstetrics, including for recruiting and training an obstetrician 3.2.5 Ensure efficient and effective allocation of skilled care attendants across SDPs, including in OI clinics and other referral facilities 33 Strategic objective 3: Improve maternal, newborn and child health Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 3.3 Improve maternal and child health facilities and equipment. Reproductive 3.3.1 Investigate feasibility and value of Health Policy establishing a separate postnatal ward and Strategy at TCH 3.3.2 Investigate feasibility and value of establishing a specialist neonatal facility and a specialist paediatric Recurrent budget From 2016, ongoing intensive care unit at TCH (including specialised training required to staff the facilities) SMC 3.3.3 Investigate feasibility and value of upgrading hospitals on Kiritimati Island and Tabiteuea North from basic to comprehensive EmOC facilities 3.3.4 Ensure adequate obstetrics equipment and supplies at all SDPs, and implement a maintenance/repair system including a process to report on maintenance/repairs needs 3.4 Collect quality health information and data and use to improve MNC health care practice. HIU 3.4.1 Improve processes for collecting SMC, Health Information Unit (HIU) maternity care data from obstetrics ward, OI clinics and referral facilities, and from TBAs operating outside of Recurrent budget the formal health care system 2016, ongoing 3.4.2 Re-establish the role of Ward Clerk, to be responsible for data collection in the obstetrics ward 3.4.3 Strengthen and systematise processes for reviewing all cases of maternal death, including using and implementing review findings to improve health care practice 34 Strategic objective 3: Improve maternal, newborn and child health Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 3.5 Strengthen community-based and outreach maternal and child health services. 2016, ongoing Child Survival 3.5.1 Empower communities to sustain Recurrent budget, Strategy, community-controlled system through, and IMCI for example, helping communities set up health committees (eg, Village Welfare Committees) and maintaining regular interaction with these groups 2016, ongoing

3.5.2 Continue to train PH nurses in IMCI and UNICEF support them to train community 2016, ongoing members in IMCI 2016, ongoing 3.5.3 Design and implement community IMCI UNICEF protocols that provide guidance in the 2016, ongoing recognition of conditions and in pre- measure/ intervention treatments that can be given in the community/home DPHS 2016, ongoing 3.5.4 Develop and implement system for WHO/UNICEF monitoring community IMCI and for reporting back information to PH nurses 3.5.5 Strengthen care of new Investigate feasibility and value of consolidating community support groups (eg, in IMCI and breastfeeding/nutrition), or at ways UNICEF to promote joint working borns and children though implementing the Baby Friendly Hospital Initiative and designing and implementing standard treatment protocols for management of common paediatric and neonatal conditions 3.6 Develop and implement set of guidelines for MNCH (treatment and referral) . Child Survival 3.6.1 Develop a workable referral guideline Strategy, Recurrent budget 2016, ongoing from the community to the Public IMCI health clinics and hospital. 3.6.2 Strengthen detection and referral of DPHS UNICEF, UNFPA high risk MNCH cases. 3.6.3 Support awareness on high risk criteria in relation to MNCH cases 3.7 Development of mother and baby friendly settings – workplace, institutions . Child Survival Recurrent budget 2016, ongoing 3.7.1 Work towards Mother and Baby friendly Strategy, accreditation on all the 3 hospitals IMCI 3.7.2 Promote the establishment of Mother DPHS UNICEF and Baby friendly workplaces and Institutions. 3.8 Scale up MNC programs through inter-sectoral policies and legislations 35 Strategic objective 3: Improve maternal, newborn and child health Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe . Child Survival Recurrent Recurrent 3.8.1 Ensue that MNC programs are reflected 2016, Strategy, DPHS budget in existing inter-sectoral policies and UNICEF, IMCI ongoing legislations UNFPA

3.9 Integrate Child eye health into Child health programs . Child Survival Recurrent Recurrent 3.9.1 Develop a Child Eye Care system in the 2016, Strategy, DPHS budget hospital, Schools and the community UNICEF, IMCI ongoing UNFPA (a) Including to other strategic actions in the KHSP, other strategies and plans (including for programmes), and other agencies. 36 Strategic objective 4: Prevent the introduction and spread of communicable diseases, strengthen existing control programmes and ensure Kiribati is prepared for any future outbreaks Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 4.1 Strengthen the ongoing delivery and sustainability of the TB Control Programme 4.1.1 In implementing the TB Strategic Plan: TB Control Programme  Collaborate with other MHMS programmes, other government departments and NGOs to advocate for the role of social environmental factors in TB transmission, address factors that SPC, and, increasingly, recurrent budget increase the risk of developing TB, and for active case finding and effective referral mechanisms 2016, ongoing  Promote universal and DPHS equitable access through expanding DOTS coverage  Strengthen capacity to diagnose and monitor treatment of TB cases, including drug-resistant TB, TB-HIV and TB-DM  Strengthen TB Drug Management system and programmatic management of MDR-TB, TB-HIV and TB-DM co- morbidities 4.1.2 Investigate funding sources to extend the DOTS initiative beyond 2017 4.2 Strengthen the ongoing delivery of the Leprosy Control Programme 4.2.1 Develop and implement a plan to provide effective national leadership and management of the Leprosy Control Programme 4.2.2 Develop and implement training for Pacific Leprosy Foundation medical assistants/nurses in the OI to improve their capacity to check for

Other (drugs) 2016, ongoing signs of leprosy, to follow-up MDT DPHS WHO treatment and to undertake systematic contact tracing 4.2.3 Develop and implement a robust process of recording the provision of treatment and providing monthly reports on this, potentially as part of the MS-1 system 4.2.4 Develop and implement outreach initiatives to raise public awareness of leprosy and its treatment 37 Strategic objective 4: Prevent the introduction and spread of communicable diseases, strengthen existing control programmes and ensure Kiribati is prepared for any future outbreaks Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 4.3 Implement the ongoing National Plan for Lymphatic Filariasis, Trachoma and soil transmitted helminthiasis and manage morbidity caused by the disease 4.3.1 Implement targeted strategy involving active surveillance of patients and contacts, and:  Complete treatment assessment survey (TAS) in the Gilbert Islands 2016, ongoing  DPHS Complete two annual rounds of MDA and TAS in the Line Islands WHO  Complete final round of MDA and TAS in South Tarawa 4.3.2 Provide ongoing individual follow-up, treatment and care to patients, including education to patients and their families on how to manage the impact of the disease 4.4 To Review the National HIV and STI Strategic Plan 2012–2015 with a focus on reversing the spread of STIs through improved prevention, increased testing and improved treatment services Kiribati 4.4.1 MHMS to lead the implementation plan Red Cross, KFHA, 4.4.2 MHMS to monitor and evaluate UNFPA, implementation, including undertake a UNICEF mid-term review 4.4.3 Investigate funding sources for those activities in the Plan which do not currently SPC (Global Fund, Response Fund, have an identified funding source 4.4.4 In implementing and monitoring the Plan: 2016, ongoing  Review and improve ways to target at risk groups DPHS Recurrent budget  Promote and strengthen multi- sectoral initiatives  Strengthen systems for surveillance, data collection and analysis  Complete the full integration of the STI and HIV programmes  Promote the guideline on syndromic approach to STI diagnosis and management

38 Strategic objective 4: Prevent the introduction and spread of communicable diseases, strengthen existing control programmes and ensure Kiribati is prepared for any future outbreaks Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 4.5 Improve preparedness for disease outbreaks Diagnostic and treatment services through strengthening multi-sectoral surveillance and response systems, including in the Outer Islands KAP III. 4.5.1 Maintain strong relationship with the NFCCA., KDP Pacific Public Health Surveillance (KPA4) Network, and with MELAD, in outbreak MELAD, surveillance and response President’s Office, WHO 4.5.2 Provide further specialist training to (water nurses in OI in disease surveillance and quality how to respond to an outbreak testing) 4.5.3 Increase capacity to use data and IT systems for surveillance purposes, including in statistical analysis 4.5.4 Improve syndromic surveillance systems and review current tools to include conditions of local (OI) importance 4.5.5 Strengthen capacity of laboratory so it Recurrent budget can provide timely diagnostic 2016, ongoing responses and review adequacy of equipment and test kits/tools DPHS 4.5.6 Improve processes for water testing and analysis of reticulated water supplies and wells by ensuring a constant supply of reagents 4.5.7 Maintain scheduled water monitoring and, ideally, increase the frequency of testing and monitor a wider range of water sources 4.5.8 Allocate laboratory space for the EHU and investigate options for addressing the transport needs of the unit 4.5.9 Undertake initiatives and support multi-sectoral approaches to climate change adaptation planning, including actively responding to the Disaster Risk Reduction (DRR) measures, and considering both impacts of sea level rise and drought 39 Strategic objective 4: Prevent the introduction and spread of communicable diseases, strengthen existing control programmes and ensure Kiribati is prepared for any future outbreaks Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 4.6 Undertake initiatives and support multi-sectoral and coordinated approaches to increase access to, and use of, safe water and basic sanitation services, and promote improved hygiene 4.6.1 In coordination with other agencies, MPWU, Recurrent budget, UNICEF develop and implement strategies to MELAD, KHSP improve access to safe water and (SA 2.5.7,

2016, ongoing sanitation, and to improve hygiene 2.5.8 & 3.5), DPHS 4.6.2 Actively promote and support the UNICEF WASH work of the Water Sanitation Coordinating Committee 4.6.3 Investigate opportunities to access regional support initiatives relating to water safety and sanitation 4.7 Strengthen the implementation of the National Environmental Health Action Plan, 2015-2020 4.7.1 Coordinate and strengthen the Recurrent Implementation of the National 2016, Environmental Health Action Plan. DPHS budget, UNICEF ongoing 4.8 Strengthened activities to reduce antimicrobial resistance 4.8.1 Strengthen recording and reporting of antimicrobial drug resistance cases. Recurrent budget 2016, ongoing 4.8.2 Increase awareness to health care providers DPHS (a) Including to other strategic actions in the KHSP, other strategies and plans (including for programmes), and other agencies. 40 Strategic objective 5: Address any gaps in health service delivery and strengthen the pillars of the health system Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 5.1 Improve the effectiveness and efficiency of health service delivery, focusing on addressing gaps in healthcare system and referral services. 5 5.1 5.1.1 Undertake focused health service planning in the following service areas:  general and specialist medical treatment Recurrent 2016,  pharmacy budget ongoing  laboratory  biomedical  radiology  rehabilitation  dental  emergency 5.1.2 Ensure plans are focused on addressing gaps in health service delivery through:  identifying population health service needs, and forecasting future needs  prioritising health service needs DHS  assessing how well services meet these needs, considering levels of service, complaints against the existing service, availability/suitability of treatment guidelines, facilities, technology and workforce  identifying challenges, gaps and opportunities  costing options for addressing gaps, and prioritising investment  integrate planning to promote continuity of care 2016 5.1.3 Consult key stakeholders on plan and seek Recurrent 2016, agreement/endorsement budget, NZ ongoing 5.1.4 Implement health service plans, monitor and review Aid 2016, 5.1.5 Improve system of patient referrals from OI and system of Programme ongoing specialist visits to OI (Medical Treatment 2016, Scheme) ongoing 5.1.6 Maintain access to medical evacuations and referrals for MFED seriously ill or injured patients to be treated overseas Recurrent 2016 KDP 5.1.7 Maintain access to medical evacuations and referrals for DHS seriously ill or injured patients to be treated overseas budget ongoing 5.1.8 Strengthen Outer island health services

41 Strategic objective 5: Address any gaps in health service delivery and strengthen the pillars of the health system Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 5.2 Strengthen leadership and governance of health within and beyond the Ministry of Health and Medical Services. Permanent Recurrent 2015, MFED, 5.2.1 Provide clear strategic direction for the MHMS Secretary, budget ongoing KDP and the wider health sector, that is consistent SMC (KPA5), with the broader KDP, by implementing the PSO KHSP and communicating the strategic direction of the health sector to staff and Annually partner agencies 2015, 5.2.2 Develop policies, annual and multi-year ongoing strategies and work plans that are linked to and that give effect to the KHSP 2015, ongoing 5.2.3 Provide adequate training to I-Kiribati to ensure that the capacity for leadership 2015, extends to all levels of the health system ongoing 5.2.4 Effectively manage the health system through the use of laws, regulations, accreditation, By January standards and guidelines each year 2015, 5.2.5 Align the MHMS’ accountability frameworks, ongoing including for performance monitoring of departments and staff, to the KHSP 5.2.6 Monitor and report on progress of the strategic actions against the indicators and targets in the KHSP 5.2.7 Involve the HSCC in the implementation of the KHSP 5.3 Strengthen systematic and strategic (long term) workforce plans and systems. Permanent Recurrent 2015 PSO, KDP 5.3.1 Develop a comprehensive, long term Secretary, budget, (KPA1), workforce plan (incorporating a human Deputy WHO, Medical resource development plan) that identifies: Secretary, AusAID Council, SMC, KSoN (KANI) Nursing  the essential health workforce, Council skills required, specialties sought  the wider health sector workforce requirements, skills base, etc.  how cover will be ensured for essential roles (including succession planning)  the continuing education needs for 2015, key positions and how they will be met ongoing 2015,  training policy: where people will ongoing be sent, priority/non-priority training 2015, areas ongoing 42

Strategic objective 5: Address any gaps in health service delivery and strengthen the pillars of the health system Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe  means of reintegrating Kiribati health professionals trained overseas  means of improving retention 2015, ongoing  means of encouraging youth to pursue a career in the health sector  indicators to monitor progress on workforce and human resource development 5.3.2 Implement the plan, after seeking 2015, Government endorsement ongoing 2015, 5.3.3 Review the plan regularly to revise and extend ongoing it forward 5.3.4 Engage with the Public Service Office to ensure that all recruitment and training decisions are aligned with the workforce plan and all such decisions are consulted on with the Permanent Secretary of the MHMS before decisions are made, and decisions are communicated to heads of department in the MHMS 5.3.5 Implement professional regulation and ongoing competency of health staff through:  improving administrative and recording processes of the Ministry and the Medical and Nursing Councils  maintenance of the register by the Medical Council  enforcement of current disciplinary procedures by both regulatory bodies 5.3.6 Promote staff accountability and performance 5.3.7 Develop a system for staff-initiated improvements and efficiencies, and communicate and promote this system across the Ministry 5.4 Implement annual analysis of National Health account and secure sustainable health financing to ensure cost-effective and efficient delivery of services. Permanent Recurrent 2019 5.4.1 Develop a comprehensive budget format Secretary budget, incorporating the all activities listed under the strategic plan. 43 Strategic objective 5: Address any gaps in health service delivery and strengthen the pillars of the health system Indicative (a) Strategic actions and indicative activities Lead(s) Budget Links timeframe 5.5 Develop and implement a formal asset maintenance and replacement programme for infrastructure and equipment. Permanent Recurrent 2019 5.5.1 Develop a comprehensive formal asset, Secretary, budget, maintenance and replacement program for DHS infrastructure 5.5.2 Planning and identification of funding for the maintenance and replacement of infrastructures. 5.6 Improve systems to ensure equitable and ready access to essential medical products, vaccines and technologies. Permanent Recurrent 2019 5.6.1 Develop a system to ensure equitable and Secretary, budget, ready access to essential medical products, DHS vaccines and technologies. 5.7 Improve systems for the collection, analysis, reporting and use of health information/data. Permanent Recurrent 2019 5.7.1 Develop effective MHMS database Secretary, budget, DHS 5.7.2 Recruitment of the Epidemiologist to train staff, analyse data and manage the HIS department.

5.7.3 Support Database Maintenance and system security. 5.8 Improve and expand hospitals and clinics to meet the health need of the community Permanent 2019 5.8.1 Build a new extension to TCH hospital Secretary, Kuwait DHS 5.8.2 Build a new hospital in Xmas Island Taiwan 5.8.3 Build a new extension to Betio hospital Taiwan 5.8.4 Building of Buota, Betio, Tabuaeran and Teraina clinic Taiwan 5.9 Strengthen KITP to ensure sustainability and quality of the program Permanent DFAT, 2019 5.9.1 Develop a KITP transitional plan post 2015 to Secretary, Taiwan, 2019 DHS Recurrent 5.9.2 Seeking further support from donors to the KITP program beyond 2015 5.9.3 Ensure that local doctors are send for postgraduate training to take up supervisory roles at the KITP 44 Budget Public policy Financial Key Performance Division Performance Targets Objective Implications Indicator Responsible 2016 2017 2018 2019 1. High burden and incidence of Non-communicable diseases Tobacco smoking Tobacco smoking prevalence 25–64 years) 1.1 Improve data prevalence 25–64 Female 34% monitoring and DB $40,000 years) Male 61% strengthen the Female 34% integration of RC $30,000 Male 61% Tobacco smoking prevalence (15–24 years) NCD Female 13% interventions Tobacco smoking Male 39% into primary prevalence (15–24 health care years) Obesity rate (25–64 years) 1.2 Strengthen DB $50,000 Female 13% Female 59% initiatives Male 39% Male 42% around tobacco RC $30,000 control and Obesity rate (25–64 Prevalence of diabetes alcohol misuse. years) Female 27% Public health 1.3 Strengthen DB $50,000 Female 59% Male 30% initiatives Male 42% around healthy RC $35,000 Number of diabetics-related amputations 90 eating. Prevalence of diabetes 1.4 Strengthen DB $20,000 Female 27% Smoke free initiatives Male 30% Maneaba 50 around physical RC $20,000 Workplace 40 activity. Number of diabetics- Schools 10 1.5 Strengthen DB $20,000 related amputations 90 cervical smear tests 760 initiatives % cases confirmed 9% around RC $30,000 Smoke free prevention, Maneaba 50 Number of hypertension cases detected and treated 734 detection and Workplace 40 management of Schools 10 Number of diabetic-related amputations 68 diabetes and its cervical smear tests complications. 760 Number of treated diabetic retinopathy cases (complication) 80 1.6 Strengthen DB $10,000 % cases confirmed 9%

45 initiatives Number of cases caused by road safety around road RC $10,000 Number of a. Injury 69 safety hypertension cases b. Deaths 0 1.7 Promote DB $20,000 detected and treated prevention, 734 Number of active partnerships between NCD team and groups focused on addressing four NCD risk detection and RC $40,000 factors early treatment Number of diabetic- •Maneaba 200 in relation to related amputations 68 •Workplaces 50 cervical cancer, •Schools 50 hypertension, Number of treated heart disease, diabetic retinopathy Number of cervical smear tests, HPV tests and percentage of cases (confirmed by cytology and chronic lung cases (complication) 80 rapid test) 760/20% disease, and their Number of cases Number of hypertension cases detected and treated >750 complications. caused by road safety 1.8 Improve mental DB $10,000 a. Injury 69 health services RC $20,000 b. Deaths 0 1.9 Improve oral RC $10,000 health services Number of active partnerships between NCD team and groups focused on addressing four NCD risk factors •Maneaba 200 •Workplaces 50 •Schools 50 Number of cervical smear tests, HPV tests and percentage of cases (confirmed by cytology and rapid test) 760/20% Number of hypertension cases detected and treated 46 >750 2. High population growth 2.1 Improve skills, DB $50,000 SDPs at least three quality of contraceptive methods SDPs at least three contraceptive methods 85% services and RC $30,000 85% access to family Contraceptive prevalence rate 36% planning drugs Contraceptive and prevalence rate 36% SDPs reporting stock-outs of family planning drugs and commodities in last 12 months 21% commodities for rural and urban SDPs reporting stock- Fertility rate 4.1 islands. outs of family planning 2.2 Reinvigorate DB $50,000 drugs and commodities Reduced number national RH in last 12 months 21% of teenage pregnancy 100 committee to RC $40,000 proactively Fertility rate 4.1 Revised National SRH policy Public health monitor & evaluate the Reduced number Number of islands 12 data input of teenage pregnancy towards FP 100 Number of communities visited for FP awareness 30 services 2.3 Engage with DB $50,000 Revised National SRH Increase partnership with churches All in 2016 development policy partners around RC $30,000 support for Number of islands 12 initial implementation Number of of the RH communities visited strategy, and for FP awareness 30 initiate work to identify a Increase partnership sustainable with churches All in funding 2016

47 mechanism. 2.4 Strengthen DB $20,000 partnership with KFHA, RC $10,000 FBOs, youth groups and other non- government organisations to expand fp services and increase involvement of men. 2.5 Engage with DB $20,000 other GOK ministries RC $20,000 departments to coordinate and integrate resources & approaches to managing population growth to benefit the 48 aspirations of all sectors. 3. High maternal and Child morbidity (including macro and micro nutrient deficiency) and mortality 3.1 Improve the DB $60,000 Maternal mortality 3 Public Maternal mortality 3 deaths quality of deaths health services and RC $20,000 Public Births attended by skilled health personnel 98% care procedures Births attended by health during skilled health Antenatal care coverage (at least one visit) 100% pregnancy, personnel 98% delivery and the SDPs meeting standards for basic EmOC functions 1.8% immediate Antenatal care postpartum and coverage (at least one Hospitals meeting standards for comprehensive EmOC functions 1 for the newborn visit) 100% 3.2 Improve the DB $50,000 Under-five mortality (per 1000 live birth) 30 skills and SDPs meeting capacity of RC $30,000 standards for basic Infant mortality (per 1000 live births) 22 maternal and EmOC functions 1.8% neonatal care Newborn infants weighing less than 2500 g at birth 30% reduction attendants. Hospitals meeting 3.3 Improve DB $30,000 standards for One-year-old children immunised against measles(a) >90% maternal and comprehensive EmOC child health RC $10,000 functions 1 Newborn receiving Hepatitis B birth dose (<24hrs) >90% facilities and equipment. Under-five mortality Number of active, trained community IMCI groups in Kiribati 6 3.4 Collect quality DB $30,000 (per 1000 live birth) 30 health Percentage of anaemia in pregnant women 50% reduction by 2025 information and RC $10,000 Infant mortality (per data and use to 1000 live births) 22 Number of cases of pneumonia (children aged <5 years) <3568 improve Maternal, Newborn infants Number of cases of severe diarrhoea (children aged <5 years) <10 Neonatal and weighing less than Child health 2500 g at birth 30% Number of cases of malnutrition (LWA, VLWA, Bilateral Oedema)(children aged <5 years) 25% care practice. reduction reduction 3.5 Strengthen DB $30,000 community- One-year-old children Number of cases of stunting (children aged <5 years) 40% Reduction by 2025 based and RC $10,000 immunised against 49 outreach measles(a) >90% Number of cases of overweight (children aged <5 years) No increase maternal and child health Newborn receiving services. Hepatitis B birth dose 3.6 Develop and DB $30,000 (<24hrs) >90% implement set of guidelines for RC $10,000 Number of active, Maternal, trained community Neonatal and IMCI groups in Kiribati Child health in 6 terms of Management, Percentage of treatment, anaemia in pregnant referral and women 50% reduction Continuity of by 2025 Care 3.7 development of DB $30,000 Number of cases of mother and pneumonia (children baby friendly RC $10,000 aged <5 years) <3568 settings – workplace, Number of cases of institutions severe diarrhoea 3.8 Scale up DB $30,000 (children aged <5 Maternal, years) <10 Neonatal and RC $10,000 Child health Number of cases of programs malnutrition (LWA, through VLWA, Bilateral collaboration Oedema)(children with Key aged <5 years) 25% stakeholders reduction adopting policies and Number of cases of legislations in stunting (children aged place. <5 years) 40% (Examples; CRC- Reduction by 2025

50 convention on Number of cases of the rights of the overweight (children child, Labour aged <5 years) No Policy (National increase & International), Human rights, etc.) 4. High burden & incidence of communicable diseases (TB, leprosy, lymphatic Filariasis, STIs and HIV/AIDS, Trachoma and Soil Helminthiasis) 4.1 Strengthen DOTS Development TB case notification Public TB case notification rate (all forms, per 100,000 population) 287 services and budget rate (all forms, per health existing diseases $100,000 100,000 population) TB cases cured under DOTS 97% surveillance and 287 outbreak Leprosy prevalence (per 10,000 population) 20 response for TB, TB cases cured under leprosy, DOTS 97% Lymphatic filariasis prevalence (total population) 1.5% lymphatic filariasis, STIs Leprosy prevalence Number of tests conducted for STIs and percentage of positive cases 2708/5% and HIV/AIDS (per 10,000 population) 20 Number of tests conducted for Hepatitis B and percentage of positive cases 10266/10% Lymphatic filariasis Comprehensive correct knowledge of HIV/AIDS ( 15–24 years) prevalence (total Female 44.6% population) 1.5% Male 48.6% Number of tests Population using improved drinking water source 48% conducted for STIs and percentage of positive Population using improved sanitation facility 35% cases 2708/5% Number of tests conducted for Hepatitis B and percentage of positive cases 10266/9% Comprehensive correct 51 knowledge of HIV/AIDS ( 15–24 years) Female 44.6% Male 48.6% Population using improved drinking water source 48% Population using improved sanitation facility 26% 5. Apparent gaps in health service delivery 5.1 Re-assess human Development Health service delivery Curative, Health service delivery resources needs budget Number of health Admin Number of health service plans reviewed/developed and address $200,000 service plans Leadership and governance- 2 per annum gaps/issues reviewed/developed Recurrent: Leadership and KHSP implementation and progress reports against indicators and targets- By end of Jan. each year $50,000 governance- 2 per 5.2 Strengthen post Development annum Nursing Number of meetings of the MHMS Senior Management Committee - 6 per annum and basic budget training $100,000 KHSP implementation Number of meetings of the Health Sector Coordinating Committee amongst service and progress reports Workforce- 8 per annum providers against indicators and 5.3 Provide Development targets- By end of Jan. Admin, Comprehensive workforce plan developed and implemented equipment and budget each year Curative Health financing- Developed by Dec. 2015 maintenance $500,000 including Number of meetings of Complete National Health Accounts training on how the MHMS Senior Infrastructure and equipment - Implemented by Dec. 2016 to operate Management complex health Committee - 6 per Facilities management plan developed and implemented machines annum Medical products, vaccines and technologies - Implemented by Dec. 2016 5.4 Expansion and Development building of budget Number of meetings of Review essential drugs list - Biannual hospitals and $8,000,000 the Health Sector clinics Coordinating Health information

52 Committee Monitor and report on the indicators and targets in this KHSP and in the KDP- By end of Jan. each Workforce- 8 per year annum Develop and implement a checklist/survey for assessing client satisfaction - By June 2015 Comprehensive workforce plan developed and implemented Health financing- Developed by Dec. 2015 Complete National Health Accounts Infrastructure and equipment - Implemented by Dec. 2016 Facilities management plan developed and implemented Medical products, vaccines and technologies - Implemented by Dec. 2016 Review essential drugs list - Biannual Health information Monitor and report on the indicators and targets in this KHSP and in the KDP- By end of Jan. each year 53 Develop and implement a checklist/survey for assessing client satisfaction - By June 2015 6. Weak health care services for victims of gender based violence and services that specifically address the needs of youth 6.1 Strengthen Development Implement GBV SOP By Public Implement GBV SOP By June 2015 standard budget June 2015 health operating $20,000 Private GBV clinic By December 2015 procedures and Private GBV clinic By Gender Based December 2015 SDPs where staff have received basic specialised training on the management and care of GBV Violence victims 100% by December 2015 (ESGBV) Policy SDPs where staff have 6.2 Improve health Development received basic Number of AHD clinics in school and community settings4 by December 2015 care facilities budget specialised training on and systems for $60,000 the management and SDPs offering YFHS 50% by December 2015 the care of GBV victims management, 100% by December Adolescent fertility rate (per 1000 women aged 15–19 years) 29 by December 2015 treatment and 2015 Implement GBV SOP By June 2015 care of victims of GBV Number of AHD clinics Private GBV clinic By December 2015 6.3 Build the Development in school and capability and budget community settings4 SDPs where staff have received basic specialised training on the management and care of GBV capacity of the $10,000 by December 2015 victims 100% by December 2015 health workforce to SDPs offering YFHS Number of AHD clinics in school and community settings4 by December 2015 care for the 50% by December needs of victims 2015 SDPs offering YFHS 50% by December 2015 of GBV. 6.4 Implement Development Adolescent fertility Adolescent fertility rate (per 1000 women aged 15–19 years) 29 by December 2015 national budget rate (per 1000 women Implement GBV SOP By June 2015 operational $40,000 aged 15–19 years) 29 guidelines for by December 2015 Private GBV clinic By December 2015 Youth Friendly 54 Health Services SDPs where staff have received basic specialised training on the management and care of GBV (YFHS) and victims 100% by December 2015 implement in coordination Number of AHD clinics in school and community settings4 by December 2015 with multi- sectoral SDPs offering YFHS 50% by December 2015 initiatives. 7.5 Improve Development Adolescent fertility rate (per 1000 women aged 15–19 years) 29 by December 2015 planning of, budget Implement GBV SOP By June 2015 and access to, $80,000 YFHS Private GBV clinic By December 2015

SDPs where staff have received basic specialised training on the management and care of GBV victims 100% by December 2015 Number of AHD clinics in school and community settings4 by December 2015 SDPs offering YFHS 50% by December 2015 Adolescent fertility rate (per 1000 women aged 15–19 years) 29 by December 2015 55 Ministry Operational Plan The plan will link with the Kiribati Development Plan 2015–2019. The previous KPAs reflect international and regional conventions, and government policies. The Kiribati Development Plan (KDP) includes a set of indicators to enable progress in each KPA to be monitored and evaluated. KPA 3 sets out six core issues and 12 strategies for health (Table 1). There is a strong desire to align the Kiribati Health Strategic Plan with the priority issues and strategies in the new KDP. Table 1: Issues and strategies identified in the Kiribati Development Plan (2012–2015) Issues Strategies 1. High burden and incidence of other 1. Improve outreach of NCD services (curative) diseases (Non-communicable diseases) 2. Improve and expand coverage on awareness of the root causes of NCD (prevention) 3. Improved screening, detection and access to treatment services for all NCDs 2. High population growth 4. Promote family planning services 5. Strengthen partnerships with faith-based organisations 3. High maternal morbidity (including macro 6. Improve delivery of emergency and obstetric care and micro nutrient deficiency) and mortality services 7. Improve access to antenatal and post natal care 4. High child morbidity (including malnutrition 8. Expand Continuity of Care (CoC), EPI coverage and and childhood injuries) and mortality IMCI services for children at risk 5. High burden & incidence of communicable 9. Strengthen DOTS services and existing diseases diseases (TB, leprosy, lymphatic filariasis, surveillance and outbreak response for TB, leprosy, STIs and HIV/AIDS) lymphatic filariasis, STIs and HIV/AIDS 6. Apparent gaps in health service delivery 10. Re-assess human resources needs and address gaps/issues 11. Strengthen post and basic training amongst service providers 12. Provide equipment and maintenance including training on how to operate complex health machines 13. Strengthen outer island health system 14. Expansion and building of hospitals and clinics 7. Weak health care services for victims of 15. Strengthen standard operating procedures and Gender gender based violence and services that Based Violence (ESGBV) Policy. specifically address the needs of youth 16. Improve health care facilities and systems for the management, treatment and care of victims of GBV. 17. Build the capability and capacity of the health workforce to care for the needs of victims of GBV. 18. Implement national operational guidelines for Youth Friendly Health Services (YFHS) and implement in coordination with multi-sectoral initiatives. 19. Improve planning of, and access to, YFHS.

56 Budget Project and Recurrent Personal Operational plan Emolument Process of Budgeting Project documents Cabinet Matrix Supplementary Strategic plan ER NCS Secotr plan Cabinet decisions Emergencies Disasters and Outbreaks KDP Pacific Health UN SDG Ministers Meeting 57 Results management The importance of relationships, partnerships and inter-sectoral coordination and collaboration is apparent in many of the strategic actions in this Strategic Plan. Domestic coordination In working towards the objectives in this Strategic Plan, there are opportunities for strengthening coordination between the MHMS and other GOK departments and agencies, and with NGOs and community-based groups. This includes collaborating on health system issues, such as with the Public Service Office (PSO) on objectives relating to health workforce planning and development, the Ministry of Finance and Economic Development (MFED) on investigating alternative sources of health financing, and the National Statistics Office to build capacity in the collection and analysis of health information. It also includes working with others more directly to coordinate support on implementing specific programmes/interventions. This includes, for example:  Working directly with the Kiribati Police Service (KPS) and Ministry of Internal and Social Affairs (MISA) on initiatives targeting gender based violence.  Collaborating with the Ministry of Education on health promotion initiatives for young people; on the provision of facilities and spaces for physical activity (eg, sports fields/courts); and on trying to encourage young people to pursue careers in health.  Collaborating with MFED to promote higher taxes for tobacco and alcohol, and/or securing increased funding from such taxes to fund initiatives targeting NCD risk factors.  Working in partnership with the Ministry of Environment Land and Agriculture Development (MELAD) to implement initiatives targeting environmental health.  Working with maneaba to promote initiatives that target NCD risk factors, such as health eating initiatives, exercise classes, and alcohol and tobacco restrictions.  Working with maneaba and community support groups to strengthen health outreach initiatives designed to empower communities to care for people with needs in the home/community before referring to a clinic/hospital (eg, recognising early signs and symptoms of poor health in children and providing any pre-interventions to treat in the home, or caring for someone with a disability, or supporting a new mother and her baby). The Strategic Plan notes a number of existing mechanisms for coordinating planning and implementation of initiatives, such as the Water Sanitation Coordinating Committee. Where they are not formalised structures or systems for coordination on specific programmes or broader health system issues, the benefits of establishing such processes will be investigated as part of the implementation of this Strategic Plan.

58 Coordination with development partners The MHMS has built strong relationships with numerous bi-lateral and international development partners. These partners have provided technical assistance and funding for a number of programmes, health service infrastructure, and workforce development and training. Over recent years this has included (among others) support for TB control, combating HIV/AIDS, reproductive health, sanitation, nurse training, the EPI programme, and hospital and health clinic development. Strong coordination and prioritising among development partners and the MHMS is required in order to promote the effectiveness and efficiency of such support. The Ministry has, with its development partners, established a Health Sector Coordinating Committee (HSCC) in order to strengthen coordination of support for, and planning and delivery of, health services in Kiribati. The HSCC comprises the Senior Management Committee of the MHMS and representatives from AusAID, New Zealand Aid Programme, Taiwan International Cooperation and Development Fund (TaiwanICDF), Japan International Cooperation Agency (JICA), KFHA, UNICEF and the WHO. The strong commitment on the part of development partners, and of the Ministry in engaging with these partners, provides an opportunity to integrate this support in to the Kiribati Health Strategic Plan. To this end, the HSCC will support the implementation of this Strategic Plan through providing a mechanism to: Assist with identifying priority areas for funding and with the efficient mobilisation of resources, through working together to coordinate assistance, to give effect to the KHSP. Promote integrated, multi-sectoral and regional initiatives that are consistent with the KHSP. Identify initiatives to promote improvements in the efficiency, effectiveness and quality of health service delivery. Review progress of activities against the indicators and targets in the KHSP. Report to the Government of Kiribati and development partners on the implementation of the KHSP, including in such a way that rationalises reporting and other accountability processes to promote greater efficiency The HSCC will meet eight times per annum during the period of this Strategic Plan. One meeting per annum will focus on the review of progress against the Strategic Plan. At the following meeting, in each annual cycle, the MHMS will present an annual action plan for the next year for discussion and agreement. One or two members of the HSCC will have oversight of each strategic objective in the KHSP. These members are not responsible for implementation of the objective; they are responsible for overseeing the HSCC’s role in relation to the objective. The following table indicates oversight responsibilities. Strategic objective Oversight role 1. Increase access to and use of high quality, comprehensive family planning services, KFHA and RH particularly for vulnerable populations including women whose health and Coordinator wellbeing will be at risk if they become pregnant Improve maternal, newborn and child health Dir. Health Services Prevent the introduction and spread of communicable diseases, strengthen existing Manager TB Control control programmes and ensure Kiribati is prepared for any future outbreaks Programme Strengthen initiatives to reduce the prevalence of risk factors for NCDs, and to reduce Dir. Public Health morbidity, disability and mortality from NCDs Address gaps in health service delivery and strengthen the pillars of the health system Deputy Secretary and WHO 59 Strategic objective Oversight role Improve access to high quality and appropriate health care services for victims of UNICEF and AHD gender based violence, and services that specifically address the needs of youth Coordinator

MONITORING The MHMS’s Senior Management Committee is responsible for monitoring the implementation of this strategic plan. The HIU will coordinate the collection and analysis of information to report against the indicators and targets in the plan. Data for the majority of indicators in this strategic plan will be sourced from the Ministry’s health information systems and from heads of department/programmes, and will be collated on an annual basis. A small number of indicators rely on external data sources. This includes the Census, for which baseline data has been used from the 2010 Census and the only reporting will be based on the next Census in 2015, which coincides with the end point of this strategic plan. It also includes data collected from external surveys, notably the 2009 Kiribati Demographic and Health Survey and WHO STEPS surveys. The availability of data to monitor and report against these indicators will be regularly reviewed, as it is likely to be subject to these survey instruments being repeated. 60