National Health Strategic Plan 2022-2026

1.1 Background to the National Health Strategic Plan (NHSP) ................................................................. 1

1.2 Overview of the Existing Policy Foundations ...................................................................................... 2 1.3 Overview of Seychelles Efforts to Achieve the Sustainable Development Goals ............................... 2

1.4 Rationale for the NHSP 2022-2026 ..................................................................................................... 3

1.5 NHSP Development Process ............................................................................................................... 3 2 Review of implementation of NHSP 2016-2020 ........................................................................................ 6

2.1 Achievement of NHSP 2016-2020 Goals ............................................................................................. 6

2.2 Review of 2016-2020 Strategic Priorities............................................................................................ 6

2.3 Stakeholders’ perspectives ................................................................................................................. 8 3 Situation Analysis ..................................................................................................................................... 11

3.1 The Seychelles Context ..................................................................................................................... 11

3.2 Health Status ..................................................................................................................................... 16

3.3 State of Health System ...................................................................................................................... 29

3.4 Identified Priorities ........................................................................................................................... 33 4 Strategic Agenda for 2022-2026 .............................................................................................................. 36

4.1 Vision, Mission, Goals ....................................................................................................................... 36

4.2 The NHSP 2022-2026 Framework ..................................................................................................... 37 SD1: Strengthen Governance, Leadership and Administration .............................................................. 40 SD2 Protect and Improve UHC ................................................................................................................ 47 SD3: Address Health Security.................................................................................................................. 55 VII | P a g e SD4 Promote Healthy Populations.......................................................................................................... 60 SD5 Invest for Results ............................................................................................................................. 69 SD6 Improve Data for Impact ................................................................................................................. 85 5 Implementation Arrangements ............................................................................................................... 91

5.1 Roles and Responsibilities ................................................................................................................. 91

5.2 Implementation Risks and Assumptions ........................................................................................... 99 6 Monitoring and Evaluation .................................................................................................................... 105

6.1 Monitoring Achievement of Goals and Targets .............................................................................. 105

6.2 Data Needs ...................................................................................................................................... 106

6.3 Data Sources ................................................................................................................................... 107

6.4 Data Architecture ............................................................................................................................ 108

6.5 Indicators ........................................................................................................................................ 109 List of Annexes .......................................................................................................................................... 119 VIII | P a g e Tables and Figures Figures Figure 1 Review of Health System Issues - Fishbone diagram (TWG 1)........................................................ 7 Figure 2 Population Trends 2016-2020, Seychelles .................................................................................... 11 Figure 3 Seychelles' Socioeconomic Environment ...................................................................................... 13 Figure 4 Contribution of each MPI indicator to National MPI, Q3 2019. ................................................... 14 Figure 5 Comparison of top 10 causes of death in 2009 and 2019, all ages combined. ............................ 16 Figure 6 Estimated prevalence of Hypertension, Diabetes, and Obesity, with projections to 2030 .......... 17 Figure 7 Cancer incidence and cancer-related deaths, 2013-19, with extrapolations to 2030 .................. 17 Figure 8 Life Expectancy at Birth, by gender, 1980-2020. .......................................................................... 19 Figure 9 Leading causes of Death in Seychelles, 2016-2020....................................................................... 20 Figure 10 Registered deaths by month, Jan-Sep 2020 and 2021, compared to 5y Average (2015-19) ..... 22 Figure 11 Suspected Dengue cases, by week; from week 52 of 2015 to week 16 of 2020. ....................... 23 Figure 12 Newly detected cases of HIV infection by year, 2014-2020. ...................................................... 24 Figure 13 AIDS-related Mortality, 2014-2020. ............................................................................................ 24 Figure 14 Prevalence of Obesity and Overweight in Girls, 1998-2019. ...................................................... 26 Figure 15 Prevalence of Overweight and Obesity in Boys, 1998 to 2019. .................................................. 27 Figure 16 Share of Current Health Expenditure (CHE) spent on Preventive Care, 2014-2018. .................. 30 Figure 17 NHSP 2022-2026 Framework ...................................................................................................... 38 Figure 18 Social (Environmental and Economic) Determinants of Health (SDH). ...................................... 60 Figure 19 Causal pathways linking poor SDHs with risk factors and later disease. .................................... 61 Figure 20 Framework describing how change impacts global public health. ............................................. 63 Figure 21 Health Finance inputs and pathways to production of Health interventions ............................ 69 Figure 22 Monitoring and Evaluation Conceptual Framework ................................................................. 106 Figure 23 Data Architecture ...................................................................................................................... 108 Tables Table 1 External Stakeholders engaged in NHSP 2022-2026 Development process .................................... 4 Table 2 Progress towards Main Goals of NHSP 2016-2020 .......................................................................... 6 IX | P a g e Table 3 Projected Population of Seychelles, 2021 to 2050......................................................................... 12 Table 4 Maternal and Infant Deaths, 2019-2020. ....................................................................................... 18 Table 5 Life Expectancy at Birth (Years), 2016-2020. ................................................................................. 19 Table 6 Top five causes of Death, Seychelles, Q1-3, 2019-2021. ............................................................... 21 Table 7 Registered Live births to Teenage girls, 2015-2020. ...................................................................... 25 Table 8 Spending on Health, 2014-2020. .................................................................................................... 29 Table 9 Identified priorities to improve Health System and Health Status, by building blocks. ................ 33 Table 10 NHSP Framework: Strategic Directives with Key Objectives........................................................ 39 Table 11 SD1 Strengthen Leadership, Governance and Administration: Specific Objectives .................... 43 Table 12 SD2 Protect and Improve UHC: Specific Objectives ..................................................................... 50 Table 13 SD3 Address Health Security: Specific Objectives ........................................................................ 58 Table 14 SD4 Promote Healthy Populations: Specific Objectives ............................................................... 66 Table 15 SD5 Invest for Results: Specific Objectives................................................................................... 78 Table 16 SD6 Improve Data for Impact: Specific Objectives....................................................................... 87 Table 17 NHSP Roles and Responsibilities at senior levels of Government. .............................................. 92 Table 18 Roles and Responsibilities of Non-Health Stakeholders. ............................................................. 93 Table 19 MoH and Entities' Roles and Responsibilities in implementation of NHSP 2022-2026. .............. 94 Table 20 Lead Responsibility for Implementation of Strategic Directions of NHSP 2022-2026. ................ 98 Table 21 Anticipated Risks and proposed Mitigation Strategies .............................................................. 102 Table 22 Data Sources............................................................................................................................... 107 Table 23 Indicator Matrix: Inputs ............................................................................................................. 110 Table 24 Indicator Matrix: Outputs........................................................................................................... 111 Table 25 Indicator Matrix: Service Coverage ............................................................................................ 112 Table 26 Indicator Matrix: Health Risk Factors ......................................................................................... 114 Table 27 Indicator Matrix: Health Status .................................................................................................. 115 Table 28 Indicator Matrix: Health Security ............................................................................................... 117 Boxes Box 1 Definition of Universal Health Coverage (UHC) ................................................................................ 47 X|Page List of Acronyms Acronym Full form Acronym Full form A&E Accident & Emergency IHME Institute for Health Metrics and AIDS Acquired Immunodeficiency Evaluation Syndrome IHR International Health Regulations ANC Antenatal Care IMR Infant Mortality Rate APR Annual Health Sector Performance IPC Infection Prevention and Control Report IT Information Technology ART Antiretroviral Therapy KPIs Key Performance Indicators ASFF Alliance of Solidarity for the Family LE Life Expectancy AU African Union LoTC Long Term Care CDCU Communicable Diseases Control M&E Monitoring and Evaluation Unit MDAs Ministries, Departments and CEHS Centre for Environmental Health Agencies Services mHealth Mobile Health CIC Consultant in Charge MoEdu Ministry of Education CPD Continuous Professional MFTIEP Ministry of Finance, Trade, Development Investment and Economic Planning CRD Chronic Respiratory Diseases MoH Ministry of Health CVD Cardiovascular Diseases MPI Multidimensional Poverty Index DALY Disability Adjusted Life-Years NBS National Bureau Statistics DSRU Disease Surveillance and Response NCDs Non-Communicable Diseases Unit NDS National Development Strategy eHealth Electronic Health NEET Not in Employment, Education or eHIS Electronic Health Information Training System NGO Non-Governmental Organisation EPI Expanded Programme on NHA National Health Accounts Immunization NHSP National Health Strategic Plan GBV Gender-Based Violence NHWA National Health Workforce GDP Gross Domestic Product Accounts GLASS Global Antimicrobial Resistance NIC Nurse in Charge Surveillance System NIHSS National Institute of Health and HALE Health-Adjusted Life Expectancy Social Studies HASO HIV/AIDS Support Organization NM Nurse Manager HBV Hepatitis B Virus NSP National Strategic Planning HCA Health Care Agency OECD Organisation for Economic HCV Hepatitis C Virus Cooperation and Development HCW Heath Care Workers PBM Performance-Based Management HDI Human Development Index PDA Personal Digital Assistants HIA Health Impact Assessment PHA Public Health Authority HiAP Health in All Policies PHC Primary Health Care HIV Human Immunodeficiency Virus PHEOC Public Health Emergency HRH Human Resources for Health Operations Centre XI | P a g e Acronym Full form Acronym Full Form PLHIV People Living with HIV SD Strategic Direction PM&E Performance Monitoring and SDG Sustainable Development Goals Evaluation SOP Standard Operating Procedure PMO Principal Medical Officer SOW Statement of Work PMS Performance Management System STI Sexually Transmitted Diseases PNO Principal Nursing Officer TA Technical Assistance PPBB Programme Performance Based TFR Total Fertility Rate Budgeting TGHE Total Government Health PWID People Who Inject Drugs Expenditure PWUD People Who Use Drugs THE Total Health Expenditure QI Quality Improvement TOP Termination of Pregnancy QoC Quality of Care ToR Terms of Reference RBM Results Based Management TWG Technical Working Group RMNCAH Reproductive, Maternal, New-born, UHC Universal Health Coverage Child and Adolescent Health UN United Nations RTA Road Traffic Accidents UNAIDS Joint United Nations Program on SIDS Small Islands Developing States HIV/AIDS SAMOA SIDS Accelerated Modalities of VNR Voluntary National Review Action WASH Water Sanitation and Hygiene SARA Service Availability and Readiness WHA World Health Assembly Assessment WHO World Health Organisation YLL Years of Life Lived XII | P a g e Chapter 1 Introduction 0|Page 1 Introduction

1.1 Background to the National Health Strategic Plan The origins of the current Seychelles Public Health System date back to the late seventies, to the years immediately following the 1976 independence. The country had inherited a rudimentary health system and it was imperative to develop one that would respond to the needs and aspirations of the young Seychellois nation. Inspired by the global Health for All movement1, Seychelles embraced the primary health care approach promoted by WHO as of 1978. In the early years, the focus was on improving geographic and financial access to care, by developing a network of primary healthcare centres, free at point-of-use. At the same time, secondary care, based primarily at and around the Seychelles Hospital (then Victoria Hospital) expanded at a steady pace. Through sustained political commitment and investment in the health sector, the government managed over the years to improve health outcomes - infant mortality rates dropped from 43.2 in 19772 to 11.6 in 20203, life expectancy at birth increased from 69.5 years in 19804 to 77.3 years in 2020. The right of the citizens to health care, the state's obligation to make health care available to all its citizens and the emphasis on individual responsibility for one’s health are anchored in Article 29 of the 1993 Constitution of the Third Republic. The period 1993 to date has seen drastic changes in the socio-political and health landscape. An increasingly more educated and health literate population, a widely travelled population, freedom of expression, access to health information via widely available internet and social media, the rapid expansion of the private health sector and the introduction of new health technologies have resulted in a vocal population with very high expectations on the quality of health care services. The health system has not always been able to meet or manage these expectations. The mismatch between expectation and level of satisfaction of the population with the health care services they received prompted the government to set up a Health Task Force in 2013 to cast a critical look at the health sector and propose a way forward to improve health service delivery and health outcomes. The Health Task Force presented its findings and recommendations in the Health Task Force Report 2013, which laid the foundations for the “modernisation” of the health sector and led to the development of the Seychelles National Health Policy 2015. The “modernisation process” bestowed leadership and oversight role to the Ministry of Health, delegating health service delivery and regulatory functions to statutory entities under its portfolio. The first National Health Strategic Plan (NHSP) of the “modernisation era” took effect in 2016, for the five years to 2020. 1 Mahler, Halfdan "The meaning of health for all by the year 2000"." World Health Forum. Vol. 2. 1981. 2 Population and Vital statistics mid-year estimates 2015, NBS, Seychelles 3 Annual Performance Review 2020, MoH 4 Population and Vital Statistics December 2016, NBS, Seychelles 1|Page

1.2 Overview of the Existing Policy Foundations Human health and sustainable development are inextricably linked. Health strategies therefore must be consistent with national and global agendas for sustainable development. Seychelles’ long-term vision for sustainable and equitable development, ‘Vision 2033’, is based on six key pillars: Good Governance; People at the Centre of Development; Social Cohesion; Innovative Economy; Economic Transformation and Environmental Sustainability; and Resilience. The National Development Strategy (NDS) 2019-2023 is the first of three strategic plans to achieve Vision 2033. The NDS goal for health, anchored in Pillar 2, is ‘the attainment of the highest level of health and well-being’. This goal is well-aligned with Goal 3 of the Sustainable Development Framework5 and Goal 3 of the African Union (AU)’s ‘Agenda 2063: The Africa We Want’6. Two broad strategic priorities for the health goal are firstly, to pursue effective health protection, promote empowerment and personal and societal responsibility for holistic health, and secondly, to build a high-quality integrated healthcare system with a focus on people-centred care. This NHSP is also aligned to the National Health Policy formulated in 20157, which places health and well-being at the centre of national development, both as a beneficiary of and contributor to socioeconomic development. It reaffirms the right to health enshrined in the Constitution and emphasises individual responsibility in health matters. Together with other Small Island Developing States (SIDS), Seychelles, in 2014, was a signatory to the SAMOA (SIDS Accelerated Modalities of Action) Pathway8 for sustainable development, which articulates the sustainable development pathways and aspirations for SIDS for the next ten years. Seychelles has endorsed various other commitments, including World Health Assembly resolutions, the UN General Assembly Political Declaration on Non-Communicable Diseases9, and the UNAIDS Getting to Zero declaration10. This NHSP will take into account these commitments as well as targets set out in various national policies and strategic plans (Annex 1: List of National Health Commitments).

1.3 Overview of Seychelles Efforts to Achieve the Sustainable Development Goals In 2017, Seychelles had an SDG index11 of 67 compared to 85 for Singapore and 71 for Mauritius. The country developed a baseline SDG report in 2019 based on local specificity and available data and submitted a Voluntary National Review (VNR) in 2020. Although Seychelles has achieved most of targets for four SDGs, namely SDG 4 Quality Education; SDG 10 Reduced Inequalities; SDG 11 5 https://www.un.org/sustainabledevelopment/development-agenda/ 6 https://au.int/en/agenda2063/overview 7 Seychelles National Health Policy, MoH 2015 8 https://sustainabledevelopment.un.org/samoapathway.html 9 https://digitallibrary.un.org/record/710899/?ln=en 10 https://www.unaids.org/sites/default/files/sub_landing/files/JC2034_UNAIDS_Strategy_en.pdf 11 https://vizhub.healthdata.org/sdg/ 2|Page Sustainable Cities and Communities, and SDG 12 Responsible Consumption and Production, there is still room for improvement. The country is well on track to meet the other SDGs. Seychelles progress on the SDGs is summarised in Annex 2: Seychelles Progress on SDGs. While displaying areas of progress towards achieving the SDGs, the Voluntary National Review has also highlighted gaps and weaknesses that may impede further progress on the goals12. It is, therefore, necessary to identify alternative and innovative financing mechanisms to implement and monitor development projects. Weak intergovernmental and stakeholder coordination results in lack of synergy and coherence in policy planning. Improved coordination will not only contribute towards better harmonisation of policies but also identify areas of duplication. Reporting on the SDGs has identified data collection, utilisation, and dissemination gaps – required data are often unavailable, while available data often lack disaggregation and granularity.

1.4 Rationale for the NHSP 2022-2026 In 2020 with all attention being on the response to the COVID-19 pandemic, the Ministry of Health (MoH) extended the lifespan of the NHSP 2016-2020 to 2021. The COVID-19 crisis has negatively affected all the building blocks of the health system, as well as jobs, livelihood, and the economy as a whole. This NHSP process has reviewed the strategic priorities in the context of the current health landscape and socioeconomic situation. A thorough analysis of the implementation of the current NHSP provided insight into achieved targets, remaining gaps and challenges as well as some of the root causes for persistent failures. The NHSP 2022-2026 gives direction, sets milestones, and proposes goals to guide the nation and the health sector during the next five years.

1.5 NHSP Development Process Strategic planning is a core component of the Results-Based Management (RBM) Framework advocated by the successive Governments of Seychelles. The development process for this NHSP, therefore, is closely aligned to national guidelines. The development of the NHSP under the leadership of the MoH Secretariat, started with wide consultations within the MoH and its statutory entities, the private health sector, health-related civil society organisations (CSOs), and partner Ministries, Departments and Agencies (MDAs) – see Annex 3: List of in-person Consultations. The NHSP Steering Committee constituted different technical working groups to review the implementation of the NHSP 2016–2020, conduct a situation analysis and identify priorities for the next five years, assess perspectives of leadership, service providers and beneficiaries on health and 12 VNR 2020, Republic of Seychelles, Economic Planning Department, Ministry of Finance, Trade, Investment and Economic Planning 3|Page draft and validate the strategic plan. The tasks and objectives of each technical working group are outlined in Annex 4: Tasks and Objectives of the TWGs. The Technical Working Groups (TWGs) worked in parallel to provide a comprehensive overview of the state of the sector and identify emerging priorities. The Steering Committee presented the work of the TWGs to leadership and senior management for discussion through a series of workshops. The aim of the workshops was to build consensus on strategic priorities for the next five years. From the outcomes of the workshops, the Steering Committee formulated the broad strategic directives with key interventions and milestones. Further consultations and workshops followed with different target groups (from primary care, secondary and specialised care, programmes, support services and the inner islands) leading to a zero draft. The draft was shared with reviewers including the Department of Economic Planning and the World Health Organization country and regional offices for their inputs. The Steering Committee engaged non-MoH and non-health stakeholders in the NHSP development process (Table 1). Table 1 External Stakeholders engaged in NHSP 2022-2026 Development process Lead Process Stage Non-MoH/Non-Health Stakeholders TWG 2 Situation Analysis (Health Private health sector, including Seychelles Private System) Clinics Association TWG 3 Perspectives of service  Seychelles Medical Services providers (Non MOH  Seychelles Prison Services facilities) and beneficiaries  SDF Medical Centre  Private Physiotherapists  STC Clinic TWG 4 Drafting the NHSP  Department of Economic Planning  External Reviewers 4|Page Chapter 2 Review of implementation of NHSP 2016-2020 5|Page 2 Review of implementation of NHSP 2016-2020

2.1 Achievement of NHSP 2016-2020 Goals The TWG1 reviewed the implementation of NHSP 2016-2020 strategic investment priorities, achievement of set targets and identified unfinished agendas. Progress has been uneven, with certain goals achieved fully, others partially, and still others with little-to-no progress. Table 2 outlines progress across the main goals of the NHSP 2016-2020. Table 2 Progress towards Main Goals of NHSP 2016-2020 Goals Indicator Baseline 2020 Results End-term (2015) Target Increased expectation of LE/Years M: 72 M: 72.7 M: 74 life at birth F: 78 F: 82 F: 80 Both: 77.3 Reduced incidence, Mortality (30-70 60.32% 59% <40% prevalence and mortality years) from NCDs (as associated with priority % of all deaths) non-communicable and AIDS -related deaths 15 10 <0.2513 communicable diseases (per 100,000 pop.) Deaths from RTAs (% 1.8% 1.6% <1% of all deaths) Increased level of Surveys Patient SARA 2017 No Target satisfaction of people and Satisfaction (Increased health professionals with Survey 2013 satisfaction for existing health services (16 areas 11 of 16 areas) assessed) Improved overall Surveys No Baseline Not Measured No Target wellbeing of all people in Seychelles

2.2 Review of 2016-2020 Strategic Priorities The NHSP 2016-2020 set the following strategic investment priorities: 1. Strengthening integrated health care 13 Target not clearly defined in NHSP 2016-2020. 6|Page 2. Promoting and protecting health 3. Human resources for health 4. Sustainable financing for health 5. Research and innovation 6. Partnership and cooperation 7. Governance and leadership A review of the strategic priorities showed mixed results. While some specific objectives have been achieved, important gaps remain (see Annex 5: Strategic Investment Priorities). Root cause analysis to evaluate the pillars of the health system (Figure 1) revealed the following Figure 1 Review of Health System Issues - Fishbone diagram (TWG 1) 7|Page The TWG identified the following as lessons learnt:  The NHSP 2016-2020 was not widely disseminated and communicated to stakeholders within and beyond MoH – the majority of health workers did not understand /know that their routine work should be contributing to the achievement of sector goals and targets.  A lack of ownership of specific targets and objectives – good and poor results were not owned by one particular entity/unit/person.  A disconnect between the NHSP set targets/objectives and what was done in practice (the NHSP did not guide the development of budgets, work plans, disease-specific strategic plans etc.).  Absence of a formal monitoring and evaluation framework prevented  There was no accountability framework across all levels of the health system.  The work of PHA, in particular, on emergency preparedness and response was not well included in the NHSP plans and targets  A mid-term review was not conducted to assess progress made  The ‘quality of care’ indicators were not monitored.  The annual performance reports (APR), which report on sector core indicators and targets, were not disseminated, discussed and used to guide implementation of remedial actions.

2.3 Stakeholders’ perspectives The task of TWG3 was to capture the perspectives of various stakeholders on health-related matters. The group consulted with MoH leadership, which included chairpersons of entity boards and chief executives and also with clinical and non-clinical staff, professional councils, allied health professionals, the private health sector and beneficiaries. Knowledge of NHSP 2016-2020 Knowledge of the NHSP 2016-2020 was evident among leaders, some of whom participated in that strategic plan’s development process. Among clinical staff, many had limited knowledge of the NHSP. For others with more understanding of the NHSP, alignment of NHSP to operational plans was limited. NIHSS and NAC are guided by their specific strategic plans with some coherence with the NHSP. Although there is a good working relationship between the MoH and the private health facilities, many private health providers had insufficient knowledge of the NHSP. The same applies for beneficiaries, however, some health-related associations have a good understanding of the NHSP, which guides their area of work. Achievement of NHSP 2016-2020 Goals and Objectives Health leaders acknowledged some progress in the last five years; however, some felt they could have achieved more with more resources and effective coordination among entities. Some health care workers felt that lack of proper communication, accountability and commitment have led to 8|Page inconsistent quality of care and hindered the achievement of set targets. Some nurse managers did not see the value of PPBB and felt that it did not help achieve sector goals. Key considerations for New NHSP (2022-2026)  New NHSP must be disseminated widely for buy-in.  Human resource units needed to be more proactive than just transactional. Additionally, more should be done during the next five years to improve staff welfare and remuneration.  More targeted capacity building is needed to strengthen the skills of all health workers.  Establish formal M&E in the health sector (public and private).  Fully implement eHIS.  There is a need to strengthen the referral system between different levels of health facilities, including private ones.  Remove communication barriers (doctors who do not speak local languages).  Improve health infrastructure. 9|Page Chapter 3 Situation Analysis 10 | P a g e 3 Situation Analysis

3.1 The Seychelles Context The estimated mid-year population of Seychelles was 99,202 in 2021, representing an annual growth rate of 0.7% over the 2020 estimates. The annual number of registered live births in Seychelles has remained between 1600 and 1700 in the last five years (Figure 2). The crude birth rate continued to decrease from 17.4 per thousand population in 2016 to 15.8 in 2020, while the crude death rate was seven per thousand population in 202014. The population is projected to reach 108,000 in 2045 after which it is forecast to decrease (Table 3)15. Figure 2 Population Trends 2016-2020, Seychelles 3000 98462 100000 97625 96762 98000 2500 95843 94677 96000 94000 No of Births/Deaths 2000 Populations 1645 1651 1650 1605 92000 1554 1500 90000 88000 1000 818 795 747 748 668 86000 84000 500 82000 0 80000 2016 2017 2018 2019 2020 Number of registered live births Number of registered deaths Mid-Year population estimates Source: National Bureau of Statistics (NBS), Seychelles 14 Mid-Year Population Estimates 2021, National Bureau of Statistics Seychelles 15 Seychelles in Figures, 2020 Edition, National Bureau of Statistics, Seychelles 11 | P a g e Table 3 Projected Population of Seychelles, 2021 to 2050 Projected pop. (in 1000s) 2021 2030 2035 2040 2045 2050 Male 50.4 52.9 53.3 53.4 53.3 52.9 Female 48.8 51.9 53.0 54.1 54.7 54.8 Total 99.2 104.8 106.3 107.5 108.0 107.7 Source: National Bureau of Statistics (NBS), Seychelles The percentage of the population, aged 65 years and above, increased from 9.6% in 2017 to 12.0% in 2021. This percentage is expected to reach 13.1% in 2030 and 21.3 % in 2050. This gradual shift towards an ageing population will increase the demand for health and social care. Like all other SIDS, Seychelles faces numerous challenges due to its small population size, small landmass and remote geographical location. Most of what is consumed come from external markets, due to Seychelles’ narrow resource base and local manufacturing capacity. The country relies on a service-based economy, namely tourism and, in recent years, financial services. There is limited scope for diversification of the economy, and the country remains vulnerable to global economic shocks. Seychelles’ vulnerability was laid bare by the COVID- 19 pandemic with worldwide travel restrictions severely affecting the local tourism industry and causing massive depreciation of the Seychelles rupee against all international currencies, a resultant increase in the cost of living and an increase of the national debt burden. As a small island state, Seychelles is also vulnerable to climatic phenomena, especially those associated with rising global temperatures, extreme weather events and rising sea levels. Over eighty per cent of economically productive activity are in low-lying coastal areas, with increased vulnerability to coastal erosion and flooding. The socioeconomic environment in which the MoH is developing a new national health strategic plan is outlined in Figure 3. 12 | P a g e Figure 3 Seychelles' Socioeconomic Environment The country enjoys political stability. Multi-party democracy was re-introduced in 1993. The general elections held in 2020 ushered in a new administration in a peaceful transition of power. Seychelles is ranked 67th out of 189 countries in the 2020 Human Development Index, scoring 0.796, one place behind Mauritius16. The country attained high-income status in 2015. However, there is significant inequality in the distribution of wealth, as evidenced by 2013 report of the NBS17, which estimated the Gini index, at 45.9%. The report further revealed a poverty rate of 39.3% based on the national poverty line of USD 15.22 (in 2013 Purchasing Power Parity USD) per person per day. However, the VNR of 2020 shows there is progress towards improving inequalities. A World Bank and National Bureau of Statistics study reported by the National Bureau of Statistics in February 2021 found that about 25 percent of Seychelles' population is living below the poverty line, which is SCR 4,376 ($206) per month per adult. The Multidimensional Poverty Index (MPI) adopts a broader approach to poverty measurement, looking beyond traditional monetary measures. "In the third quarter of 2019, the poverty incidence (H) was 11.88%, and the average intensity (A) was 33.26%. The Multidimensional Poverty Index (MPI), which is the product of H and A (H*A) was 0.040"18. The study looked at four dimensions of poverty, namely Living standards, Health, Education and Employment. The largest contributor to poverty was deprivation in the highest level of education attained, i.e., at least one member of the household did not complete secondary education. Other 16 Human Development Report 2020,The Next Frontier: Human Development and the Anthropocene, 2020 - UNDP 17 Poverty and Inequality Estimates – 2013, NBS 18 Multidimensional Poverty Index Report 2019, NBS 13 | P a g e major contributors were Youth Not in Employment, Education or Training (NEET) and informal employment. Figure 4 shows the contributions of each indicator towards multidimensional poverty in Seychelles. The MPI measures reflect the poor state of some of the social determinants of health, which are the root causes of ill health, influencing risk factors, health-seeking behaviours and health outcomes. Figure 4 Contribution of each MPI indicator to National MPI, Q3 2019. Source: Data sourced from Multidimensional Poverty Index, 2019. NBS, May 2020. Since 2006, the country has been experiencing an increase in the use of illicit drugs, including heroin. It is estimated that people who use heroin represented 4.6% the total population of Seychelles in 2016. The estimated number of people who inject drugs increased by 28.3% from 2011 to 2016, from 1,671 to 2,144 (representing 2.3% of the total population in 2016)19. 19 Benjamin Vel. Seychelles Biological and Behavioural Surveillance Of Heroin Users 2017: Round One Final Report APDAR. February 2018. http://www.apdar.com/wp-content/uploads/2018/05/IBBS-HU-FINAL- REPORT-2017-Version-8-21-03-2018-1.pdf 14 | P a g e The combination of widespread substance abuse, harmful use of alcohol and poverty is fertile ground for all forms of social ills, including gender-based violence (GBV) and child abuse - 57% of women report having experienced GBV at least once in their lifetime20. Most incidents of GBV, including intimate partner rape, occur in the home. There was significant association between alcohol consumption and intimate partner violence. There was a decrease in most categories of crimes reported to the police between 2019 and 202021. As at 31st March 2021, the total prison population was 292 (295 per 100 000 pop.), of which 7% were female, and 16% pre-trial detainees22. This is a significant decrease in the rate from 837 per 100 000 population in 2016, just before the enactment of the Misuse of Drugs Act 2016, which promotes treatment and rehabilitation for people dependent on drugs. Despite the high HDI score, challenges remain in addressing some social determinants of health. These social ills may erode health gains and compromise the achievement of the objectives of this strategic plan. 20 Peace begins @ home Gender Based Violence (GBV) National Baseline Study in Seychelles - Preliminary findings 21 Crime Justice and Security Statistics, Q2-2021, National bureau of Statistics 22 https://www.prisonstudies.org/country/seychelles 15 | P a g e

3.2 Health Status

3.2.1 Mortality Seychelles started to undergo the epidemiologic transition to chronic diseases more than three decades ago23. Until the end of 2019, non-communicable diseases (NCDs) were the most significant health burden (Figure 5). Figure 5 Comparison of top 10 causes of death in 2009 and 2019, all ages combined. Source: Institute for Health Metrics and Evaluation (IHME) Seychelles profile. Despite the transition to chronic diseases, communicable diseases like HIV/AIDS, dengue and leptospirosis remain public health concerns and since 2020, COVID-19 is contributing significantly to morbidity and mortality. After detecting the first case of COVID-19 in March 2020, the country experienced community transmission by the end of December 2020, and by September 2021, 21,470 cases had been reported24. Projected burden of disease from key NCDs From available routine data and survey estimates, the key NCDs of hypertension, diabetes and cancer, and the associated major risk factor for all three (poor nutrition, sedentary lifestyle and substance abuse), all show a steady and increasing trend. Extrapolating these trends can provide rough estimates of the projected disease burden in the coming years. 23 Pascal Bovet for the Investigators of the Seychelles Heart Study. The epidemiologic transition to chronic diseases in developing countries: Cardiovascular mortality, morbidity, and risk factors in Seychelles (Indian Ocean). Soz Präventivmed 40, 35–43 (1995). https://doi.org/10.1007/BF01615660 24 Annual Health Sector Performance Reports 2020. 16 | P a g e Figure 6 Estimated prevalence of Hypertension, Diabetes, and Obesity, with projections to 2030 Estimated prevalence of Hypertension (HTN), Diabetes (DM), and Obesity in population aged 25-64, with extrapolations to year 2030. 30000 25735 25000 25169 20000 19170 16743 15000 8266 10000 5000 5544 0 1989 1994 1999 2004 2009 2014 2019 2024 2029 HTN HTN_Projection DM DM_Projection Obesity Obesity_Projection Source: Seychelles Heart Study series (I-IV), UPCCD. Figure 7 Cancer incidence and cancer-related deaths, 2013-19, with extrapolations to 2030 500 459 450 396 400 350 298 300 250 202 174 184 200 150 100 151 119 50 0 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Incidence Forecasted_Incidence Deaths Forecasted_Deaths Source: Seychelles Cancer Registry, 2020 The incidence of cancer is expected to almost double within the next decade, with over 450 cases and 200 deaths per year by 2030 (see Figure 7). In comparison, the prevalence of hypertension, diabetes and obesity is estimated to increase by 34%, 49% and 52%, respectively, by 2030, over 2013 estimates (see Figure 6). This prediction has serious implications for life expectancy, population health and wellbeing, impacts on economy and society, provision of health services, and health sector planning. Noting that these conditions have downstream costly complications – namely heart disease and kidney disease – there is a domino effect on their true burden on the health system. 17 | P a g e The potential benefits of strong investment in preventive and promotive health services, creating an environment and society that readily supports healthy living, and revisiting treatment guidelines and protocols to include newer therapeutics will be significant. However, it is evident that there will be increased spending on healthcare in the medium term. Maternal and Child Mortality The annual number of maternal deaths in Seychelles has varied from zero to three since 1978. The country did not achieve the NHSP 2016-2020 infant mortality target of <10/1000 live births but has reached the SDG target. In 2020, the rates for stillbirth, neonatal and perinatal mortality were lower than the five-year average (see Table 4). Table 4 Maternal and Infant Deaths, 2019-2020. SDG Indicator 2019 2020 2016- NHSP 2016- 2020 2020 Targets Average

3.1.1 Maternal Mortality Ratio/100,000 live 62.3 64.4 61.7 0 births 3.2.2 Neonatal mortality rate/1000 live births 8.7 9.0 10.2 <5 Infant mortality rate/1000 live births 16.8 11.6 14.3 <10

3.2.1 Under-five mortality rate/1000 live 17.4 14.2 16.0 < 12 births Perinatal mortality rate/1000 total births 8.1 8.3 13.2 No target Still birth rate/1000 total births 5.0 5.1 8.0 No target

3.2.2 Neonatal mortality rate/1000 live births 8.7 9.0 10.2 <5 Life Expectancy (LE) There was an increase in life expectancy (LE) at birth for both sexes in 2020 to 77.3 years (Table 5); this was partially due to decreased deaths due to external causes, following restrictions of movement due to COVID-19 public health measures. It is likely that this gain has been reversed in 2021. 18 | P a g e Table 5 Life Expectancy at Birth (Years), 2016-2020. 2016-2020 NHSP 2016- LE by Sex/y 2016 2017 2018 2019 2020 Average 2020 Target Male 69.5 70.3 68.5 69.7 72.7 70.1 74 Female 80.8 78.5 77.3 78.4 82.0 79.4 80 Both 74.8 74.3 72.6 73.9 77.3 74.6 No target In 2020, the LE at birth for women was above the NHSP end-term target of 80 years, while the target of 74 years for men was not reached25. Despite the increase in LE in 2020, the average LE for the last five years for both sexes is below the NHSP end-term targets. The average annual death rate for 2016-2020 was less than 10/1,000 population26, and data show that men disproportionately die young. There remains a wide gap in LE between men and women. Figure 8 Life Expectancy at Birth, by gender, 1980-2020. 82 80 78 76 Male 74 Female 72 Both 70 5 per. Mov. Avg. (Male) 68 5 per. Mov. Avg. (Female) 66 5 per. Mov. Avg. (Both) 64 62 1980 1985 1990 1995 2000 2005 2010 2015 2020 Figure 8 shows the trend in LE for the past 40 years; women live on average live ten years longer than men do. There is a difference of approximately 10 years between LE and health-adjusted life expectancy (HALE)27. LE and HALE are key health indicators, which are highly influenced by the socioeconomic determinants of health. The gap between LE and HALE has implications for health services and social care. 25 Ministry of Health, Seychelles: National Health Strategic Plan 2016-2020. 26 Annual Health Sector Performance Report, 2020. 27 Annual Health Sector Performance Report, 2020. 19 | P a g e Main Causes of Mortality The leading causes of mortality in Seychelles have remained the same in the last decade (Figure 9), with the majority of deaths caused by NCDs. Pneumonia in particular, contributes a large proportion of deaths. Mortality from external causes (injuries, accidents, poisoning, assaults, etc.) accounts for approximately 6-10% of deaths – 80% of those deaths occur in young men. Figure 9 Leading causes of Death in Seychelles, 2016-2020. 100% 90% 18% 20% 16% 20% 22% 80% 5% 6% 6% 4% 7% 7% 5% 7% 6% 70% 8% Others 13% 18% 15% 60% 17% Infectious/Parasitic 12% 50% External Causes 17% 19% 18% 20% Respiratory 40% 19% Neoplasms 30% Circulatory 20% 39% 37% 33% 32% 34% 10% 0% 2016 2017 2018 2019 2020 20 | P a g e

3.2.2 Impact of COVID-19 on Life Expectancy In 2021, Seychelles experienced a surge in COVID-19 cases from January to July. Registered COVID- 19 related deaths were highest in persons aged 65+ years and those with co-morbidities. COVID-19 related deaths were the second leading cause of death in Q1-Q3 of 2021 (Table 6). Table 6 Top five causes of Death, Seychelles, Q1-3, 2019-2021. ICD-10 Mortality Jan-Sep Jan-Sep Jan-Sep Leading Causes of death (Condensed codes) 2019 2020 2021 Total Deaths 587 495 718 Diseases of the Circulatory 1064-1071 186 191 209 system U07.1* COVID-19 related deaths28 - - 180 1026-1047 Neoplasms 111 86 96 Diseases of the Respiratory 1072-1077 98 81 69 system 1095-1103 External causes of mortality 36 26 22 Infectious and parasitic 1001-1025 35 20 17 diseases Other causes of death 121 91 125 COVID-19 related deaths reported by the Statistics Unit are from registered causes of death by the Civil Status Office, However, the Public Health Emergency Operations Committee (PHEOC) reported only 116 deaths during the same period, ‘directly’ caused by COVID-19 through their assessment. The country also experienced excess deaths, defined as the difference between the observed numbers of deaths from all causes during a crisis and expected numbers of deaths in the same period under “normal” circumstances. Figure 10 compares the monthly number of deaths (all-cause mortality) for January to September 2020 and 2021 with the five-year average, clearly demonstrating an excess of deaths in 2021. 28 COVID-19 related deaths reported are from registered causes of death by the Civil Status Office, However, PHEOC reported only 116 deaths during the same period, assessed to be ‘directly’ due to COVID-19. 21 | P a g e Figure 10 Registered deaths by month, Jan-Sep 2020 and 2021, compared to 5y Average (2015-19) 100 80 60 2020 2021 40 2015-19 Avg. 20 0 Jan Feb Mar Apr (- May Jun Jul Aug Sep (+11%) (+32%) (+16%) 5%) (+44%) (+67%) (+53%) (+10%) (+20%) Note: Registered deaths by month, absolute numbers, January to September, for 2015-19 averages, 2020 and 2021. Excess deaths in 2021 expressed in brackets under each month, as % change from 2015-19 average. Source: Statistics Unit, MoH

3.2.3 Mortality due to NCDs NCDs include cardiovascular diseases (CVD), neoplasms, diabetes and chronic respiratory diseases (CRD). The total number of deaths due to NCDs in 2020 was 400 (231 Males, 169 Females), representing 60% of total deaths. Of these deaths, 245 (61%) were from diseases of the circulatory system, 128 (32%) from neoplasms, 14 (4%) from diabetes and 13 (3%) from CRD. There is underreporting of diabetes as an underlying cause of death. The end-term NHSP 2016-2020 target for premature deaths from NCDs was ‘less than 40% of total deaths in the age group 30-70 years’, while the target in the Seychelles Strategy for the Prevention and Control of NCDs is ‘a 25% relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes and CRD by 2025’. The probability of dying from any CVD, cancer, CRD between age 30 and 70 years for Seychelles in 2019 was 21.1%29 (compared with Norway at 8.7% and Mauritius, 23.2%). Mortality from Neoplasms A total of 307 (161 Males, 146 Females) new cancer cases were reported in 2020, representing an increase from the 281 new cases reported in 2019 and also higher than the 222 and 216 new cases reported in 2018 and 2017, respectively (See APR 2020). Clearly, efforts to address preventable cancers are urgently needed30. 29 World health statistics 2021: monitoring health for the SDGs, sustainable development goals. https://reliefweb.int/sites/reliefweb.int/files/resources/whs-2021_20may.pdf 30 WHO, IAEA, IARC – imPACT Review on Cancer Control Capacity and Needs Assessment Report (2019). 22 | P a g e Mortality from Diabetes Diabetes and its complications contribute to NCD mortality. Information is under-reported and not always captured when registering the underlying cause of death. Diabetes is also the leading cause of end-stage kidney disease, which itself is a significant cause of mortality31.

3.2.4 Mortality from key Communicable Diseases Among infectious and communicable diseases, pneumonia, leptospirosis, dengue fever, and HIV/AIDS are the most important in Seychelles. Data on the number of notified cases of leptospirosis and dengue are not available for most of 2020, and 2021. Leptospirosis There were three deaths (all male) due to leptospirosis in 2020, less than the seven and six deaths reported in 2019 and 2018, respectively. The NHSP end-term target for leptospirosis mortality is a case fatality rate of <10%. Like in 2019, this was not calculated in 2020, as accurate data for the total number of cases diagnosed was not available. Dengue Fever Dengue fever is a common infectious disease in Seychelles. The country is experiencing a sustained epidemic starting end of 2015 (Figure 11). In 2020, 185 patients had a discharge diagnosis of dengue (Male Medical Ward 101; Female Medical Ward 44; Paediatric Ward 40), and dengue fever accounted for two deaths (one man and one woman). The case fatality rate for dengue could not be calculated in 2020, as accurate data for the total number of cases diagnosed was not available, due to interruption of routine disease notification systems. Figure 11 Suspected Dengue cases, by week; from week 52 of 2015 to week 16 of 2020. Source: Disease Surveillance and Response Unit (DSRU). 31 Annual health Sector performance Report, 2020. 23 | P a g e HIV/AIDS HIV/AIDS remains an important communicable disease. The number of newly detected HIV cases (84) decreased in 2020 (Figure 12) compared to previous years but remained above the NHSP end- term target of 60. Similar the preceding years, the majority (69%) of cases were detected among men. Surveillance surveys indicate that Seychelles has a concentrated HIV epidemic among key populations with the highest prevalence among people who inject drugs (PWIDs); however, the proportion of people PWID has decreased among annual new cases of HIV detected in the last three years. Figure 12 Newly detected cases of HIV infection by year, 2014-2020. 140 120 120 112 109 105 100 91 84 75 80 60 40 20 0 2014 2015 2016 2017 2018 2019 2020 Total Males Females Source: Communicable Disease Control Unit (CDCU). AIDS-related mortality decreased in 2019 and 2020, after a spike in 2018 (Figure 13). Figure 13 AIDS-related Mortality, 2014-2020. 25 20 6 15 9 6 6 Females 4 6 Males 10 17 3 11 12 12 5 10 8 6 0 2014 2015 2016 2017 2018 2019 2020 Source: Communicable Disease Control Unit (CDCU). 24 | P a g e

3.2.5 Other Causes of Mortality Mortality due Road Traffic Accidents External causes of mortality are responsible for a significant number of deaths in young men. The main causes are falls, road traffic accidents (RTA) and drowning. The country has reported seventy- four deaths from RTA since 2015. The majority of the victims were young men. The death rate from RTAs [SDG 3.6.1] in 2020 was 11.2/100,000 population. RTAs were responsible for 1.6% of all deaths in 2020, higher than the NHSP end-term target of less than 1%. Intentional Self-harm There was a steady decrease in reported cases of intentional self-harm from 2016 to 2019, but the numbers increased in 2020 compared to 2019. Of the cases in 2020, 21 were males, and 37 were females. The NHSP end-term target for intentional self-harm is less than 100 cases, and this target has consistently been achieved since 201632. Three suicide deaths (all males) were reported in 2020, giving a suicide rate of 6.1 per 100,000 population [SDG 3.4.2].

3.2.6 Fertility The total fertility rate (TFR) was 2.29 in 202033. This is above the average replacement fertility34 of 2.05 births per woman35. The number of registered live births to young girls aged 10-19 years was 193 in 2020 (Table 7), representing 12% of total live births. For the last five years, the birth rate among adolescents aged 15-19 was approximately 60 per thousand. This figure is above the global average of 42.5 for 2015-2020, and the average for the European region of 21, but lower than the African region average of 102. Table 7 Registered Live births to Teenage girls, 2015-2020. Ages 2015 2016 2017 2018 2019 2020 10-14y 5 3 3 5 9 4 15-19y 187 206 201 212 228 189 32 Refer to Annual Performance Report 2020 for additional information. 33 Population and Vital Statistics, 2021/1. National Bureau of Statistics, 2021. 34 Replacement Fertility rate is the TFR at which a population replaces itself from generation to generation, assuming no migration. 35 Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017. Seattle, WA: IHME, 2018 25 | P a g e

3.2.7 Risk Factors for Health NCDs have remained the leading cause of death in Seychelles in the last few decades. Several behavioural risk factors increase the disease burden of both communicable and non-communicable diseases. Annual analysis of data from the School Health Programme shows increasing trends in obesity among school children. From 1998 to 2019, the combined prevalence of overweight and obesity increased steadily in school children from 13% to 36% in girls and 9% to 28% in boys, respectively (Figure 14 and Figure 15). In comparison to European countries, overweight or obese among 15- year-olds was at an average of 19% in 2018 and 16% in 201036. Figure 14 Prevalence of Obesity and Overweight in Girls, 1998-2019. 40% Girls_Obesity Girls_Overweight 35% 30% 20.80% 17.30% 25% 20% 16.8% 15.0% 15.3% 17.2% 14.4% 14.0% 14.7% 12.9% 13.7% 15% 14.4% 13.7% 13.5% 10% 12.2% 13.0% 11.4% 14.90% 14.80% 9.8% 9.7% 10.5% 10.8% 9.6% 11.7% 8.8% 8.4% 8.4% 5% 5.4% 5.8% 6.4% 6.4% 6.8% 4.9% 4.9% 3.0% 0% 36 OECD/European Union (2020), Health at a Glance: Europe 2020: State of Health in the EU Cycle, OECD Publishing, Paris, https://doi.org/10.1787/82129230-en. 26 | P a g e Figure 15 Prevalence of Overweight and Obesity in Boys, 1998 to 2019. 30% Boys_Obesity Boys_Overweight 25% 15.6% 14.3% 20% 14.4% 12.3% 13.1% 12.3% 12.9% 13.0% 15% 12.0% 11.3% 9.4% 9.2% 10.9% 10% 8.3% 7.6% 7.9% 12.1% 12.5% 2.3% 6.9% 3.0% 6.3% 5% 9.2% 8.8% 9.2% 9.0% 10.6% 6.8% 7.4% 8.1% 3.7% 3.9% 3.9% 5.1% 4.9% 4.0% 0% Note: Measures are made of students in Primary 4 (Avg. age 9.2y), Secondary 1 (Avg. age 12.2) and Secondary 4 (Avg. age 15.1) to estimate above rates of Overweight and Obesity. Source: Mangroo G, Marie G, Bovet P. School Screening Programme: Update of the prevalence of overweight and obesity between 1998 and 2019. Four national NCD surveys37 conducted in 1989, 1994, 2004, and 2013 in the population aged 25-64 years showed the following:  A marked 25-year downward trend for smoking (due to the strict implementation of national measures in line with WHO FCTC);  Slightly downward trends for high blood pressure and high blood cholesterol; and  Marked upward trends for diabetes and obesity. The increasing trend in obesity among adults and schoolchildren is a serious public health concern, increasing the risk of NCDs and severe COVID-19 disease38. Harmful use of alcohol and use of illicit drugs Harmful use of alcohol has been a major risk factor for health for many years in Seychelles. In 2016, the total annual alcohol consumption per capita (persons aged 15 years and more) was the equivalent of 20 litres of pure alcohol for men and 4 litres for women39. Globally in 2019, the annual consumption of alcohol was 5.8 litres per capita40. 37 Ministry of Health. National Survey of Non-Communicable Diseases in Seychelles 2013-2014 (Seychelles Heart Study IV): methods and main findings. Seychelles : 2015. http://www.who.int/chp/steps/Seychelles_2013_STEPS_Report.pdf 38 Caussy C, Wallet F, Laville M, Disse E. Obesity is Associated with Severe Forms of COVID-19. Obesity (Silver Spring). 2020 Jul; 28(7):1175. doi: 10.1002/oby.22842. 39 World Health Organization – Non-communicable Diseases (NCD) Country Profiles, 2018. https://apps.who.int/iris/handle/10665/274512 40 World health statistics 2021: monitoring health for the SDGs, sustainable development goals. https://reliefweb.int/sites/reliefweb.int/files/resources/whs-2021_20may.pdf 27 | P a g e An integrated bio-behavioural study conducted in 2016 among heroin users estimated the number of heroin users to be 4,318 and the number of persons who inject heroin 2,14441. The same study found an HIV prevalence of 8% and hepatitis C prevalence of 35% among heroin users. The HIV prevalence among PWID increased from 5.8% in 201142 to 12.7% in 201743. 41 Seychelles Biological and Behavioural Surveillance of Heroin users, 2017. APDAR. 42 Integrated bio-behavioural Study among people who inject drugs, 2011, MoH. 43 Seychelles Biological and Behavioural Surveillance of Heroin users, 2017. APDAR. 28 | P a g e

3.3 State of Health System

3.3.1 Governance and leadership Based on a review of the health system by a special task force in 2013, the health system was restructured to separate the service delivery functions, provided by the Health Care Agency (HCA), from regulatory functions, by the Public Health Authority (PHA), and oversight functions, by the MoH. In the practical implementation of the new structure, many areas remain undefined to date, such as clear reporting lines by entities as well as roles and responsibilities of administrative boards of entities. Feedback and accountability mechanisms need to improve, and policy and legal frameworks may require updates to address evolving needs, such as introducing an electronic health information system. Since 2020, in response to the COVID-19 pandemic, leadership has operated under an emergency governance structure that takes into account the functions of different entities within the health system as well as incorporating the presence of other key national bodies. In light of the changing health landscape, as well as the continued evolution of the health system, a review of the effectiveness of the present structure at delivering effective health services is warranted.

3.3.2 Health Financing Health services in public health institutions are free at the point of delivery, with the Government being the principal financier for health services (from tax-based revenues). Spending on health services has increased steadily in the past decade (Table 8), with a concurrent increase in out-of- pocket (OOP) spending for health. Table 8 Spending on Health, 2014-2020. Total Health Expenditure (THE) 2014 2016 2018 2020 THE as % of total government expenditure 9.7% 9.9% 11% 11% THE as a % of nominal GDP 3.8% 5.4% 5.6% 5.8% Source: National Health Account Reports (MoH); National Budget 2020 (Amendment), MFTIEP. OOP expenditure accounted for an estimated 23.1% of CHE in 2018, compared to 23.8% and 25.3% in 2017 and 2016, respectively44. This mirrors the rapid expansion of the private health sector (including complementary health) in recent years. 44 National Health Accounts 2016-202017 and 2018, MoH Seychelles 29 | P a g e The largest share of the budget is allocated to the HCA, with haemodialysis, overseas treatment and cancer care being major cost drivers in relation to number of patients benefiting from them. The NHA also shows an increasing trend in spending on preventive care in recent years (see Figure 16). Figure 16 Share of Current Health Expenditure (CHE) spent on Preventive Care, 2014-2018. 22.0% 19.4% 17.7% 11.7% 12.2% 2014 2015 2016 2017 2018 Source: National Health Accounts series, 2014–2018. The MoH has fully implemented Programme Performance Based Budgeting (PPBB) framework as prescribed by the Ministry responsible for Finance. However, this has not brought about expected improvements in performance. This is likely due to the inflexibility of the PPBB structure, line managers being unware of budget allocations, and misalignment with actual service delivery. There is inadequate information on the cost-efficiency of services, which presents challenges in making cost-conscious policy decisions. Many services have been outsourced over the years without the necessary additional contract management and monitoring mechanisms in place; this has led to an apparent cost escalation, as well as multiple complaints; the quality and cost-efficiency of these services are in question. Weak administration of user fees and delayed payments for produced supplies and services also present challenges to effective management of health finance.

3.3.3 Infrastructure MoH owns most of the service delivery infrastructure. However, many facilities are dated and may not meet ideal requirements for modern standards of care delivery. Many safety risks remain chronically unaddressed – fire, flood, storm, chemical, biological and radiological. Preventive maintenance systems are weak, and repairs/replacements often much delayed. Safe storage space is a major challenge, prompting the need to rent off-site storage space and leading to storage of medical supplies in clinical areas and along corridors. There is need for expertise in project management and an infrastructure management plan. The Seychelles Hospital Masterplan, although conceived at significant cost, is yet to be implemented. 30 | P a g e

3.3.4 Commodities An elaborate essential medicines list supports good treatment access. However, there is no such list to-date for medical technologies and supplies. Notable challenges include occasional stock-outs of certain medicines and supplies, and the need for more effective in-country stock-management and distribution of medicines and supplies. There is a need for more involvement of line managers when planning any supply cuts to minimise negative impacts on service delivery. The maintenance and servicing of medical equipment have improved, directly attributable to a more effective biomedical engineering unit. Maintenance of more advanced equipment (such as MRI scanners) remains a challenge. The sector receives many donations of supplies and medicines, but these donations are often not tailored to needs and/or are not of adequate standard/quality for local use.

3.3.5 Service delivery The Seychelles public health system is widely accessible geographically, and without financial barriers to Citizens. It provides decentralised access to emergency services across the main islands, has elaborate diagnostic capacity, and provides access to an expanded list of medicines and therapeutic services. Multiple initiatives, such as patient-centred care and maternal death reviews, have taken root in recent years, with the aim of improving quality. But the health system does not routinely measure quality of care. The need for a stronger clinical governance model is evident to improve accountability and support safe, effective and quality services. The relative neglect of preventive, promotive and long-term care services, including palliative care, also needs to be addressed. Referral systems are weak, systems for back-referrals and feedback are lacking and/or require more streamlining. Language barriers pose another chronic challenge; itself linked to high dependence on and quick turnover of an immigrant health workforce. The COVID-19 pandemic has moved public health to the forefront of the health system. The PHA as the main guarantor of public health, has robust legal frameworks. However, the regulatory wing and relevant enforcement mechanisms, require further strengthening. Health programmes focus principally on supporting promotive and/or preventive services. They access much technical assistance and engage wieldy with external stakeholders. But programme managers often work alone, and there is poor coordination and cooperation across programmes. The private health sector is growing rapidly. Communication between MoH and the private sector is still poor; private-sector regulatory frameworks are weak, with inadequate reporting. 31 | P a g e

3.3.6 Impact of COVID 19 on the health system COVID-19 has affected the whole country, the health and wellbeing of the population, as well as all aspects of the health system. The COVID-19 response has nudged the health system to promote remote-work, and improve coordination across different departments and service areas. This is reflected in the increased use of instant messaging platforms for sharing information and coordinating work, electronic platforms for data management around testing and surveillance, video conferencing systems for meetings, social media platforms and e-mails for risk communication, etc. There is a renewed emphasis on infection prevention and control, with more complete guidance, training, monitoring and enforcement. In addition to direct illness, admissions and deaths, the COVID-19 pandemic has increased the workload on healthcare workers (HCWs) and imposed a chronic strain on the health system. Most HCWs were redeployed, and many services were (temporarily) interrupted. The response also revealed key weaknesses in the health system around data management and effective, timely communication and coordination. 32 | P a g e

3.4 Identified Priorities Based on the unaddressed agenda (unfinished business) from the implementation of the NHSP 2016- 2020, and the situation analysis, the different TWGs and stakeholders identified the following priorities for health system and health status (see Table 9). Table 9 Identified priorities to improve Health System and Health Status, by building blocks. Health System Key Health System Priorities Building Block Leadership and  Adopt a Proactive and long-term approach to sector planning. Governance  Ensure Participatory decision-making.  Strengthen HR and financial management capacities.  Strengthen legal and regulatory frameworks for health. Human  Improve appraisal systems. Resources for  Improve staff welfare, retention mechanisms, health and safety. Health (HRH)  Develop an HRH strategy. Health Financing  Review revenue generation and user-fees structure.  Review tender process and performance of outsourced services.  Improve cost-benefit awareness. Health  Address fire, flood, storm, chemical, biological and radiological risks, Infrastructure across the sector.  Improve preventive maintenance and ensure timely repairs.  Systematically consider disability access.  Invest in MoH-owned safe storage space. Medicines and  Improve stock management and forecasting. supplies  Develop a Donation policy to guide responsible donations.  Ensure rational use of medicines and supplies.  Use a Standardised list of medical equipment. Health  Adequate IT infrastructure with strong technical support. Information  Prompt implementation of the eHIS. systems  Develop data management and research policies.  Invest in digital solutions for health.  Establish Central data warehousing. 33 | P a g e Health Service  Develop SOPs and clinical guidelines. Delivery  Establish Quality improvement initiatives; standards of care.  Strengthen communication and coordination.  Improve referral and appointment systems.  Introduce new service/programmes to address existing gaps.  Strengthen regulatory wing of PHA.  Consolidate and improve reporting systems. Private Health  Establish regular communications platform. Sector  Share and monitor adherence to guidelines, SOPs, regulations. Health Status Priorities  Maintain high Life Expectancy (LE) for women.  Increase LE for men and close gap in LE between men and women.  Increase healthy life expectancy.  Continue to improve maternal and child health.  Decrease morbidity and premature mortality due to NCDs.  Decrease mortality due to external/accidental causes especially in men.  Reduce morbidity and mortality due to priority45 infectious diseases.  Reduce number of cases and mortality due to COVID-19.  Address risk factors for health (especially obesity in adults and children, harmful use of alcohol, abuse of drugs).  Track and improve non-fatal outcomes for priority diseases.  Prevent, prepare and respond to health emergencies.  Implement the Health in All Policies (HiAP) approach to address social determinants of health. 45 Priority diseases include Pneumonia, HIV/AIDS, Dengue and Leptospirosis. 34 | P a g e Chapter 4 Strategic Agenda for 2022-2026 35 | P a g e 4 Strategic Agenda for 2022-2026

4.1 Vision, Mission, Goals As articulated in the National Health Policy 2015, the national vision for health is the “attainment, by all people living in Seychelles, of the highest level of physical, social, mental and spiritual health and living in harmony with nature”. True to this vision, the mission of the sector is “to relentlessly promote, protect and restore health and quality of life and dignity of all people in Seychelles with the active participation of all stakeholders, through the creation of an enabling environment for citizens to make an informed decision about their health”. The NHSP 2022-2026 is the second strategic plan of the National Health Policy 2015. Like the first medium-term plan, this NHSP embraces the guiding principles of “Health for, Health by all and Health in all”. The goals of this strategic plan are to:  Increase life expectancy and healthy life expectancy  Achieve and sustain all dimensions of Universal Health Coverage (UHC)  Prevent, Prepare for, detect early and respond adequately to all health emergencies  Promote healthy populations The NHSP proposes bold changes to maintain and build on health gains for all people in Seychelles throughout the life-course. It recognises that promoting, protecting and restoring health in the fragile and unpredictable post-pandemic social and economic situation requires bold and innovative approaches. It recognises that health gains can be easily eroded; and that renewed and sustained investment is needed. 36 | P a g e

4.2 The NHSP 2022-2026 Framework This NHSP has six strategic directions represented by the six pillars (see Figure 17): 1. SD1 Strengthen leadership, governance and administration 2. SD2 Protect and improve UHC 3. SD3 Address health security 4. SD4 Promote healthy populations 5. SD5 Invest for results 6. SD6 Improve data for impact What the sector is planning to achieve is captured under SD2, SD3 and SD4, while critical inputs required to achieve these results are captured under the other three pillars (SD1, SD5 and SD6). See Table 10 for an overview of broad objectives. The NHSP sets out the priorities for each pillar for the next five years. While there is collective ownership of this five-year plan, the different entities will be responsible for delivering on specific objectives under these pillars. 37 | P a g e Figure 17 NHSP 2022-2026 Framework 38 | P a g e Table 10 NHSP Framework: Strategic Directives with Key Objectives SD1 Strengthen SD2 Protect & SD3 Address Health SD4 Promote SD5 Invest for SD6 Improve Data Governance, Leadership Improve UHC Security Healthy Populations Results for Impact & Administration General Objective (GO): GO: To protect and GO: To promote and GO: To advocate for a GO: To ensure GO: Build an integrated To ensure MoH Governance improve UHC throughout protect health security. conducive environment effective, efficient Health Information and Leadership has the life-course and that supports healthy and sustainable System (HIS), and appropriate structures and address priority diseases. living, safe & healthy investment in strengthen efforts to processes necessary to neighbourhoods, and health and the collect, process, report successfully steer the health improve wellbeing of health system. and use health data. sector. people. Specific Objectives (SO): SO: SO: SO: SO: SO:

1.1 Build strong 2.1 Improve health 3.1 Strengthen the One 4.1 Promote healthy 5.1 Human 6.1 Set-up one governance and services across the Health approach. living for different Resources for integrated HIS leadership structure life-course and 3.2 Implement the IHR age-groups Health 6.2 Improve data

1.2 Renew stewardship address priority health to prevent, detect 4.2 Address risk factors 5.2 Health governance function of MoH conditions. and manage for health. Financing 6.3 Enable data use

1.3 Ensure accountability at 2.2 Champion Quality outbreaks 4.3 Revitalise HiAP 5.3 Medicines and 6.4 Implement eHIS all levels Improvement across 3.3 Implement IDSR 4.4 Promote good Health 6.5 Invest in health

1.4 Implement effective health system 3.4 Strengthen mental health and Technologies data coordination and 2.3 Improve collaboration regulatory functions address substance 5.4 Infrastructure 6.6 Strengthen communication with private health of the PHA abuse 5.5 Information research capacity systems sector and health- 3.5 Improve public 4.5 Promote and Technologies 6.7 Improve health

1.5 Engage the community related NGOs health standards advocate for information

1.6 Build meaningful 2.4 Mitigate risks and and legislation effective public products relationships mainstream resilience 3.6 Strengthen public health

1.7 Implement RBM across the health health programmes system       Lead Entity: MoH HCA PHA MoH MoH/HCA MoH - Entity two-year Operational Plans - - Sector, Entity and Disease-specific Monitoring and Evaluation Plans - 39 | P a g e SD1 Strengthen Governance, Leadership and Administration Leaders in health are responsible for developing and implementing national health strategies, setting health goals and targets for improving health, delivering quality health care services, and monitoring the population's health. The health sector is also responsible for ensuring that the policies of other sectors promote and positively impact health. Governance and leadership is one of the six building blocks of the health system, essential for guiding the health sector towards achieving its strategic vision. However, governance is generally poorly defined and may be difficult to operationalise. The WHO definition of governance and leadership includes “ensuring strategic policy frameworks exist and are combined with effective oversight, coalition- building, regulation, attention to system-design, and accountability”46. Good governance is transparent, inclusive and based on a robust system of mutual accountability. MoH needs solid formal governance structures and processes to lead and engage all health providers and the community in a shared purpose and vision. SD1 Outstanding Issues Governance structure Since the 2013 reform of the MoH47, functions of the MoH have been assigned to several semi- autonomous statutory entities with their own governing boards, while the MoH Secretariat, headed by the Minister, is responsible for political leadership, sector stewardship, accountability and performance monitoring. The situation analysis for the development of the current NHSP noted that there had been no review of the objectives of the 2013 reforms and inadequate clarity around roles, responsibilities and boundaries of various leadership posts and bodies. Communication, coordination and collaboration There are weaknesses with the flow of information within and across entities within MoH and communication from MoH to other sectors and the private health sector. There is a need for mechanisms to allow clear and timely communication within MoH and with other sectors and the community. 46 WHO. https://www.who.int/health-topics/health-systems-governance#tab=tab_1 47 Health Task Force Report, 2013, Strengthening and Modernising Seychelles Health System to Improve Health Outcomes 40 | P a g e Accountability One of the reasons for not achieving desired health outcomes is the lack of accountability in the health sector. Accountability refers to the act of holding public officials/service providers answerable for processes and outcomes and imposing appropriate measures if specified outputs and outcomes are not delivered to the minimum expected standards. Technical leads develop and submit regular progress reports but do not receive feedback from leadership. Roles and responsibilities of professional councils and entity leadership about disciplinary actions are blurred. To improve health system performance and achieve desired outcomes, there is a need for all in MoH to be accountable. Formal mechanisms are required to make workers at all levels answerable for professional conduct and performance, focusing on utilisation of resources, outputs, and results. Accountability also applies to the private health sector, monitored by the PHA. Leadership should shape organizational culture. Policy and Planning MoH has developed many policies over the years; however, less effort has been made to plan policy implementation, review progress and its impact. For the next five years, MoH will assess and understand policy gaps and develop urgently needed policies such as policies on donation and quality of care. Additionally, mechanisms will be developed to periodically review policy implementation to understand and report on policy failures and successes. MoH will seek buy-in for an inter-sectoral policy platform, to advance the HiAP approach. Partnership Health is complex, and efforts to promote better health requires using a whole-of-government and whole-of-society approach by engaging all partners, including the community, private health providers and other line ministries. The MoH will initiate inter-sectoral interventions to advance the health agenda, act as a health advocate while engaging the community in health policy formulation, research and sector monitoring. MoH’s efforts to promote and protect health can only achieve results when the community is empowered and actively engaged. Despite some efforts, there are still untapped opportunities to involve the community and support citizen and patient empowerment to improve health outcomes, health system performance, and satisfaction with health care. MoH also works with important global partners, particularly the WHO. MoH, with support from global partners, will work to advance the national health agenda and also to achieve regional and global commitments. 41 | P a g e Results-Based Management (RBM) The government has approved the rollout of RBM consisting of four pillars: Strategic planning, Programme Performance Based Budgeting (PPBB), Performance Monitoring and Evaluation (PM&E) and Performance Management System (PMS). MoH, like other sectors, needs to establish a performance-driven work culture where accountability for results is continually strengthened. Lead portfolio institutions have been tasked to establish a portfolio- level RBM Committee to oversee the implementation of all RBM pillars and ensure harmonization of the strategic plan with all other pillars of RBM. The MoH Secretariat will continue to conduct sector monitoring by tracking and reporting on a set of core indicators annually through the annual health sector performance report; however, sector and entity M&E frameworks were not developed for the previous NHSP. SD1 Priority Areas 1. Clarify and strengthen MoH governance structures and processes. 2. Improve communication, coordination and collaboration within and beyond MoH. 3. Ensure accountability at all levels of the health sector (public, private and non-health actors). 4. Develop needed synergistic health policies. 5. Engage the community and build meaningful partnerships. 6. Implement the RBM strategy. 7. Drive the quality in health agenda and mobilise high-level engagement for HiAP. SD1 General Objective Ensure that MoH governance and leadership has the appropriate structures and processes necessary to successfully steer the health sector to:  Provide strategic vision and guidance  Ensure accountability, effectiveness and efficiency  Develop and monitor implementation of synergistic policies  Foster community engagement and build meaningful partnerships  Ensure cooperation and policy synergy across public and private sectors and civil society  Monitor performance and achievement of desired outcomes and goals. 42 | P a g e SD1 Specific Objectives Table 11 SD1 Strengthen Leadership, Governance and Administration: Specific Objectives SD 1: Strengthen Leadership, Governance and Administration Lead Contributing Specific Objectives Key Interventions Milestones Entity Entity

1.1 Build strong Conduct a review of the objectives and implementation of Report of review of 2013 reforms with recommendations MoH PHA; HCA; governance and 2013 health reforms (Fit for purpose, need for new NIHSS; NAC leadership governance architecture etc.) structure Develop a framework for governance defining clear roles and Governance framework developed and disseminated MoH responsibilities and reporting lines of MoH, entities and entity boards Develop key indicators/milestones to monitor governance Indicators developed and monitoring conducted MoH and leadership functions Conduct annual assessments and develop reports on health Annual governance report developed and disseminated MoH governance and leadership Develop a governance structure for health emergencies with Health Emergency governance structure developed and PHA MoH clear roles and responsibilities validated

1.2 Renew Conduct a review of existing health policies and policy gaps Policy review report and recommendations MoH stewardship function of MoH Formulate strategic policy directions as required (Priorities: Required policies developed and disseminated MoH quality of care, donation) Review implementation of key health policies and make Report of review of policy implementation MoH recommendations Develop a shared policy platform with key sectors and Policy platform developed and functional MoH monitor health coherence Collect and use health intelligence to develop policy briefs Policy briefs developed and disseminated MoH Continue to strengthen professional councils. Councils strengthened and independent. MoH Build confidence of HCWs in leadership by ensuring clear All HCWs understand organisational culture and leadership MoH direction, commitment. actions are consistent with sector vision, values and strategy. 43 | P a g e

1.3 Ensure Develop accountability framework to define accountability Health Sector accountability framework developed, and MoH HCA accountability at requirements at all levels (who is accountable, for what and accountability monitored. PHA all levels to whom) – leaders, managers, HCWs, councils, entity boards. Monitor and report on the implementation of all pillars of Entity and sector RBM committees set up MoH HCA RBM Annual RBM reports PHA Develop and disseminate annual health sector performance Annual health sector performance report developed and MoH reports and follow up on the implementation of remedial disseminated within and beyond MoH actions as necessary Remedial measures identified, discussed and implemented by relevant entities Develop entity annual performance report Annual entity performance reports developed and HCA disseminated, achievements and failures discussed and PHA plans for remedial actions developed (HCA, PHA, NAC, NIHSS NIHSS) MoH Use progress report as a management tool  New format for progress report developed and used. PHA  Review format/frequency of progress report  Feedback is given for all reports submitted. HCA  Review format for feedback and monitor Develop and disseminate annual Drug Observatory Report  Annual Drug Observatory report developed and MoH disseminated.  Follow-up action plan developed and implemented. Revise scope of work of CIC and nurse managers to include Revised scope of work of CIC and nurse managers HCA clear roles and responsibilities

1.4 Implement Develop formal coordination mechanisms within and across Formal coordination mechanisms developed by MoH and MoH effective entities and for actors beyond MoH (circulars, information entities. PHA coordination and bulletins, leadership blogs, forums, committees, platforms). HCA communication NIHSS system Ensure weekly decisions of senior executive committee reach Decisions of the senior executive committee are shared MoH HCA all health care workers in MoH (and the private sector when every week and as needed. PHA needed) Conduct annual coordination meetings with the private  Annual coordination meetings conducted with private HCA health sector and civil society and bi-annual PHC/Hospital health care providers and NGOs. PHA coordination meetings  Annual coordination meetings conducted PHC and MoH hospital services. Develop and implement effective communication strategies Communication strategies implemented MoH PHA HCA

1.5 Engage the Include community consultation in the development process Meeting reports of community consultations. MoH PHA community of all health policies/strategies and understand their values HCA and preferences 44 | P a g e Disseminate and explain key findings from annual Annual meetings on Mahé, Praslin and La Digue MoH performance report and other important reports to the community and obtain feedback Build community leadership for priority health conditions (rf. Community leaders for NCDs and key communicable MoH HCA SD2 p. 47). diseases identified, trained and supported. PHA Develop mechanisms to engage vulnerable and key Vulnerable and key populations engaged in the MoH PHA populations and their advocates in relevant policies and development of programmes and services that target them programmes

1.6 Build Map key partners and develop a framework to guide the Mapping report of key partners in health MoH meaningful engagement of local and external partners in health. Framework to guide partnership developed and partnership disseminated. Develop a policy to guide donations to MoH. Policy on donation developed, disseminated and used. MoH HCA PHA Develop annual reports on grants, TA and donations (on aid Annual reports on donations and aid effectiveness in MoH HCA effectiveness). health. PHA Develop brief outlines of key priority projects that are above Project outlines developed. MoH budget allocation to inform donation requests. PHA HCA Define key areas/projects where external technical support Annual TA needs developed jointly by MoH and entities. MoH HCA (e.g. WHO/UN agencies) is required, at start of each year. PHA NIHSS Contribute to the development and monitor implementation WHO biennium plans developed jointly and are in line with MoH HCA of WHO biennial work plans. national health agenda. PHA NIHSS Review, jointly with UN agencies, the mechanisms for Recruitment and engagement of TA from UN agencies are MoH HCA recruitment and engagement of TA. structured to add value to partnership PHA

1.7 Implement Sensitise managers on RBM and theory of change. Sensitisation workshops conducted. MoH Results-Based Finalise and disseminate NHSP 2022-2026. NHSP 2022-2026 developed and disseminated. MoH Management Each entity develops a two-year operational plan Operational plans developed. MoH HCA (RBM) PHA NIHSS Set up entity and sector RBM committees with ToRs as RBM committees set up and functioning. MoH PHA specified by MFTIEP and report to government HCA Develop sector and entity PM&E frameworks with support PM&E frameworks developed. MoH PHA from DPA/TA HCA Develop indicator protocol to monitor core health indicators. Indicator protocol developed. MoH PHA HCA Monitor and report on sector and entity core indicators. Annual reports from MoH and entities on core indicators. MoH PHA 45 | P a g e HCA Strengthen M&E capacity with support from government Recruit M&E officers for entities MoH PHA HCA Conduct a mid-term review of the NHSP 2022-2026 and Drug-control Master Plan and NHSP mid-term review report MoH Drug-control Master Plan and recommendations developed and disseminated

1.8 Drive changes Define and agree on purpose and quality goals and assign Quality leads assigned to PHC, in-patient care, specialised MoH required to leaders services, programmes and in private health sector PHA improve quality in HCA health Develop a framework to drive quality in health, and support  Framework on quality in health developed and MoH and monitor implementation of QI initiatives disseminated. PHA  Reports QI projects. HCA Share local best practices within the health sector Best practices identified and shared MoH HCA PHA ‘Get Boards on board’ – to provide insight, monitor Entity boards to put quality on the agenda PHA MoH performance and hold managers accountable Set up ‘quality committees’ on boards. HCA NIHSS Re-engineer health processes so that quality becomes a Quality governance and management system set up. PHA disciplined and integrated management system. HCA

1.9 Mobilise Mobilise buy-in for HiAP by sensitising Cabinet and NA, and HiAP meetings held with Cabinet and NA. MoH commitment and obtain pledges PHA action for HiAP Advocate for extended health impact assessment before the Health impact assessment conducted. MoH PHA development of key projects Conduct annual review of HiAP commitments Annual HiAP Report MoH 46 | P a g e SD2 Protect and Improve Universal Health Coverage Health services are free, easy to access geographically and have high utilisation rates. However, quality, equity, outcomes and user experience and satisfaction are not adequately measured. This may imply certain population groups may be ‘left behind’, but not picked up by current routine monitoring – making a case for stronger measurement of these aspects of care. While public health sector services remain free of user charges, a series of NHA reports show increasing out-of-pocket spending on health, chiefly driven by increasing utilisation of private health services. The two seminal global conferences on primary care (Alma-Ata, 1978, and Astana, 2018) have emphasised the importance of primary care as the key vessel to deliver quality health services to all, to improve everyone’s health and wellbeing. In recent years, UHC (defined in Box 1) has been the flagship approach of the WHO (and the wider United Nations) for improving health and wellbeing within the Sustainable Development Agenda 2030 framework48. The principle aims to expand the range of health services provided, at high quality, to the whole population, with maximum financial protection. The ideals of achieving and improving UHC through strengthening primary care, are well aligned with both the global health goals (SDG 3) and the National Vision for Health. Box 1 Definition of Universal Health Coverage (UHC) “Universal health coverage means that all people have access to the health services they need, when and where they need them, without financial hardship on them. It includes the full range of essential health services, from health promotion to prevention, treatment, rehabilitation, and palliative care… high quality health services… through people-centred primary care.” – Definition of Universal Health Coverage, World Health Organisation Primary care and the achievement of UHC are intricately linked to public health (aimed at prevention), health promotion (aimed at prevention and promotion), and health systems strengthening (provides the supports to improve the platform through which UHC services are delivered). Seychelles has a relatively high UHC index of 7149. WHO criteria and targets are, however, generally not tailored for high-income contexts, and do not accurately reflect changes to UHC in the Seychelles context. As such, particularly in the context of an economic crisis, there is risk for erosion of past gains in UHC, which may go undetected in the annual standard UHC index measurements, hinting at a need for 48 https://www.who.int/health-topics/universal-health-coverage#tab=tab_1 (accessed 24 Nov 2021). 49 World Health Statistics Report, WHO, 2021, p67. 47 | P a g e more tailored criteria and thresholds. There are also a need to measure equity and quality of health services. SD2 Outstanding Issues  Urgent need to address priority diseases: NCDs (cancer, diabetes and cardiovascular disease outcomes) and communicable diseases (COVID-19, HIV, Viral Hepatitis).  Measurements and reporting are mortality-centric; non-fatal outcomes are not well measured.  Weak clinical governance mechanisms:  Lack of standardisation of care – great variation across health system.  Gaps in clinical care: inadequate guidelines, unclear care pathways, no clinical audit cycles, weak referral systems, no standards for care, inadequate measurement of quality and safety in services, lack of a quality policy, and no formal clinical audit.  Traditionally tertiary-care-centric role of clinical specialities – need for oversight and responsibility for improving care and services under the relevant speciality for the whole country, and not just the specific hospital unit.  Lack of a clear policy on process for overseas treatment, a major cost-driver.  Only a few innovations in care delivery; inadequate modernisation of services; outdated service delivery models.  Majority of health funding focused on curative care, much less on primary care, promotive and/or preventive health services.  Effectiveness, efficiency and cost-benefits of services are not measured.  Equity is not measured – possibly leaving behind certain groups.  Communication barriers – with public, and within health system.  Fragmentation of operations within health system; weak coordination mechanisms. SD2 Priority Areas 1. Use a combination of life-course (RMNCAH, men’s health, healthy ageing, etc.) and disease- specific (cancer, CVDs, COVID-19, HIV, etc.) approaches to address health needs. 2. Innovate and modernise care delivery – new service delivery models aimed at improving outcomes of prevention and care. 3. Make quality a top priority in service delivery. 4. Increase spending on preventive and primary healthcare services. 5. Strengthen and promote a preventive care agenda. 6. Ensure no one is left behind: Measure and improve equity in access to health services, and health outcomes. 7. Improve health system resilience. 48 | P a g e SD2 General Objective To protect and improve Universal Health Coverage (UHC), through continued provision of quality preventive, promotive, curative and palliative health services to everyone in-need, without undue financial risks, and establish a system of continuous quality improvement. The key strategic domains to guide the direction are:  Improve health services across the life-course and address priority health conditions.  New direction for primary health care.  Improve secondary and tertiary care.  Innovate and modernise health programmes.  Champion quality improvement across the health system.  Implement a quality framework.  Develop and implement a clinical governance model.  Improve efficiency and effectiveness of services.  Improve collaboration with private health sector and health-related NGOs.  Partnership to provide services.  Mitigate risks and mainstream resilience across the health system.  Improve health and safety and staff wellbeing supports.  Climate change mitigation and adaptation in health sector.  Institutionalise COVID-19 response functions and build resilience. 49 | P a g e SD2 Specific Objectives Table 12 SD2 Protect and Improve UHC: Specific Objectives SD 2: Protect and Improve UHC Specific Lead Contributing Key Interventions Milestones Objectives Entity Entity

2.1 Improve 2.1.1 A new direction for primary health care health services  Operationalise package of services to be offered in  PHC package operationalised HCA PHA across the life- primary care. course and  Reorganise community health services into a fit-for-  Criteria for PHC defined. HCA MOH address priority purpose system, with clear organisational structure  Organisational structure defined of PHC facilities and PHA health conditions. based on agreed criteria, to deliver effectively and services. efficiently on the PHC package.  New Master Facility List available  Repurpose/close health centres not meeting set  A population register for each clinic catchment area criteria for delivery package. Redeploy any free developed. resources.  Establish mechanisms for strong oversight and  Create a PHC council with mandate on quality and HCA MOH continuous service improvement. efficiency. PHA  PHC indicators and targets defined.  Implement chronic disease care models to support self-  Service delivery model for chronic diseases developed HCA MoH management, treatment adherence and improve and implemented. PHA health literacy.

2.1.2 Address challenges in operations of PHC services to maximise access and effectiveness of services.  Fully implement appointment systems.  PHC appointment system functional. HCA  Develop tools and processes for a seamless, active and  Active seamless referral system in place. timely referral system.  Coordination meetings between PHC and hospital  Establish minimum language proficiencies for health services conducted at least twice a year. service providers.  Review operating hours of PHC facilities  Improved coordination and support across services and centres, including with Praslin and La Digue.  Address discrimination and protect rights of vulnerable  Access for vulnerable populations to health and social MoH population groups (substance abuse, mental health, services improved in existing facilities and planned for HCA social ills). future facilities. PHA 50 | P a g e  Targeted interventions to reach vulnerable populations developed.

2.1.3 Improve secondary and tertiary care  Define needs, roles and package of services for  Inpatient and Specialised Care package of services HCA inpatient and specialised care services. define and used to inform clinical guidelines and access to diagnostics and therapeutics.  Establish adequate management capacity for  Competent staff to fill all management HCA Seychelles Hospital and annexes. positions/functions appointed  Strengthen governance and coordination of specialist  Governance structure for specialised services defined. HCA outpatient, oncology and accident and emergency (A&E) services.  Review scope-of-work for specialist services, to ensure  Scope of work for clinical leads (PMOs, PNOs, NMs, CICs, HCA relevant broader health system and societal needs are Regional lead Dr) are redefined, with reporting/M&E incorporated. and service improvement roles.  Review after-hours service provision based on needs,  After-hours services package and requirements and HCA access and utilisation. location defined  Improve standards of inpatient care.  Define standards of operations and minimum HCA MoH requirements for all wards and units/services. PHA  Rationalise use of diagnostics and therapeutics.  Guidelines developed for access to diagnostics and HCA therapeutics  Improve long-term care (LoTC) services.  Package of services provided in LoTC facilities defined. HCA  Closer coordination with social workers in care  Dedicated Social workers for different health services planning for vulnerable groups. appointed.  Transfer ‘Regional Homes’ management to Ministry  Regional homes transferred to relevant ministry. responsible for social affairs.  Establish clear governance and accountability structure  Governance structure for overseas treatment HCA MoH for overseas treatment. established.  Establish overseas treatment policy to complement the  Overseas treatment policy developed. Act.  Review and annual report on overseas treatment  Conduct a review of overseas treatment (needs, costs, developed. outcomes).  Annual reports on overseas treatment services, with outcomes.

2.1.4 Innovate and modernise health programmes  Improve leadership, organization and management of  Organizational structure and coordination of HCA MoH health programmes programmes reviewed. PHA  Build capacity in programme leaders for M&E and  Capacity building of programme leaders for M&E and quality improvement. quality improvement conducted. 51 | P a g e Strengthen programmes to address health needs across  Programmatic services on offer are better aligned with HCA MoH the life-course and across disease conditions. target population needs. PHA  Support the conduct of the next round of the Seychelles Heart Study series.  Review implementation of new initiatives.  Implement PHC package of services  Implement programmes according to PHC Package HCA  Monitor outcomes of programmes  Key indicators and targets for each programme PHA developed.  Annual report of programmes developed and shared.  Build synergies across programmes through  Communities of practice for related groups of HCA PHA communities of practice. programmes set up and running. MoH  Develop and pilot an integrated preventive health  Health Prevention Hub developed. services hub.  Address policy support gaps for key programmatic  National Cancer Control Strategy developed. HCA MoH services.  School Health Policy developed. PHA  Expand utility of vaccination in disease prevention  Revised EPI schedule for children. HCA MoH  Expand capacity of the Expanded Programme on  Capacity of EPI Unit strengthened. Immunisation (EPI).  Review current vaccination schedule to include additional evidence-based vaccination in: (1) routine childhood vaccination, (2) routine adult vaccination, and (3) travel vaccination.  Strengthen collaboration between programmes and  Coordination mechanisms for programmes and health MoH HCA health promotion. promotion developed. PHA  Develop a health promotion policy and strategy.  Health promotion policy and strategy developed. Improve community engagement for addressing priority  Focal persons in the community for key programme MoH HCA health conditions. areas identified and sensitized. PHA

2.1.5 Address priority health conditions Substance abuse and Harmful use of Alcohol  Quality indicators for harm reduction services MoH PHA  Ensure continued, quality, service provision for mental developed and monitored. HCA health and substance abuse disorders.  Programme to address harmful use of alcohol revived.  Institutionalise and consolidate essential services for  Aspects of harm reduction services mainstreamed into substance abuse (prevention, treatment and after- PHC services. care, as per the NDCMP).  Expand services to address harmful use of alcohol.  Integrate provision of substance abuse and mental health services into the PHC. 52 | P a g e Key Non-Communicable Diseases  Regular Monitoring and reporting on key priority PHA MoH  Revitalise implementation of the NCD Strategy. diseases (HIV/AIDS, COVID-19, Cancer, Cardiovascular  Support conduct of the next iteration of the Seychelles diseases, Viral Hepatitis, etc.). Heart Study series, and use information to inform  Annual report on implementation of NCD Strategy. review and update of the NCD Strategy 2016-2026.  End-term review of NCD Strategy conducted; new NCD  Review implementation of new disease-specific Strategy developed. initiatives (such as SEYPEN).  New Cancer Control Strategy developed.  Report of the next Seychelles Heart Study survey results. Key Communicable Diseases  End-term review of HIV/AIDS and Viral Hepatitis NAC  Review the National Strategy for HIV/AIDS and Viral Strategy conducted. PHA Hepatitis Strategy.  Updated policy and strategy on HIV/AIDS, Viral Hepatitis  Update and implement the COVID-19 response plan. and STIs developed.  Also refer to SD3 for COVID-19 response and priority  Integrated COVID-19 response plan developed. Annual vector-borne and zoonotic diseases. reports produced.

2.2 Champion 2.2.1 Improve quality of health services Quality Develop and implement a quality framework.  Quality Framework developed and operationalized. HCA MoH Improvement (QI)  Regular clinical audits in all units and service areas across the health conducted. system  HCWs and public sensitized on QI initiatives. Establish standards of care and quality indicators by  Standards of Care and Quality indicators defined and HCA MoH service area. implemented. PHA  Formal unit/service-area specific monthly CPD/CME system in place. Promote rational prescribing and antibiotic stewardship.  AWaRe classification of antibiotics, with monitoring HCA through the implementation of GLASS framework used.  Adherence to treatment protocol monitored regularly. Define Care Pathways for key conditions/services.  Care pathways defined, disseminated and implemented. HCA

2.2.2 Improve efficiency and effectiveness of services at all levels (Subject to joint discussion with Department of Finance).  Build capacity for monitoring efficiency in the health  Health economist recruited. MoH system.  Cost-benefit assessments for key services and health HCA  Improve technical and allocative efficiency in services. condition s conducted.  Guidance for efficiency developed and used.  Line managers and administrative staff aware of costs and benefits of common health services.  A formal system for monitoring cost-efficiency, as part of wider M&E framework developed.

2.3.1 Explore social franchising with private health sector and health-related NGOs. 53 | P a g e

2.3 Improve  Utilise private health sector and/or health-related  Annual meetings with private sector conducted. HCA MoH collaboration with NGOs to help deliver key preventive, promotive and  Social franchise developed. PHA private health primary care services. sector and health-  Build social franchise where appropriate. related NGOs

2.4 Mitigate risks 2.4.1 Climate change mitigation and adaptation in health. and mainstream  Improve awareness of climate impacts on health.  Vulnerability and adaptation assessment for the health MoH HCA resilience across sector; Establish relevant CPD and training conducted PHA the health system  Considerations of climate change mainstreamed in plans for health facilities  Mainstream climate mitigation and adaptation through  Develop a Health National Adaptation Plan aligned with MoH HCA climate-informed health system strengthening. National Climate Change Policy. PHA  Access global climate finance for supporting wider  Improved networking with Department of Climate MoH HCA health system strengthening. Change to access climate funds for mitigation and PHA adaptation projects.

2.4.2 Institutionalise COVID-19 services and build resilience  Institutionalise COVID-19 care and other related  Finalise and implement the Continuity of Essential HCA considerations throughout the health system. Health Services (CEHS) plan. PHA  Define essential health services; ensure their  Emergency Operations Plan and SOPs. continuity.  Define key Indicators for prevention, preparedness, etc. for health emergencies.  Continue relevant up/cross-skilling of staff in basic COVID-19 response related functions across health system.  Clear guidelines for care of long-COVID/post-COVID syndrome.  Ensure continued, dedicated isolation and treatment  Rational utilization of tier 2 and tier 3 COVID-19 care HCA capacity. capacities.  Full implementation of COVID-19 care pathway and clinical management guidelines. 54 | P a g e SD3 Address Health Security Global health security is defined as the proactive and reactive activities required to minimise the danger and impact of acute public health events that endanger people’s health across geographical regions and international boundaries. Population growth, rapid urbanization, environmental degradation, and the misuse of antimicrobials are disrupting the equilibrium of the microbial world. New diseases, like COVID-19, are emerging at unprecedented rates, disrupting people’s health and causing negative social and economic impacts. Billions of passengers travel on airplanes each year, increasing the opportunities for the rapid international spread of infectious agents and their vectors. The use of chemicals in agriculture and industry has increased, as has an awareness of the potential hazards for health and the environment. Air quality may decline with increasing urbanisation and the increasing use of fossil fuels. As the globalisation of food production increases, so does the risk of tainted ingredients and foodborne diseases. With the world’s population becoming more mobile and increasing economic interdependence, these global health threats increase. Traditional defences at national borders cannot protect against the invasion of a disease or vector. Pandemics, health emergencies, and weak health systems. Climate change effects, including sea-level rise, coastal erosion, extreme weather events and flooding, hold immediate and long-term threats to health. Effects on the marine eco-systems will adversely impact food availability and quality and elevate the risk of toxicity. SD3 Outstanding Issues One-Health Approach The One Health approach50, which promotes multi-stakeholder collaboration to achieve better public health outcomes, is yet to be well understood and appreciated by the different sectors. One key aspect of One Health is the collaborative, multi-sectoral, and transdisciplinary approach working at the local, regional, national, and global levels, to achieve optimal health outcomes recognizing the interconnection between people, animals, plants, and their shared environment. It aims at designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work towards the prevention of illnesses and disease outbreaks in people. There is an urgent need to build strong partnerships with non-health sectors to prevent effectively detect, prevent and respond to zoonosis and food safety problems. 50 WHO. https://www.who.int/news-room/questions-and-answers/item/one-health 55 | P a g e A Joint External Evaluation conducted in 2018 systematically evaluated the strengths and weaknesses of the different sectors and derived a plan of action for implementation by all the relevant sectors. The National Action Plan for Health Security will guide the process to strengthen this multi-sectoral collaboration. Integrated Disease Surveillance and Response (IDSR) and IHR capacity Seychelles has validated the adapted 3rd Edition IDSR Technical Guidelines since August 2019. Rollout of the guidelines, including training, was planned for 2020, but has been delayed because of the COVID pandemic. These revised guidelines is will support the implementation of a robust disease surveillance system for early detection of outbreaks and swift response. Non-Communicable Diseases NCDs cause considerable morbidity and are the leading causes of death. The country is implementing the National Strategy 2020- 2025 that was developed in line with global recommendations. While there has been a decrease in the prevalence of smoking over recent years, there are increases in obesity, and diabetes; in particular, rising obesity among children is alarming. A more coordinated and integrated national approach and actions is vital for efficient and effective A more coordinated and integrated national approach is vital for efficient and effective intervention surveillance, prevention, detection, screening, treatment and control of NCDs and palliative care. These are key components of the response to NCDs to meet national and global targets to reduce the burden of NCDs. Communicable Diseases Seychelles detected its first case of COVID-19 in March 2020 and moved quickly to implement required public health measures and health system response. The country experienced a surge in cases in April- June 2021, with COVID-19, directly and indirectly, leading to excess mortality in 2021. COVID-19 has also negatively affected all the building blocks of the health system and the national economy. Other communicable diseases of importance for Seychelles are HIV/AIDS, Viral Hepatitis C, Dengue and Leptospirosis. Like the rest of the world, the country conducts surveillance for newly emerging or re- emerging diseases that threaten health security. The country is committed to achieving the global goal to end HIV/AIDS as a public health threat by 2030. In the two years before the COVID-19 pandemic, HIV testing increased; however, more efforts are needed to implement effective biomedical prevention interventions at scale and for better HIV treatment and care outcomes. Several factors contribute to the increase in dengue infections the country has recorded over the last five years; they include high mosquito density, susceptibility to circulating serotypes, favourable air 56 | P a g e temperatures, precipitation, and humidity. Although no studies were done recently, these can be linked to change in weather patterns due to climate change. Vaccine-preventable, foodborne, zoonotic, healthcare-related and communicable diseases pose significant threats to human health and may sometimes threaten international health security. Socioeconomic, environmental and behavioural factors, as well as international travel and migration, foster and increase the spread of communicable diseases. Health Regulatory Structure The private health sector is expanding rapidly, and the number of private healthcare facilities has increased over the years, including pharmacies, health clinics, and diagnostic laboratories. There is a need for strong regulatory instruments and monitoring to ensure that all private health facilities adhere to norms, regulations and good practices. Currently, required legal instruments are either lacking or outdated and cannot respond to the continued development and expansion of the private health sector. Presently the Seychelles Licensing Authority licenses these activities and the concern is that once a license is issued, there is no follow up and ensure compliance. The PHA has been given the task of developing the necessary legislation, tools and processes for regulating the private health sector. SD3 Priority Areas 1. Strengthen the One Health approach. 2. Implement the IHR to prevent and swiftly detect outbreaks. 3. Implement IDSR. 4. Develop and strengthen regulatory function of the PHA. 5. Improve public health standards and legislative documents. 6. Strengthen public health law enforcement. 7. Strengthen public health programmes. SD3 General Objective To promote and protect health security, through the:  Strengthening and implementation, in collaboration with national and international partners, the One Health Approach, in line with the IHR and IDSR.  Development and implementation of legal instruments and national standards in accordance with the provisions of the Public Health Authority Act 2013.  Strengthening of public health programmes. 57 | P a g e SD3 Specific Objectives Table 13 SD3 Address Health Security: Specific Objectives SD 3: Address Health Security Lead Contributing Specific objectives Key Interventions Milestones Entity Entity

3.1 Strengthen the Establish coordination mechanism for  National One Health Coordination Committee established. PHA One Health One Health approach.  Clear TOR developed. approach  Formalized processes in place to guide communication between animal health and human health sectors. Implement and monitor National Action  A final and workable National Action Plan for Health Security NAPHS PHA Plan for Public Security (NAPHS). validated and operationalized.  Performance indicators and targets defined  Annual Progress reports from PHA and other sectors involved.

3.2 Implement the Establish a functional team for the  A functional team established. PHA IHR to prevent, and coordination and integration of relevant  TOR developed. swiftly detect and sectors in the implementation of IHR. manage disease Build, strengthen and maintain the IHR  Staff including sectoral focal persons adequately trained. PHA outbreaks workforce capacity.  Public health workforce strategy developed.  Local training capacity on field epidemiology developed. Establish mechanisms for detecting and Mechanisms established and implemented. PHA responding to public health threats and events or emergencies. Map priority public health risks and Mapping completed and disseminated. PHA MoH resources. Monitor implementation of IHR.  Indicator and targets defined. PHA  State Party Annual Report (SPAR) submitted.

3.3 Implement IDSR Strengthen disease surveillance and  Revised IDSR guidelines widely disseminated PHA response.  SOPs for implementing surveillance developed.  IDSR training rolled out to human and animal health staff. Develop regulations to strengthen  Regulations developed and implemented PHA reporting from private facilities.  Real-time reporting from all reporting sites. Improve analytical capacity to maximize  Analysis modules in web-based surveillance system. PHA the use of surveillance data.  Selected staff trained in biostatistics.  Ongoing operational research. 58 | P a g e

3.4 Strengthen Strengthen human resource capacity for All units adequately staffed. PHA regulatory regulatory functions. functions of the Finalize regulations for registration of  Regulations approved and implemented. PHA PHA health and health-related facilities.  New facilities registered under new regulations.  Deadlines and guidelines for existing facilities to comply with new regulations. Define roles, responsibilities, M&E Roles, responsibility and M&E defined. PHA requirements for regulatory services.

3.5 Improve Public Revise and update existing and required  Directory of outdated or substandard legal instruments developed. PHA MoH health standards public health laws/regulations.  Legislative review calendar developed. and legislative  New and revised legislative documents as per calendar. documents Develop SOPs guidance documents. SOPs and guidance documents developed, disseminated and implemented. PHA Develop national standards to ground National standards developed and endorsed. PHA preventive public health. Monitor adherence to standards and take  Standard monitoring tools developed. PHA corrective action where needed.  Ongoing monitoring.  Annual compliance report published.

3.6 Develop and Strengthen programme management  Strong programme managers appointed PHA Strengthen public capacity.  Clear job description and TOR developed health programmes  Formal coordination and communication mechanism in place to facilitate and encourage collaboration between programmes Develop and revise relevant disease  National Cancer Strategic Plan endorsed. PHA MoH specific strategic plans and policies.  Mental Health Policy finalised.  Conduct mid-term review of NCD Strategy. 59 | P a g e SD4 Promote Healthy Populations The WHO defines health as “the state of complete physical, mental and social wellbeing, and not merely the absence of disease and infirmity”. The right to health is fundamental for every human being and enshrined in Article 29 in the constitution of Seychelles51. The conditions in which people are born, grow, live, work and age are known as the social determinants of health (SDHs) and include factors like socioeconomic stability, education, neighbourhood and physical environment, employment, and social support networks, as well as access to health care (Figure 18). Figure 18 Social (Environmental and Economic) Determinants of Health (SDH). Source: Social Determinants of Health, based on Dahlgren and Whitehead (1991). These SDHs, in-turn, influence various risk factors and behaviours, which subsequently lead to ill health and disease Figure 19. 51 Constitution of the Republic of Seychelles, 1994. 60 | P a g e Figure 19 Causal pathways linking poor SDHs with risk factors and later disease. Social Risk Factors & Disease Determinants of Behaviours • Cancer Health • Alchohol • Diabetes • Poverty • Smoking • Heart Disease • Unemployment • Poor diet • Infections Addressing social determinants of health is not only important for improving overall health, but also for reducing health disparities that are driven by social and economic disadvantages. Higher income and social status are usually linked to better health. The greater the gap between the rich and the poor in society, the greater the differences between their health52. In regards to education, low education levels are linked with poor health, more stress and lower self-confidence. Additionally, the MPI report of 2019, published by the NBS, showed that factors such as large household/ overcrowding, substance abuse, unemployment, and low education level, strongly contributed to multidimensional poverty, thereby also impacting the health status of individuals. A healthy, productive population forms the pillar of the country’s sustained growth and prosperity. The health and wellbeing of the people of Seychelles continuously faces major threats. The double, and increasing, burden of infections (like HIV, Viral Hepatitis, and pneumonia), as well as chronic non- communicable diseases (like diabetes, hypertension, cancer, and cardiovascular disease), combined with social and mental health problems (like injection drug use, psychological disorders), are creating an unprecedented challenge to maintain and improve health, as well as to maintain sustainability of livelihoods and economic growth. 52 Marmot, Michael, and Ruth Bell. "Fair society, healthy lives." Public health 126 (2012): S4-S10. 61 | P a g e Harmful use of alcohol is one of the four modifiable and preventable risk factors for NCDs. Excessive alcohol consumption has been associated with negative social impacts such as interpersonal violence, unemployment, poor academic performance, and in addition, child and elderly neglect. These collective factors have devastating impact on individuals and their families further affecting overall health. Strong political leadership is essential to address social determinants of health. Promoting healthier population requires improving the physical and mental health and wellbeing of the population. This can be extremely challenging as it requires intensive, coordinated long term efforts, across many government departments and sectors. The HiAP is an approach that promotes collaboration between government sectors and non-government stakeholders to maximize the health benefits of government policies and reduce health inequalities, such as differences in life expectancy between different population groups. The approach also aims at minimizing any harmful consequences of public policies on determinants of health and health system. The Government of Seychelles has pledged to the HiAP approach in 2017 and committed to engage all sectors of the government and non-governmental organizations through leadership, partnership, and advocacy to achieve improved health outcomes. Climate change is an insidious but very real threat to health and the wider society. Its impacts on health can be direct (through extreme weather events and related injuries and deaths), indirect (through changes to quality of air, water and nutrition) or through disruption of social and economic activity (which lead to adverse health outcomes). Figure 20 describes the mechanisms that drive climate change, and lead on to population exposures that result in ill health. Evidence for the extreme health consequences of climate change are already evident – increased rates of cardiovascular disease, kidney disease, diabetes, malnutrition, etc. The poorest countries, countries in hotter climates, and coastal and small-island states will be impacted the hardest from these changes. Even though Seychelles is only a minor contributor to climate change, we will bear the brunt of the consequences of climate change, emphasising the importance of elaborate and timely evidence-based mitigation and adaptation strategies, including in the health sector. 62 | P a g e Figure 20 Framework describing how climate change impacts global public health. Source: Framework for climate change and global public health, Source: Tord Kjellstrom and Anthony J.McMicheal (2013). 63 | P a g e SD4 Outstanding Issues Health in All Policies Approach (HiAP) Although the HiAP approach was endorsed by the Cabinet of ministers (from previous administration) in 2017, not a lot has been done since. There is a strong need for the endorsement of the current administration and re-integration of the HiAP in all government sectors, private entities, and civil societies. MoH needs to build linkages with other government entities and ensure that there are health considerations in their policies and projects. Communication strategy (for addressing risks to health) A coordinated advocacy and communication plan to guide the ongoing efforts at reaching out to communities and households is not yet in place. Communication strategies are needed to address behavioural, environmental, and metabolic risk factors. Health Promotion Some of the NHSP 2016-2020 objectives and expected outcomes were not achieved, like behaviour change communication advocacy. There is also weak national coordination system for health promotion activities. Inadequate access to finance makes it difficult to plan impactful interventions. Cancer and mental health Outstanding needs include the development and implementation of a National Cancer Control Plan, and finalisation and implementation of the National Mental Health Policy, with participation of other sectors, as well as the community. Nutrition  Create a supportive environment for breastfeeding in workplaces, and fully implement code of marketing of breast-milk substitutes, to protect and promote breastfeeding.  Develop and implement policies that protect children from the harmful effects of marketing of unhealthy products on media.  Integrate regulatory reforms to improve food environments.  Develop appropriate policies to facilitate introducing nutrition and environmental standards for public institutions.  Build capacity of health and community workers as food system agents of change everywhere when developing and implementing solutions.  Conduct operational research to assess barriers to behaviour change.  Fully implement strategies outlined in the National NCD Strategy (2016-25).  Enforce policies and regulations for quality of foods and drinks that are sold in commercial outlets. 64 | P a g e  Finalize and implement school nutrition policy, policy for nitrites and trans-fatty acid. Health in Educational settings  Build capacity of those working in School Health Programme.  Child and Adolescent Health areas deficient in life-course approach to health promotion.  Ensure health policies cover educational institutions at all levels (pre-primary, primary, secondary and post-secondary).  Need for strict bans on fast-food outlets in proximity of schools, need to finalize and implement school health policy. SD4 Priority Areas 1. Promote healthy living for different age groups. 2. Address key risk factors for health. 3. Revitalize the health in all policies approach. 4. Promote prevention and management of substance abuse and mental health. 5. Transform Health Promotion. 6. Promote/ advocate for Effective Public Health. SD4 General Objective Support the creation of a conducive environment to:  Support healthy living.  Reduce and control risk factors for health.  Promote safe and healthy neighbourhoods.  Engage MDAs and other stakeholders to promote and improve health and wellbeing of people. 65 | P a g e SD4 Specific Objectives Table 14 SD4 Promote Healthy Populations: Specific Objectives SD 4: Promote Healthy Populations Specific Lead Contributing Key Interventions Milestones Objectives Entity Entity

4.1 Promote Develop and implement new evidence-based approaches for promoting healthy living. healthy living for Introduce monthly healthy living/ well-being clinic. Healthy living/ well-being clinic introduced. HCA MoH all age groups PHA Adopt a gradient approach across the life course to cater for the Gradient approach adopted. HCA MoH needs of different age groups and socioeconomic groups in the PHA population. Integrate healthy living approach in all health programmes Healthy living approach developed. HCA Develop healthy living approach for specific health program. PHA

4.2 Address risk Address risk factors for NCDs and communicable diseases. factors for health Integrate WHO best- buys for NCDs into relevant health WHO best buys for NCDs integrated PHA MoH programmes. Strengthen implementation of NCD strategy to address key risk Existing NCD strategy implemented PHA factors. HCA  Develop and implement NCD campaign: ‘Know your numbers’. NCD Campaign developed and implemented. MoH  Launch a ‘know your status’ campaign for addressing HCA communicable diseases in the community. PHA  Declare obesity as a public health emergency and introduce  Childhood obesity is declared as a public health PHA population-based and multi-level approaches to gain emergency. MoH participation from multiple actors.  Combating obesity mainstreamed across life HCA  Develop national framework to prevent and manage obesity course and disease-specific programmes. jointly with other MDAs.  Multi-sector framework developed. Develop and implement nutrition sensitive programmes and Nutrition sensitive programmes and approaches and PHA approaches and nutrition specific programmes to address the nutrition specific interventions developed and burdens of malnutrition. implemented Promote physical activity in the population (clubs at school, Physical activity clubs set up. PHA MoH workplaces, districts, etc.). HCA Review and modernise sexual health education for youth, including New toolkit for sexual health education. PHA education on avenues for accessing supports. HCA 66 | P a g e Ensure strategic information is available for action. Set up the Nutrition Information System (NIS) to improve nutrition NIS set up and functional. HCA MoH data system and monitoring. PHA Conduct population survey to understand NCD risk factors.  Population survey on NCDs conducted PHA MoH (Seychelles Heart Study V, UPCCD).  NCD survey findings used to revise/ strengthen programmes and interventions. Develop, support, and monitor the Global Nutrition Framework Seychelles’ GNF developed and implemented. MoH (GNF) for Seychelles. Empower people to develop life skills to better manage their health. Teach practical life skills to enable people to better manage and Key life skills training conducted MoH take control of their health PHA Develop self-management tools for key chronic health conditions Self-management tools developed and in-use. MoH PHA Promote use of new technologies and devices to support healthy New devices to support healthy living promoted. HCA living, e.g. Fitbit, physical activity trackers; and empower them to MoH use new devices to self-monitor existing chronic medical conditions and/or risk factors.

4.3 Revitalize the Revive, implement, and monitor the HiAP. HiAP Introduce the HiAP to, and gain the endorsement of, new Cabinet Endorsement of the HiAP by Cabinet and the MoH of ministers and members of the NA National Assembly Expand role of Health Impact Assessments Expanded HIA tools and training developed and put PHA MoH in use. Monitor and report on HiAP HiAP annual report developed and disseminated. MoH Institutionalize the Health of Our Nation campaign (HOON) Revive and institutionalize HOON. HOON institutionalized. MoH HCA; PHA Other Sectors

4.4 Promote Prevention of tobacco use, illicit drugs, and harmful use of alcohol. good mental Promote supportive environment in the communities to prevent Availability of family-based prevention programmes MoH PHA health and or reduce the use of illegal substances to address substance abuse. prevent and Promote use of harm reduction services Utilization of harm reduction services increased MoH PHA manage substance abuse  Develop and implement new campaign to address alcohol Campaign developed and implemented. MoH PHA disorders abuse in the country.  Develop campaigns to reduce tobacco use in the population. Develop policies and regulations to control the use of alcohol  Policies and regulations developed and PHA implemented. MoH  Fully implement alcohol-control policy. 67 | P a g e Improve access to, and awareness of, smoking cessation support More individuals accessing the smoking-cessation PHA services. programme. Address mental health issues in the community. Promote good mental health (e.g. Practical interventions on coping Activities to promote good mental health PHA with stress, bereavement, etc.) for different age groups. implemented. HCA Introduce social prescribing. HCWs and clients sensitized on social prescribing; HCA Social prescribing implemented. Facilitate the development of support groups. Support groups set up. HCA

4.5 Transform Bring health closer to people. Health Develop, disseminate, and implement new health promotion Health promotion policy developed and MoH PHA Promotion policy. implemented. HCA Equip people to better take care of their health Develop and implement health literacy project  Increased health literacy in the population MoH PHA  Health literacy project developed and HCA implemented.  Support community ‘champions’ to advocate for programmes Community ‘champions’ identified and supported MoH HCA promoting health. PHA  Provide capacity building for youths and adults to champion Other Sectors and promote health programmes. Strengthen Health Promotion frameworks, resources and supports  Develop a sector Health Promotion Committee Health promotion committee set up and operational. MoH PHA  Set up a health promotion committee to provide oversight and HCA guidance on methods of dissemination of health promotion messages.  Strengthen capacity to leverage on legal, fiscal and other policy Relevant fiscal, legal and partner-supports available MoH interventions to transform health promotion. and used. PHA  Implement relevant international treaties to support health promotive environment at domestic level.

4.6 Promote/ Advocate for safe and peaceful neighbourhoods Advocate for Promote safe food and water supply in the community Safe food and water supply achieved and monitored. PHA MoH Effective Public Health Promote safety at home, school, on the road, at work, leisure Safe community concept promoted events etc. Establish collaboration with civil societies on health related Quarterly meetings with civil societies involved in MoH matters. health Advocate for safe recreational areas in the community Safe recreational areas available in the neighbourhoods MoH 68 | P a g e SD5 Invest for Results Investments for health looks at all critical inputs necessary to effectively deliver health care and public health. These include financing, human resources, health technologies and infrastructure. Investment in health is, therefore, an investment in the broader economy. “Investment for health and wellbeing is a driver and an enabler of sustainable development and vice versa, and it empowers people to achieve the highest attainable standard of health for all”53. Figure 21 shows the intricate relationships between these critical inputs for the production of health interventions. It is clear that it is extremely important to balance the mix of resources for maximum health benefits54. Figure 21 Health Finance inputs and pathways to production of Health interventions The COVID-19 pandemic brought to light just how critical these inputs are to the daily operations of the health system. Resources were diverted into national COVID response very often at the expense of other services and functions. 53 Dyakova, Mariana, Hamelmann, Christoph, Bellis, Mark A., Besnier, Elodie, Grey, Charlotte N.B.et al. (2017) . Investment for health and well-being: a review of the social return on investment from public health policies to support implementing the Sustainable Development Goals by building on Health 2020. World Health Organization. Regional Office for Europe. https://apps.who.int/iris/handle/10665/326301 54 The World Health Report 2000: health systems: improving performance. 69 | P a g e HCW absenteeism due to COVID-19 exposure, staff redeployment to new isolation and treatment facilities, and demands from the expanded COVID-19 testing and dedicated ‘fever clinics’ highlighted the importance of an adequate, trained and resilient workforce. Restrictions in international air travel, depreciation of the Seychelles rupee, and in-country lock-downs in source countries severely compromised the procurement of medicines and medical products. The successful implementation of the health agenda 2022-2026 is dependent on actions to strengthen each health system building block, outlined next. Human Resources for Health The COVID-19 pandemic has further highlighted the importance of sufficient numbers of adequately trained motivated HCWs, in dealing with existing and emerging health challenges. The national vision for health, expressed in the National Health Policy, can only be achieved with an adequate resilient workforce equipped with knowledge and skills to take on these challenges. Effective human resources (HR) management strategies are crucial to achieving better outcomes in health55. Local HR Management capacity is rudimentary, focusing principally on administrative functions around ‘hiring, paying and firing’. The Human Resources Division requires much capacity building to deliver on all core HR functions. Some key areas of deficiency are staff welfare and occupational health and safety. The sector has yet to define national HR norms and standards, affecting projection and planning and better deployment of available human resources. There is a lack of quality data to inform decision making and planning. Outstanding issues in HRH Health Workforce Production The Seychelles health system is heavily dependent on foreign health workers. Fifty-seven per cent of all health professionals are expatriates and 64% are trained abroad56. The health sector faces intense competition from other sectors in attracting the best minds, especially for the local training programmes. The NIHSS Access Programme, designed to help meet admission requirements, has contributed positively to increasing enrolment. More effort is required to engage secondary school students at an early stage to increase interest in careers in health and social fields. The health sector remains dependent on foreign training for key occupational cadres. There is a need to bring uniformity to training by selecting key institutions for the different cadres. Mechanisms for access to in-service training is also inadequately defined and communicated. 55 Kabene, S.M., Orchard, C., Howard, J.M. et al. The importance of human resources management in health care: a global context. Hum Resour Health 4, 20 (2006). https://doi.org/10.1186/1478-4491-4-20 56 Health Workforce Situation in Seychelles: Insights from baseline National Health Workforce Accounts, MOH, 2021 70 | P a g e Recruitment and Deployment There is no clear policy on recruitment, especially for foreign HCW. Unnecessary bureaucracy delays the employment of identified personnel. Allocative inefficiencies are often reflected in highly trained staff with critical skills not working in the areas for which they have received training. Succession Planning Key positions in the sector remain unfilled due to poor succession planning. Managers sometimes do not adequately recognize and nurture future leaders in health, affecting succession planning. Remuneration, Incentives and Rewards Staff awareness on remuneration, appraisal and promotion policies and norms is low. Where Schemes of Service are available, these are not readily available and accessible to staff. Appraisal systems are not adequately tailored to actual work and do not sufficiently reflect performance. More continuous mechanisms for feedback on performance is lacking. Incentives are considered from a monetary perspective only. Collection, Analysis and Use of HR Data The sector does not systematically collect, analyse and use HR data to guide training, recruitment, deployment of staff. Available data is fragmented, mostly paper-based and inaccessible to decision makers. The National Health Workforce Accounts (NHWA) has been introduced to facilitate the standardization of a health workforce information system in order to improve data quality57. This reflects a step in the right direction for evidence-informed HRH planning, but more work is required towards institutionalisation of the process. Staff Wellbeing HCWs are under considerable strain. The COVID pandemic has stretched resources thin. HCWs have been redeployed to areas in need, in some instances with little or no training and little consideration of effects on their mental health and wellbeing. HCWs feel unappreciated within their organisation and are often left alone to deal with occupational and personal crises. Burnout, although not systematically measured, is a reality. An unknown number of HCWs abuse drugs and alcohol. However, the subject remains taboo, and subsequently, help is not accessed. Priority Areas in HRH 1. Develop a national Human Resources Strategic Plan. 2. Empower professional councils to become more effective regulators. 57 Understanding National Health Workforce Accounts, WHO 2017 71 | P a g e 3. Make careers in health more attractive. 4. Enable HR to deliver on all core HR Functions. 5. Provide support and guidance for career planning. 6. Care for the carers. 7. Improve HR data collection, analysis and use for decision making. Healthcare Financing Health financing involves the mobilisation and equitable distribution of funds to meet the health needs of individuals and communities. This means ensuring that no one endures financial hardship as a result of accessing essential health care. The government has always been and remains the principal investor in health. Total Government Health Expenditure was SCR 887 million in 2018, representing 11.2% of total government expenditure, below the 15% target countries committed to in the Abuja Declaration. Total Health Expenditure (THE) as a percentage of nominal GDP increased from 3.8% in 2014 to 5.6% in 20183. The major cost drivers are health care goods and services (54.5%) and compensation of employees (38.8%). Outstanding issues in Health Financing Sustainability of the current financing model Health expenditure is increasing and will continue to rise due to several factors, including the increasing incidence of NCDs, obesity, and the shift towards an ageing population. New technologies are expensive, and inflate costs especially when there is overutilization to satisfy rising client expectations. The right to health enshrined in the Constitution obligates the state to provide for free primary health care in all its institutions. However, the current palette of services includes dental care, secondary and tertiary health care, which is not sustainable in the long run. Spending is skewed towards curative care, especially specialised care In 2018, 47.4% of CHE went towards curative care and 22% towards preventive care. Consecutive NHA reports have shown a small increase in expenditure on preventive care, from 17.7% in 2016 to 19.4% in 201758. 58 National Health Accounts (NHA), 2016-202017 Report 72 | P a g e Challenges with PPBB Performance-Based Budgeting (PPBB) refers to ‘any budget that represents information on what agencies have done, or expect to do, with the money provided to them’59. In other words, PPBB is ‘the systematic use of performance information to inform budget decisions, either as a direct input to budget allocation decisions or as contextual information to inform budget planning, and to instil greater transparency and accountability throughout the budget process, by providing information to legislators and the public on the purposes of spending and the results achieved’. However, the introduction of PPBB has not brought expected improvements in results. Managers are not sufficiently engaged in the budgeting process. The abolition of cost centres with the introduction of the PPBB system has left health managers in the dark regarding available funds for the projects they are expected to implement efficiently. Lack of cost (-benefit) awareness There is a lack of cost awareness among service providers and service users. The notion of free healthcare may nudge users to undervalue the cost of the care they receive. Greater cost awareness will help guide cost-conscious clinical and administrative decision making and ultimately improve cost- efficiency of health services. Weak revenue collection systems in the public health sector Health being free at the point of use, the system is not traditionally geared towards revenue collection. There are no SOPs and guidelines to guide revenue collection from those not eligible for free services (expatriate workers, tourists) nor established mechanisms to minimize risk of diversion of funds and embezzlement. Some service areas are more vulnerable to corrupt practices than others. There are not enough cashiers, especially at the Seychelles Hospital and outside regular working hours. Most facilities are not equipped for cash less transactions. There is no centralized billing system. Very often, HCWs do not know who is eligible for free services and who is not. Priority Areas in Health Finance 1. Make PPBB work for the sector. 2. Address inefficiencies in health care management and delivery. 3. Improve revenue collection. 4. Ensure sustainability of health care financing. 5. Increase spending on preventive and promotive care. 59 OECD Best Practices for Performance Budgeting, Public Governance Committee Working Party of Senior Budget Officials. November 23, 2018. Online at: https://one.oecd.org/document/GOV/PGC/SBO(2018)7/en/pdf 73 | P a g e Health Infrastructure A Masterplan for the development of Hospitals in Seychelles was developed. It is a comprehensive infrastructure plan for the Seychelles Hospital and its annexes and the three smaller hospitals at Anse Royale, Baie Ste. Anne and La Digue. The project did not include primary health care facilities and has not been implemented to date. Infrastructure development and maintenance is not well-coordinated and is not necessarily based on needs. Outstanding issues in Infrastructure  Internal capacity to manage big projects is weak.  The sector does not have an infrastructure maintenance plan.  Some facilities are no longer fit for purpose.  Need for additional Intensive Care beds.  Need for purpose-build dedicated Isolation infrastructure.  Facilities are not disabled-friendly.  Fire, flooding, chemical, biological and radiological risks need to be addressed. Priority Areas in Infrastructure 1. Make PPBB work for the sector. 2. Address inefficiencies in health care management and delivery. 3. Improve revenue collection. 4. Ensure sustainability of health care financing. 5. Increase spending on preventive and promotive care. Health Technologies Health technology is the application of organised knowledge and skills in the form of medicines, medical devices, vaccines, procedures, and systems developed to solve a health problem and improve quality of life (WHO). Outstanding issues in Health Technologies  Lack of regulatory framework for health technologies  Stock outs of medicines and commodities  The sector does not have a list of essential technologies  The Procurement Unit does not involve service providers in prioritisation exercises  Service maintenance contracts are not always clear on roles, responsibilities and scope  The digitalisation of stock management is not complete. 74 | P a g e Priority Areas in Health Technologies 1. Strengthen procurement and stock management capacity 2. Digitalise Stock management 3. Engage Service providers in procurement processes 4. Improve service maintenance contracts 5. Ensure donated equipment, medicines or supplies align with MOH standards and needs. Information Technology Information Technology (IT) presents unprecedented opportunities for innovation in health care delivery. As these technologies become more accessible to broader sections of the population, the health sector needs to take advantage of these technologies to improve health outcomes. Electronic Health (eHealth) is the delivery of health care using modern electronic information and communication technologies when health care providers and patients are not directly in contact, and their interaction is mediated by electronic means. Mobile health (mHealth) is a subset of eHealth, defined as medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices (WHO). Outstanding Issues in IT The sector has not capitalised on the wide availability of mobile phones (193,672 mobile phones and 89,896 mobile broadband subscribers in 201960) to engage with service users. Different units have created WhatsApp groups for discussions and sharing of information; however, the sector has yet to exploit the full potential of these technologies. The MoH has introduced different telemedicine projects over the years, but none proved to be sustainable. Priority Areas in IT 1. Support for new health care delivery models – appointment systems, reminders, treatment adherence support, health education, health promotion, self-management supports. 2. Provide health professionals with point of care access to information – guidelines, standards, decision-making tools. 3. Facilitate data collection – routine reporting, surveys, monitoring. 4. Institutionalise eLearning and CPD. 5. Utilise Telemedicine to improve access to services, including in crises. 60 Seychelles in Figures, 2020 Edition, NBS, Seychelles 75 | P a g e SD5 General Objectives To ensure effective, efficient and sustainable investment in the building blocks of the health system. Human Resources for Health The sector shall develop a national Human Resources for Health Strategy to guide the production, recruitment, deployment, retention and remuneration of health care workers. Emphasis will be on support for HCW throughout their career, from induction and mentorship programmes to staff welfare programmes. MoH will strengthen the capacity of the human resources unit to deliver on all HR functions. Health Finance The sector will seek to improve efficiency in health care by raising cost awareness, conducting cost- benefit analyses of key services (including outsourced services), and redirecting funding to more cost- effective upstream interventions delivered through preventive and primary care. The sector will also conduct a review of ‘low-value care’ – care that provides little or no benefit, may cause harm, or yields marginal benefits, at disproportionately high cost. MoH will explore alternative financing sources such as national insurance funds, social enterprising, accessing global, regional and bilateral supports, and public-private partnerships in evidence-based health service delivery to ensure health sustainability. Infrastructure The health sector will elaborate a comprehensive infrastructure development and management plan to address resilience in the face of climate change, disability access to facilities, fire and other risks, and address the challenges of inadequate safe and secure storage for supplies. The plans will ensure that new buildings are more fit-for-purpose, and outdated facilities are gradually brought up to standard. The proposed centralisation of infrastructure development will benefit the health sector, which lacks the internal capacity to develop and follow through with major infrastructure projects. Health Technologies The sector will develop an Essential List of Health Products, that similar to the Essential List of Medicines, aligned with the agreed package of care and services. Both the Essential List of Health Products and the Essential List of Medicines will serve as advocacy tools for resource mobilisation and prioritisation, ensuring that facilities have access to those medicines and commodities required for their scope of health care services. The tools will also guide donations, ensuring alignment with health system needs and standards. The sector will introduce mechanisms for the introduction of new health products and technologies and revise the procurement process to avoid stock-outs. 76 | P a g e Information Technology As health care workers and the population become more technology proficient and technologies become more affordable, the sector will look for opportunities to introduce IT solutions across the spectrum of activities, including to:  Promote e-learning: Online-learning platforms with the capacity to track CPD activities, push targeted content towards specific groups and upload local content will be developed.  Provide remote consultations (telemedicine), which can significantly reduce the cost of providing many decentralised specialist services.  Support new health service delivery models: Patients will receive reminders and prompts. They will be encouraged to monitor specific parameters at home and relay this information to their service providers, who will provide the appropriate response. These platforms can also be used for health promotion and health education. 77 | P a g e SD5 Specific Objectives Table 15 SD5 Invest for Results: Specific Objectives SD 5: Invest for Results Specific Lead Contributing Key Interventions Milestones Objectives Entity Entity

5.1 Human 5.1.1 Make professional councils more relevant Resources for Revise regulatory frameworks to give Professional Professional councils’ legislation revised and harmonised. Councils MoH Health Councils the power and authority to deliver on all functions of a professional regulatory body. Develop partnerships with other Councils and Public MOUs signed and implemented. Councils MoH Health Authority to allow sharing of resources and PHA competencies. Make CPD mandatory for relicensing. Clear CPD requirements in place and monitoring of CPD for Councils MoH different cadres. HCA

5.1.2 Plan for the future HR needs Develop National Human Resources for Health National Human Resources for Health Strategic Plan developed MoH HCA Strategic Plan. and implemented.

5.1.3 Make HR planning, administration and management fit-for-purpose Create an HR Structure that meets the needs of the Structure established, roles and responsibilities clearly defined HCA sector. Increase HR expertise.  Trained and competent HR managers recruited for all HR HCA functions  In-service training plan for HR personnel developed and implemented Develop policies and Standard operating procedures  Policies and SOPS developed and implemented HCA for key HR administration functions. Implement PMS Pillar of RBM.  Performance management system institutionalised MoH HCA PHA

5.1.4 Make Health careers attractive Develop a career promotion plan.  Promotion plan developed and implemented. MoH HCA  Promotional material developed. NIHSS PHA  Planned promotional activities carried out. 78 | P a g e Re-invent health clubs in schools.  Health clubs up and running in all secondary schools MoH HCA  Health ambassadors identified in all secondary schools MoEdu PHA

5.1.5 Support and guide staff throughout their careers Make recruitment clear, transparent, expeditious and  Recruitment policy developed and implemented MoH ethical  Clear and transparent job descriptions available for all cadres HCA and positions PHA Comprehensive Induction Package for all new recruits  Entity and unit specific induction programme developed and MoH implemented HCA  All new recruits undergoing induction PHA Provide mentorship and supportive supervision.  Cadre specific mentorship programmes developed and HCA MoH implemented. PHA  Framework for supportive supervision of all cadres developed and implemented. Make career progression fair and transparent.  In-service training policy developed and implemented. MoH  Revised appraisal forms developed and implemented. HCA  Salary enhancement and promotion guidelines widely PHA disseminated.  All health professionals have a clear five-year professional progression plan. Identify and develop future leaders Succession plans for leadership positions developed and MoH implemented. HCA PHA Improve work ethics.  Employee handbook revised and widely disseminated. MoH  MoH Vision and Mission Statement visible displayed in all HCA facilities. PHA  National ethics and professional standards developed.

5.1.6 Care for the Carers Make health and safety a priority for HCWs  Role and responsibility of health and safety officer defined. HCA  Health and safety focal persons identified in all units. PHA  Tailored cadre and age-specific HCW screening programmes developed. Address mental wellbeing  Support groups and programmes for at-risk HCWs established MoH and running HCA  Structures for debriefing and counselling in place PHA  Introduce social prescribing for HCW (yoga, meditation, exercise, etc.) 79 | P a g e  Mechanism for identification and reporting of HCWs with alcohol and drug problems in place Equip HCW to provide peer support Peer counsellors identified and trained HCA PHA Explore non-monetary options for recognition of good Awards and other non-monetary recognition programme in MoH work. place. HCA PHA

5.1.7 Use data to inform HR decision making Introduce Human Resources Information System. Functional Human resource information system in place. MoH HCA PHA Councils Use evidence-based tools to guide data collection,  National Health Workforce Accounts (NHWA) MoH HCA management and analysis. institutionalised. PHA  Workload Indicators of Staffing Needs assessment conducted Councils in health facilities. Make HR data available (develop information  Annual HRH performance report produced and disseminated. MoH products).  Cadre specific annual reports produced and disseminated.  Annual NHWA reports produced and disseminated.

5.1.8 All HCWS are proficient in at least one of the three national languages Establish a language proficiency framework for all Language proficiency standards for recruitment and existing staff MoH HCA HCWs defined and implemented PHA Councils

5.2 Health 5.2.1 Ensure sustainable financing for health Financing  Advocate for increased investment in health  Aim to have 15% of total government expenditure allocated MoH to health. HCA  6% of GDP allocated to health. PHA

5.2.2. Make health care spending more efficient Spend more on prevention and primary care  Expenditure for primary care and preventive services MoH MFTIEP increased. HCA  Additional earmarked funding for improvement of PHC (1% GDP re-directed). 80 | P a g e

5.2.3 Make PPBB work for the health sector  Align PPBB programmes with service delivery  Revised/tailored PPBB programmes. MoH system.  KPIs aligned to entity mandate and NHSP targets. HCA  Review entity KPIs and align to core mandate and  Internal cost centres introduced and implemented. PHA NHSP targets.  (Re-)Introduce cost centres so managers are aware of their unit budgets (pending discussion with MFTIEP). Improve capacity for budgeting and priority setting  Managers actively engaged in the budgeting process. MoH (discuss with MFTIEP).  All managers have received basic training in PPBB.

5.2.4 Ensure efficient use of resources. Institutionalise costing of health services  Institutionalisation of costing of health services. HCA  Training of staff conducted. PHA  Baseline costing completed. Raise cost-benefit awareness amongst stakeholders  Costing information available for all services. HCA  Managers/Unit heads are aware of their unit budget. MoH  Mechanisms to prevent and monitor pilfering and diversion of resources in place. Ensure efficiency of outsourced services.  Guidelines for outsourcing services developed and HCA implemented.  Review and renegotiate outsourcing contracts.  Monitoring mechanisms in place for all outsourced services. Review and report on key expenditures (cost drivers  Key expenditures for review identified. PHA e.g. spending on COVID-19 response, Overseas Rx,  Review and reporting cycle determined. HCA Haemodialysis, Cancer care …).  Reports produced and disseminated. Cost-benefit analysis done before the introduction of Cost-benefit analysis conducted. MoH key new services. HCA Implement interventions to reduce wastage. Interventions to reduce wastage in health implemented. HCA Conduct a review of services to identify low-value Review conducted and appropriate measures taken. HCA PHA care. MoH 81 | P a g e

5.2.5 Improve revenue collection Determine who pays for what services.  Beneficiary Criteria for free services clearly defined HCA  Fees for services or service packages established and disseminated.  Fees policy for specialised services for private patients reviewed. Make revenue collection easier  Cashless payment systems widely used in all facilities.  Functioning revenue collection system, active 24x7, in place.

5.2.6 Consider alternative financing mechanisms Explore the potential for the introduction of social Analysis of potential and scope of social insurance schemes MoH insurance schemes. conducted Benefits pitfalls etc. Develop Public-Private Partnerships for investment in Policy on public-private partnerships developed and MoH health (discuss with MFTIEP). implemented. Explore revenue generation through collaboration  Framework for the provision of ambulatory care services to MoH with the private sector. tourism establishments as a mechanism for revenue generation.  Framework for the private health sector to access key MoH infrastructure and services at cost.

5.3 Health 5.3.1 Create a legislative framework for the regulation of health technologies Technologies Finalise Medical Products and Pharmacy Operations Medical Products and Pharmacy Operations Bill enacted and HCA Bill. implemented. PHA

5.3.2 Revise and strengthen procurement and supply chain management Strengthen management capacity of central stores.  All core management positions filled with trained staff. HCA Move to complete digitalisation of store functions.  Electronic store management system in place and fully- HCA functional.  Store personnel trained and competent to operate within the digital environment. Promote rational use of health products  Guidelines for rationale use of health products HCA  Review use of disposable products (e.g. protective gowns, drapes, OT towels).  Shelf life and expiry dates of products closely monitored. 82 | P a g e Implement structural and governance processes to  Effective measures in place to address diversion and wastage. HCA stop diversion and wastage Develop and monitor key performance indicators for  Key performance indicators developed. HCA Central Store  Regular performance reports produced as per agreed reporting cycle.

5.3.3 Ensure uninterrupted supply of essential health products at point-of-use Develop an essential list of health technologies  Essential list of health products developed and implemented. HCA commensurate with the health service package.  Facility specific health technology inventories developed. Revise essential medicines list taking into account new  Essential Medicine List revised HCA evidence-based treatment guidelines for priority  New Drugs for priority NCDs are readily available. NCDs. Introduce new health products. New health products introduced in line with the approved care HCA package and clinical guidelines/protocols.

5.4 Health 5.4.1 Build for purpose Infrastructure Develop infrastructure Masterplan based on actual Infrastructure Masterplan developed. HCA Infrastructure and anticipated needs (to be discussed). Agency Develop and implement local accreditation standards  Accreditation standards developed and implemented. PHA for health infrastructure.  Accreditation cycle anchored in legislation.

5.4.2 Make infrastructure resilient, safe and accessible for all Conduct inventory of infrastructure and create a Real-time inventory of infrastructure available. HCA facilities master-list. Draw up an infrastructure and equipment  Maintenance plan developed and implemented HCA maintenance plan.  Preventive maintenance conducted in line with maintenance plan. Assess infrastructure for fire, flooding, chemical,  Fire risk assessment of all health facilities conducted. HCA radiological and biological risks.  All facilities have a fire evacuation plan in place.  Regular fire drills conducted.  Facility specific risk assessment conducted. 83 | P a g e Ensure facilities are disabled friendly.  Establish minimum standards for disability access in health HCA facilities.  Wheelchair access available to all health facilities  Facilitate access for visually impaired. Address increased infrastructure needs for high-care  ICU bed capacities expanded to meet demand. HCA and infectious-disease isolation.  Dedicated purpose-built Isolation Unit ready. Mainstream climate resilience in all infrastructure Potential effects of climate change considered in all new service HCA planning. and infrastructure planning.

5.5 Information 5.5.1 Create supportive IT environment Technology Ensure internet access.  All facilities have reliable around-the-clock internet access. HCA  Review content restrictions. DICT Invest in required hardware  Teleconferencing solutions available in health facilities. HCA  All facilities have access to tablets, laptops and desktop DICT computers. Create the appropriate regulatory framework Appropriate legal and regulatory instruments developed and MoH implemented

5.5.2 Use IT to improve health care Support for new service delivery models  Systematic Appointment reminders generated. HCA  IT solutions to support treatment adherence in use.  Service users receive targeted health education and health promotion. Provide information and decision support to health  SOPs, guidelines, algorithms and other decision-making tools professionals at the point of care readily available. HCA Institutionalise telemedicine widely available  Telemedicine services defined.  Teleconsultations offered per regular schedule. HCA Facilitate learning and continuous professional  Regular virtual CPD sessions organised. HCA MoH development  Online CPD Platform introduced. PHA 84 | P a g e SD6 Improve Data for Impact Reliable and timely health information is an essential foundation of public health action and health systems strengthening, both nationally and internationally61. The health sector needs real-time, reliable and actionable data. According to WHO, one of the key lessons from the COVID-19 pandemic is that countries need to invest in data and health information systems, as part of overall public health capacity62. An integrated and collaborative approach to information governance enables health organisations to effectively manage, maintain, and use data to improve health care quality and performance within and across organisational boundaries. SD6 Outstanding Issues Health Data Governance Data governance is a set of principles and practices that ensures high quality throughout the complete lifecycle of data. In MoH, there are no formal standards and SOPs to guide data management along the life cycle to safeguard the quality and privacy of health data. The roles and responsibilities of the different data processing units are poorly defined, and there are no coordination mechanisms in place. Measuring health is complex, and health care data is complex. There is a need to have governance principles to maximise the value of health data and to improve outcomes. Healthcare data governance is the discipline of managing data as a strategic asset. It paves the way for data to support organisational priorities through the orchestration of people, processes, and technology. Data governance helps organisational leaders improve clinical, operational, and financial outcomes by focusing on enhanced decision-making. Importantly, data governance is an ongoing, enterprise-wide, cross-functional effort to optimise data for the benefit of patients, staff, and the community. Electronic Health Information System (eHIS) Data capture is primarily paper-based, using a variety of often duplicating reporting tools. Transitioning to an electronic health information system (eHIS) has been on MoH's agenda for over a decade. In 2020, work started to implement an eHIS system; however, this has stalled. There is an urgent need to complete the implementation and move from a paper-based system to an electronic one. 61 World Health Organization. Framework and standards for country health information systems / Health Metrics Network, World Health Organization. – 2nd Ed. 62 World Health Statistics 2020: monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization. 85 | P a g e Research The NHSP 2016-2020 objectives and expected outcomes were not achieved. The research unit in MoH remains very small; there is no policy to guide research and no specific budget allocated to research. Data Use Despite the availably of data, data are not always used at the point of collection, and it is often difficult to understand how metrics are used to make decisions. SD6 Priority Areas 1. Build one integrated Health Information System (HIS) for MOH. 2. Implement eHIS. 3. Improve data governance. 4. Invest in health data. 5. Strengthen research capacity and use research to improve practice. 6. Enable data use. SD6 General Objectives To build an integrated HIS, and strengthen efforts to collect, process, report and use health data. Increase the availability, quality, value and use of timely and accurate strategic health information for the following:  Estimating disease burden  Understanding health needs  Allocating resources  Developing and delivering services  Improving patient care  Identifying inequities  Tracking progress towards national, regional and global commitments. The health sector will also generate appropriate knowledge from research needed for evidence-based decision-making and improving practice. 86 | P a g e SD6 Specific Objectives Table 16 SD6 Improve Data for Impact: Specific Objectives SD 6: Improve Data for Impact Lead Contributing Specific Objectives Key Interventions Required Milestones Entity Entity

6.1 Set-up one integrated Develop a shared vision and agenda for health data in One integrated HIS set up for MoH and functioning. MoH HCA HIS line with organizational priorities and set up PHA governance structure for an integrated HIS (Stop fragmentation of data collection, processing Develop an integrated HIS strategic framework HIS strategic framework developed. MoH HCA and use, and reduce (Resources, indicators, data sources, data PHA reporting burden) management, information products, and use)63. Implement one integrated HIS for MoH. MoH HCA PHA

6.2 Improve Data Develop a data governance framework (Define roles Data governance framework developed. MoH HCA Governance and responsibilities for data management throughout PHA data life cycle). (Principles, processes and practices to ensure quality Develop standards and SOPs for managing data Standards and SOPs for data management developed, MoH HCA management of data throughout its life cycle. disseminated and training conducted. PHA across the data journey) Set up a data governance committee to lead Data governance committee set up and functioning. MoH HCA development of policy, standards and SOPs and PHA oversee implementation. Develop and implement a data sharing policy. Data sharing policy developed and disseminated. MoH HCA PHA

6.3 Invest in health data Ensure data processing units have the human Statisticians recruited including a bio-statistician. MoH resources necessary. PHA (Ensure adequate HR, hard HCA and soft ware) Build capacity of Statistics Unit and programme Staff trained in data analysis. MoH managers in data processing and analysis. PHA HCA Ensure data collection and processing units have All units fully equipped. MoH adequate hardware. PHA; HCA 63 WHO. Framework and standards for country health information systems/Health Metrics Network, World Health Organization. – 2nd Ed. 87 | P a g e

6.4 Improve health Develop and disseminate regular information Regular information bulletins developed and MoH information products bulletins with data on vital statistics, disease disseminated (Statistics, Disease surveillance. PHA surveillance, service utilization, programmes etc. HCA (Transforming data into Develop and disseminate annual high-quality Annual Reports: MoH information and evidence) statistical report with priority analyses.  Statistics report. PHA  Disease surveillance report. HCA  Cancer registry report.  Programme report. Develop dashboards and summary charts to convey Dashboards developed and maintained. MoH health data and information. PHA HCA

6.5 Improve quality of vital Develop briefs for new Civil Status Bill. Briefs developed. MoH PHA; HCA statistics Conduct sensitization meetings with maternity staff. Sensitization training conducted (Mahé, Praslin and La MoH PHA; HCA Digue). (Improve CRVS, ensure everyone is counted) Conduct training to improve quality of cause of death Complete training for planned cohort of doctors. MoH PHA; HCA reporting. Conduct training to improve analysis of cause of Staff trained. MoH PHA; HCA death data. Monitor quality of cause of death reporting. Monthly review of quality of cause of death conducted HCA MoH for Hospital and community.

6.6 Strengthen research Establish one research unit for the MoH to oversee MoH Research Unit set up with clear mandate, HR and MoH HCA capacity and follow up on all research activities. processes. PHA Develop a policy to guide research in MoH Policy developed MoH HCA PHA Identify priority areas for research Research agenda set MoH PHA HCA Develop research culture in MoH by engaging young Young professions engaged in research. PHA MoH professionals HCA Strengthen Ethics Committee Ethics committee strengthened. PHA Develop mechanisms to translate research findings Mechanisms developed. MoH HCA into practice improvement PHA Assign budget line to research activities. Research budget set annually. MoH Set up a research advisory committee. Research advisory committee set up. MoH HCA; PHA; Dissemination of report on activities and findings of Annual report on research. PHA research. 88 | P a g e

6.7 Enable data use in Seek global TA to develop an integrated data Integrated data repository set-up. MoH HCA decision making repository or portal with easy access PHA Use data to produce high-quality policy briefs and Policy briefs and summaries developed and MoH (Use data to create summaries with findings identifying key action disseminated PHA solutions) needed to improve health sector performance Develop mechanisms to connect data production with Information products shared with data contributors. MoH its use. PHA HCA Develop culture of evidence-based decision -making Track use of data in key decisions in MoH. MoH (policy, planning, budget, etc.). PHA HCA Disseminate health data to community and non-  Annual meeting with the community on key health MoH PHA health stakeholders. data. HCA  Meeting with NGOs working in health to present relevant data.

6.8 Implement eHIS Conduct User Acceptance Testing (UAT). UAT conducted. HCA MoH PHA Conduct HMIS end-user sensitisation and training. Training conducted. Training report. HCA eHIS fully implemented and functional.  Go LIVE - Phase I - roll out of the Client HCA MoH Registration / Appointment module across all PHA relevant units  Go LIVE - Phase II - rolling out of the In-Patient Department, Laboratory , Radiology , Billing, Doctors Desk modules  Go LIVE - Phase III - rolling out of the rest of the modules including Procurement/Store module, Biomedical module etc. 89 | P a g e Chapter 5 Implementation Arrangements 90 | P a g e 5 Implementation Arrangements The NHSP 2022-2026 is a comprehensive document outlining the health sector’s overall direction for the next five years. It renews the long-term vision of the health sector development and re-affirms the Ministry’s commitment to meeting its vision. The plan outlines the strategic framework for further strengthening operations in the entire health sector to address priorities and ensure consistent strategies across programmes. The NHSP 2022-2026 has six interlinked strategic directions derived from a thorough assessment of the documented progress on the last strategic plan, of the country’s current health status and broad technical input from various stakeholders. SD2 Protecting and improving UHC, SD3 Addressing Health Security, and SD4 Promoting Healthy Populations encompass all the sector plans to achieve in the next five years, while SD5 Invest for Results and SD6 Data for Impact, reflect the health system support to strengthen to help achieve these objectives. Successful implementation of this strategic plan will require strong leadership (SD1 Good Governance and Leadership), unity of purpose, ownership and accountability of sector and entity-specific goals and targets.

5.1 Roles and Responsibilities Full implementation of all four pillars of the Results-Based Management Framework will positively impact the implementation, monitoring and evaluation of the NHSP 2022-2026, with a shift from traditional public-sector management to results-oriented management. The Seychelles National Strategic Planning Policy64 clearly defines the roles and responsibilities for the decision-making and different actors in implementing national strategic plans, summarised in Table 17. 64 The Seychelles National Strategic Planning Policy Final 91 | P a g e Table 17 NHSP Roles and Responsibilities at senior levels of Government. Position/Institution Roles and Responsibilities The President Accountable for the establishment of national priorities and the overall performance of the government in achieving the national vision and the results set out in the National Development Strategy (NDS). The Vice-President Responsible for delivering the President’s national strategic plan-related roles and responsibilities, including presiding over the cabinet of Ministers on national strategic plan (NSP) matters, during the absence of the President. Also accountable for achieving the results set out in the NSP instruments for the departments and agencies under his authority. The Cabinet of Accountable collectively for reviewing, approving and ensuring the Ministers alignment and synergy of national priorities and key NSP instruments, monitoring their implementation and determining when corrective actions are required. The Ministers Accountable individually for achieving the results set out in the NSP instruments for the MDAs under their respective authority. Minister for Finance Responsible for effective coordination of the NSP system across government and its integration with the other RBM pillars. Principal Secretaries, Accountable for ensuring that policies are implemented effectively, Heads of efficiently and transparently in their respective MDAs, working Departments and collaboratively with all institutions across their portfolio and ensuring that Agencies all staff under their authority contribute to the achievement of results set out in relevant NSP instruments. Source: Seychelles National Strategic Planning Policy MoH recognises that while it has the responsibility of health care, the achievement of the broad health objectives of the NHSP 2022-2026 will only be possible in partnership with non-health governmental and non-governmental stakeholders. All sectors should recognise the vital role they play in achieving national health goals. A clear outline of the roles and responsibilities of non-health actors in the implementation of the health sector agenda are given in Table 18. 92 | P a g e Table 18 Roles and Responsibilities of Non-Health Stakeholders. Position/Institution Roles and Responsibilities The National  Hold the health sector to account for use of public funds. Assembly  Scrutinize the assurances, promises and undertakings given by the Minister for Health on the floor of the Assembly.  Support and promote the HiAP approach within the legislative branch of government. The Cabinet of  Responsible for monitoring the contributions of the health sector to the Ministers attainment of national strategic goals.  Advocate for the implementation of the HiAP approach towards public policies across sectors taking into account the health implications of decisions, seeking synergies, and avoiding harmful health impacts in order to improve population’s health and health equity. The Office of the  Develop laws and regulations that supports the implementation of the Attorney General NHP and the NHSP.  Integrate and articulate health considerations into the law-making process to improve health outcomes. Ministry of Finance, Apart from their mandates stipulated under Acts and their respective Economic Planning portfolios, the MDAs should support the implementation of the HiAP to and Trade positively influence the social determinants of health and support the health sector to achieve its goals and objectives in line with national development strategy. Other MDAs Apart from their mandates stipulated under Acts and their respective portfolios, the MDAs should support the implementation of the HiAP to positively influence the social determinants of health and support the health sector to achieve its goals and objectives in line with national development strategy. Parastatal  Provision of clean water and sanitation. Organizations  Advocate and educate the public about adopting clean energy to enhance health outcomes. Business Sector Support through funding and participation in public-private partnerships 93 | P a g e District Development  Responsible for supporting the national health agenda and ensuring that Partners whenever appropriate, it is aligned with the global health agenda.  Support community-based strategies to improve health outcomes in line with the NHP and NHSP. Households Seek adequate information and education, adopt health seeking behaviours and the appropriate and timely use of health services in order to maintain and improve health. Individuals Personal accountability means taking ownership over your actions and the outcomes of your actions. Individuals should take responsibility for their health to improve their personal health and wellbeing. The RBM framework prescribes the establishment of a portfolio RBM Committee to oversee coordination and harmonization across all portfolio MDAs. At the agency or department level, the internal RBM Committee, RBM Coordinator and focal point responsible for NSP will ensure that NSP coordination and alignment with other RBM pillars occur65. An NHSP Oversight Committee with a clear mandate and terms of reference will oversee the implementation of the health strategic plan. MoH with its specific entities, and the private health sector, have the responsibility of implementing the key interventions of NHSP 2022-2026, achieving results, and for monitoring and reporting on performance (Table 19). Table 19 MoH and Entities' Roles and Responsibilities in implementation of NHSP 2022-2026. MoH and its Roles and Responsibilities Entities The Minister and  Support a results-driven work culture where accountability for results is the MoH continually strengthened and monitored. Secretariat  Lead and support change management processes to promote growth and minimize resistance for the successful implementation of the NHSP.  Accountable for achieving the results set out in the NHSP.  Accountable to Cabinet and the National Assembly for the happenings in the health sector.  Set up a NHSP Oversight Committee to ensure successful implementation and attainment of strategic goals and objectives of the NHSP (Mandate and ToR). 65 The Seychelles National Strategic Planning Policy Final 94 | P a g e  Establish a sector RBM Committee to be chaired by Principal Secretary to coordinate the NSP process within and across portfolio and ensure coherence with other RBM pillars.  Appoint an RBM Coordinator who will also act as Secretary to the Sector RBM committee.  Play its stewardship role towards the development of policies, laws and regulations to guide the health sector.  Provide and conduct sector monitoring and reporting where necessary in line with the intended outcomes of the NHSP.  Mobilise funds to ensure adequate financing of interventions in the NHSP.  Institute and maintain linkages with all stakeholders involved in the health sector.  Ensure and monitor equity in access to health care services  Drive dialogues to keep health on the national agenda  Support effective implementation of the HiAP through collaborative policy platforms with other MDAs  Ensure entities develop 2-year costed operational plans to implement interventions set out in the NHSP  Guide the non-state health actors so that they contribute and work positively towards the vision and goals of the NHSP.  Collaborate with institutions that deliver institutional learning and training programmes, such as the Guy Morel Institute, to address capacity deficiency  Implement special programmes. Public Health  Pursuant to the Public Health Authority Act, PHA will regulate, monitor and Authority evaluate all health-related services and ensure that they adhere to good practices in the interest of the public.  Implement SD3 interventions and all other interventions under the responsibility of PHA; and support the implementation of other relevant SDs.  Develop and implement 2-year costed Operational Plan in line with interventions/objectives of strategic direction set out in the NHSP.  Conduct sector monitoring in line with mandate of PHA.  Promote and implement the HiAP; expanded HIAs.  Report on entity performance on an annual basis. Health Care  Pursuant to the Health Care Agency Act, HCA will promote, protect and Agency restore the health of the public by acting appropriately to prevent, treat and control illness and prevent disability and death resulting from illness or other causes. 95 | P a g e  Implement interventions under SD2 and all other relevant interventions under the HCA mandate.  Develop and implement 2-year costed Operational Plan in line with interventions/objectives of strategic direction set out in the NHSP.  Ensure that the prescribed requirements and standards for the provision and delivery of health care services are met.  Ensure continuous development of staff to deliver on strategic directions set out in the NHSP and maintain high professional standards.  Report on entity performance on an annual basis. National Institute  Develop and implement NIHSS Strategy. for Health and  Contribute to health and social workforce production (in and pre- service) as Social Studies per NHSP objectives and targets.  Support development of NHWA.  Develop annual performance report. Boards (NIHSS,  The Board members should be well versed with, and guided by, the NHP PHA and HCA) (2015) and the NHSP (2022-2026).  Ensure that entities have appropriate structures in place to support implementation of the NHSP.  Manage entities to achieve goals and objectives set out in the NHSP.  Monitor performance of entity. Division for the  Develop and implement 2-year costed Operational Plan in line with Prevention of Drug interventions/objectives of strategic direction set out in the Drug Master Abuse and Plan and NHSP. Rehabilitation  Report on performance on an annual basis. Professional  Mobilise and engage health professionals. Councils (SMDC,  Set and monitor mandatory requirements for the continuing professional SNMC, HPC) development of all registered practitioners.  Set and maintain standards of training and practice for healthcare professionals, and discipline those who fall short of those standards.  Should be well versed with the content of the NHP and NHSP.  Set professional and ethical standards in line with principles and values of the NHP and NHSP. 96 | P a g e Non-State Health NGOs (e.g. ASFF, Soroptimist, Round Table, Lion’s Club, Rotary Club) Service Delivery Actors (Private  Support and advocate for the implementation of health programmes, sector, PNFPs, through adequate funding and awareness, in line with the NHSP. NGOs, TCMP)  Understand the strategic directions of MoH and advocate towards that vision. Private Health Sector  Provide health services to compliment services provided by government institutions and increase consumer options for health services.  Contribute towards the achievement of health goals and objectives of NHSP.  Should be guided by the NHP other health policies.  Report notifiable diseases and other health statistics as required.  Maintain high professional standards. Patient Support Associations (e.g. Seychelles Patient Association, Cancer Concern, HASO, Pearl Autism, Diabetic Society)  Advocate for the rights of patients and support implementation of health programmes in specific areas of concerns.  Promote and advocate for the implementation of the HiAP approach.  Understand and contribute positively towards the successful outcome of the NHSP. The NHSP assigns each broad strategic direction to a lead entity, primarily responsible for the targets under that pillar (Table 20). This, however, does not absolve the other entities of their collective responsibility for the objectives listed under each pillar. For ownership of specific objectives, kindly refer to section 4 Strategic Agenda for 2022-2026. 97 | P a g e Table 20 Lead Responsibility for Implementation of Strategic Directions of NHSP 2022-2026. Strategic Direction Lead Entity(-ies) SD1 Strengthen leadership, governance and administration MoH SD2 Protect and improve UHC HCA SD3 Address health security PHA SD4 Promote healthy populations MoH SD5 Invest for results MoH/HCA SD6 Improve data for impact All Entities 98 | P a g e

5.2 Implementation Risks and Assumptions Successful implementation of the NHSP is anchored on the assumption that the necessary inputs and conditions will be available, however, several risks can have a negative impact on the achievement of defined goals. Assumptions  Strong leadership and governance.  Accountability at all levels.  Ownership of the goals and targets by all entities and health workers.  Strong coordination mechanisms within and across entities.  Oversight and steward role of MoH strengthened.  Concrete actions to work more upstream (increased resources for prevention and innovation).  Leaders monitor performance and take remedial actions when and where needed.  RBM functions fully implemented at sector and entity level.  Institutional capacity available.  Health in all policy becomes a reality with sectors mainstreaming health in their policies and strategic plans.  Strong community engagement with population invested in being an active partner protecting health. Risk and Mitigation strategies The current NHSP has been developed during a pandemic; the direct health impact of the COVID-19 pandemic and the economic difficulties resulting from the pandemic pose several known and some unforeseen risks for successful implementation of the NHSP 2022-2026. Identifying factors that may negatively impact the achievement of health sector goals is a crucial element of the NHSP. Understand these risks will permit steps to be taken to reduce their impact. Close monitoring will enable initiation of timely corrective measures. MoH has identified the following risks to the successful implementation of the NHSP: COVID 19 Pandemic The development of COVID-19 vaccines and roll-out of vaccination on a global scale was expected to bring the COVID-19 situation under control. However, waning immunity from COVID-19 vaccines, vaccine inequalities, vaccine scepticism and the emergence of new variants have raised concerns about the future trajectory of the pandemic. A protracted health emergency will put pressure on the health system and divert resources from other priority areas outlined in this strategic plan. Maintaining the 99 | P a g e current parallel governance structure for COVID-19 is not sustainable as it diverts the focus of senior management from other core health system functions. Leadership and Governance The current organisational structure with fragmentation, unclear lines of accountability and lack of formal coordination will negatively affect outcomes. Human Resources for Health HCWs have been under considerable pressure due to staff redeployment, absenteeism due to isolation or quarantine and leave restrictions since the beginning of the pandemic. This is likely to continue during a protracted epidemic resulting in burnout and other mental and physical health consequences, impacting the COVID-19 response and other priority areas. Health financing The health budget is unlikely to increase substantially in the next few years. Shifting the focus from curative-centric to prevention will necessarily take funds away from curative care. Additionally, the unpredictable nature of the COVID pandemic may divert additional funds away from interventions proposed in this strategic plan. Health technologies Despite promising signs of recovery, the Seychelles economy remains fragile and vulnerable to external shocks, including the effects of a protracted COVID-19 epidemic. This will have repercussions on the procurement of medicines and other health technologies. Continuity of Essential Care Cessation or downscaling low value interventions and services and catering for identified unmet needs may threaten continuity of care. Diversion of resources and focus towards the COVID-19 will compromise other areas of care and potentially erode health gains, e.g. decrease in life expectancy, worsening of health status. Furthermore, the impact of COVID-19 on society, including social determinants of health, cannot be ignored. MoH organisational architecture The situational analysis has clearly outlined certain deficiencies of the current health organisational structure - fragmentation, inadequate coordination and effective communication, within and across entities. Therefore, it is imperative that MoH revisits the organisational structure and implement measures, including changing mind-sets to address the identified deficiencies. 100 | P a g e Budget allocation for health not commensurate with health needs While there are signs of economic recovery, the economy remains fragile and vulnerable, especially in the uncertain COVID situation. With funding diverted to the pandemic response, adequate funding for continuity of care may be at risk. Prioritising curative over preventive care Health expenditure is heavily skewed towards curative care. Demands for new technologies and very costly specialised care services continue to increase, often fuelled by media hype and to garner political support. Investment in preventive care has sustained returns and delivers substantial health benefits. Full implementation of the eHIS The eHIS is a long-awaited investment in the health system. Partial implementation with a persisting parallel paper-based information system will increase workload on staff, hamper efforts to streamline data management processes, and significantly reduce the expected benefits of the eHIS (collaborative care, cost savings, availability of real-time data). 101 | P a g e Some of the anticipated risks and mitigation strategies are outlined in Table 21. Table 21 Anticipated Risks and proposed Mitigation Strategies Risk Overview Mitigation Strategies  Decrease transmission of COVID-19 becomes a  MoH leadership continues with COVID-19. protracted public emergency governance structure.  Increase vaccination health emergency  MoH leadership shifts focus away from coverage. NCDs and old challenges/gaps to  Improve COVID-19 case COVID-19 response. management.  All building blocks of HS negatively  Define package of essential affected. services and metrics.  Redeployment of human resources  Develop plan for with continuity of essential services continuation of services in compromised. case of emergencies.  YLL due to COVID-19 lead to decrease  Designate a lead person to in life expectancy. implement, monitor and  Poor health outcomes for non –COVID- report on continuation of 19 conditions (Increased morbidity and essential services in mortality). emergencies.  Revise organizational MoH organizational  Current MoH architecture is structure to ensure fitness architecture remains maintained with continued for purpose. unchanged fragmentation and lack of coordination  Define, implement and leading to poor results. monitor coordination within and between entities. Poor buy-in Leaders and Health workers to do work Engage and involve health care together to enact change. workers in problem solving and decision-making.  Advocate for increased Budget allocation for  Significant fraction of budget already spending on health, as it is health not spent on COVID-19 services can lead to an asset and foundation of commensurate with a decrease in health funding for core development. health needs health system operations and new  Ensure efficient use of initiatives. resources in health.  Rapid forecast of 5 yr. prevalence of  Mobilize funds for health key risk factors indicate increased from partners. health needs. 102 | P a g e Spending on Majority of spending on curative, and Advocate for discrete budget prevention not specialist treatment. lines for prevention increased interventions. eHIS not fully  Reliable, real-time data not available HCA to develop work plan and implemented for decisions-making. monitor implementation and  Continued difficulty to provide full use of eHIS. seamless care.  Implement and monitor Lack of Commitment  Increase in risks factors for health HiAP across all sectors. for HiAP (harmful use of alcohol, drug abuse,  Monitor equity in all tobacco use, lack of exercise, poor diet, programmes. increasing unemployment and poverty,  Ensure that metrics capture reduced social supports, etc.). those ‘left behind’ and  Poor treatment outcomes. develop targeted strategies.  Create posts for necessary Lack of capacity  Lack of capacity in specialised clinical specialised fields. and non-clinical posts required to  Recruit key expertise needed implement objectives of the NHSP. for successful implementation of NHSP (e.g. epidemiologist, human resource expert, supply chain expert, etc.) 103 | P a g e Chapter 6 Monitoring and Evaluation 104 | P a g e 6 Monitoring and Evaluation

6.1 Monitoring Achievement of Goals and Targets The government is pursuing the 2013 Results-Based Management (RBM) strategy as the organizing principle behind public sector reform. RBM comprises four pillars: Strategic Planning (SP); Program Performance Based Budgeting (PPBB); Performance Management System (PMS); and Performance Monitoring and Evaluation (PM&E). PM&E has the following benefits:  It increases public sector efficiency, thus creating greater fiscal savings through greater value for money, such as reduced human and financial resources and quicker delivery of programs and projects; including faster project completion;  It enhances public sector effectiveness, including the use of innovative ways and alternative ways of service-delivery, structures, tools and processes, thus enhancing both access to and the quality of service-delivery contributing to greater equity;  It strengthens transparency, thus making information more accessible and making government more open; and  It strengthens accountability, thus ensuring that government delivers on its mandate to implement service-delivery as planned, by the responsible staff, within the existing budget and timeframes. The MoH and its entities have the task of monitoring the implementation of sector strategic plans, policies, programmes. There are no formal PM&E Units within the health sector, however, MoH reports on progress towards achievement of core health indicators annually through the annual sector performance report. In the next five years, it is hoped that MoH will develop and implement an M&E framework, and that formal PM&E units will be set up, with support of other relevant ministries, with the responsibility of advancing RBM. Among very important milestones for this NHSP is the establishment of strong sector health information system, data governance and the full implementation and use of eHIS. The implementation of eHIS, combined with the support of the Department of Economic Planning, will enable the health sector to successfully fulfil its PM&E obligations. A conceptual framework for monitoring and evaluation is depicted in Figure 22. A set of core indicators to monitor progress along the results chain has been developed for this NHSP and in summarised in section 6.5 Indicators. 105 | P a g e Figure 22 Monitoring and Evaluation Conceptual Framework Source: World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and their measurement strategies. Geneva; WHO, 2010.

6.2 Data Needs The sector requires the joint action of public and private facilities to produce quality, timely data for evidenced –based decision-making. For M&E, core data is needed for the following:  To understand the social determinants of health.  To monitor health status:  Vital statistics.  Disease surveillance and response.  Disease and mortality trends.  To monitor the six building blocks of the health system  PM&E - to monitor progress towards implementation of national commitments:  NDS. 106 | P a g e  PPBB key performance indicators.  NHSP goals and targets.  Disease –specific goals and targets.  To report on global commitments (e.g. SDGs).  For accountability and transparency.

6.3 Data Sources The MoH uses a number of data sources to inform decision-making and report on local and global commitments (Table 22). Table 22 Data Sources Data Source Data type National Bureau of Statistics  Population census  Population bulletins  Household Budget Surveys Civil Status Office Vital Statistics Health Facilities/services  Service availability (Public/Private)  Service utilization  Disease notification Programmes Service coverage Individual user records Data on diseases and risk factors Population surveys; User Prevalence of disease, risk factors, service experience/satisfaction etc. utilization/equity gaps NHA, NHFWA Data on resources (health financing and human (resources). 107 | P a g e

6.4 Data Architecture All health facilities and services collect data, which is shared with a select number people. Data capture is still largely paper-based, but this will change after the implementation of eHIS. Three data processing units exist, housed in different entities, and have the responsibility of processing the data and developing information products (Figure 23 Data Architecture). Figure 23 Data Architecture 108 | P a g e

6.5 Indicators A series of indicators and targets have been developed to monitor performance of the health sector in implementing the NHSP 2022-2026 over the next five years. These are outlined in following tables.  Table 23 Indicator Matrix: Inputs.  Table 24 Indicator Matrix: Outputs.  Table 25 Indicator Matrix: Service Coverage.  Table 26 Indicator Matrix: Health Risk Factors  Table 27 Indicator Matrix: Health Status  Table 28 Indicator Matrix: Health Security The majority of indicators are standard, global health indicators, which are comparable over years and across countries. Quality of care indicators will be developed within the quality-of-care framework. The NHSP indicators have been matched to relevant Strategic directive(s) and SDGs. 109 | P a g e Table 23 Indicator Matrix: Inputs Health System Inputs Baseline value End term Reporting Responsible SDG SD NHSP Indicator Data Source (2020) (2026) Frequency Entity Health Financing SD1/5 Total Health Expenditure (estimated by NHA) (SCR/USD) 1,225,843 (2018) NHA Biennial MoH SD1/5 Total Government Health expenditure as % of nominal GDP 4.0% (2018) >6% HCA PHA SD1/5 Total Govt Allocation to Health as % of Total Govt Budget 11.75% (2022) >15% Allocation SD1/5 Total health spending per capita (SCR/USD) 911 USD (2018) >1,000 USD SD1/5 Externally sourced funding (% of current health expenditure) 2% >3% SD1/5 OOP payment for health (% of current health expenditure) 23.1% (2018) <20% Health Workforce 3.c.1 SD5 Health worker density NHWA Biennial MoH SD5 Practising doctors per 10,000 pop. 26 HCA SD5 Practising nurses per 10,000 pop. 66 PHA SD5 Practising dentists per 10,000 pop. 4.27 SD5 Practising physiotherapists per 10,000 pop. 1.74 SD5 Practising surgeons per 10,000 pop. 3.1 SD5 Training Output (NIHSS, other, by cadre) 71 (2017-19 NIHSS Annual Annual NIHSS Average) Reports SD5 Measuring CPD/CME by cadre N/A CME Criteria Councils Annual MoH Health Information Governance SD6 Number of facilities using eHIS 0 All DICT Annual HCA SD5 Registration in PHC facilities by district 0 >60% DICT Annual HCA Health Infrastructure SD5 Updated master facility list – private and public. Partial All Facilities HCA Annual HCA 66 SD5 Hospital bed density (acute beds ). 352 Maintain; HCA Annual HCA  Increase ICU beds; establish Isolation Unit. Incl. 12 ICU Commodities SD5 Number of medicine stock outs (central store) Frequent None Pharmacy Annual HCA 66 Acute beds for public health sector only. 110 | P a g e Table 24 Indicator Matrix: Outputs Health System Outputs End-Term Reporting Responsible SDG SD NHSP Indicator Baseline Value (2020) Data Source Value (2026) Frequency Entity Doctor Consultation SD2 PHC 262,430 Statistics Unit, MoH Annual HCA SD2 Emergency 41,456 Statistics Unit, MoH Annual HCA SD2 SOPD 35,601 Statistics Unit, MoH Annual HCA Prescription Filled SD2 PHC (including inner islands) 331,854 Statistics Unit, MoH Annual HCA SD2 Seychelles Hospital (wards) 57,249 Statistics Unit, MoH Annual HCA SD2 SOPD 36,105 Statistics Unit, MoH Annual HCA Specialised Services SD2 Oncology Unit 5545 (consultations); Statistics Unit, MoH Annual HCA 158 (new patients started chemotherapy) SD2 Haemodialysis 193 (patients); 25,332 (sessions) Statistics Unit, MoH Annual HCA 67 SD2 Overseas Treatment 160 (patients); 162 (cases) Statistics Unit, MoH Annual HCA Inpatients Services SD2 Hospital Admissions (government- 10,613 (Note: 9749 acute care wards on Statistics Unit, MoH Annual HCA owned hospitals) Mahé & 864 admissions to other wards) SD2 Bed Occupancy (by ward) Male medical (90%) ICU (85%) Statistics Unit, MoH Annual HCA Female medical (54%) Paediatric (47%) Male surgical (57%) NICU (35%) Female surgical (53%) Maternity (69%) Logan La Digue (11%) Psychiatric (89%) Hospice (94%) BSA Praslin (25%) North East Point (84%) SD2 Operating Theatre (surgeries) 4484 Statistics Unit, MoH Annual HCA Diagnostic Unit SD2 X-Ray 27,434 Statistics Unit, MoH Annual HCA SD2 CT Scan 8066 Statistics Unit, MoH Annual HCA SD2 MRI 1354 Statistics Unit, MoH Annual HCA SD2 Ultrasound exams 10,574 Statistics Unit, MoH Annual HCA 67 Note that two patients went twice 111 | P a g e SD2 Mammography 773 Statistics Unit, MoH Annual HCA Clinical Lab SD2 Tests done by unit 677,873 Statistics Unit, MoH Annual HCA Allied Health Services SD2 Physiotherapy (attendance) 49,388 Statistics Unit, MoH Annual HCA SD2 Occupational therapy (attendance) 7437 Statistics Unit, MoH Annual HCA SD2 Audiology (attendance) 1112 Statistics Unit, MoH Annual HCA SD2 Speech therapy (attendance) 951 Statistics Unit, MoH Annual HCA Oral Health Services SD2 Consultations dental therapists Statistics Unit, MoH Annual HCA SD2 Consultations dentists Statistics Unit, MoH Annual HCA Table 25 Indicator Matrix: Service Coverage Health Services Coverage Baseline value End term Reporting Responsible SDG SD NHSP Indicator Data Source (2020) (2026) Frequency Entity RMNCH

3.7.1 SD2 Demand for family planning satisfied with modern methods 47%* >60% World Health Annual HCA Statistics Report SD2 Antenatal care coverage 99% >99% Programme Annual HCA

3.1.2 SD2 Births attended by skilled health personnel 99% >99% Programme Annual HCA SD2 Postpartum care coverage – home >99% Programme Annual HCA SD2 Postnatal care coverage – clinic <70% >99% Programme Annual HCA Immunization 3.b.1 SD2 Immunization coverage Programme Annual HCA  DPT Dose 3 97% >95%  Penta-/Hexa-valent Vaccine Dose 3 96.9% >95%  HPV girls (and boys, if schedule revised) 99% (2019) >95%  COVID-19 % fully vaccinated (2 doses) Adults >80%; Adults >80%; PHEOC Annual HCA Adolescents Adolescents 60% (2021) >80% HIV, Viral hepatitis , Tuberculosis SD4 People living with HIV who know their status No baseline 90% NAC Annual PHA SD2/4 Prevention of mother-to-child transmission 11% <2% MTCT CDCU Annual PHA 112 | P a g e SD2 % Mother-baby pairs who receive full PMTCT interventions 89% 100% CDCU Annual PHA SD2 Antiretroviral therapy (ART) coverage 82% >90% CDCU Annual PHA SD2 HIV viral load suppression No data >90% CDCU Annual PHA 2019/2020 SD2 % Of treatment eligible HCV patients who received DAAs No Data >75% CDCU Annual PHA SD2 % Of patients on DAAs with SVR 12 No Data >90% CDCU Annual PHA SD2 % Of TB patients tested for HIV 100% 100% CDCU Annual PHA SD2 TB treatment coverage 100% 100% CDCU Annual PHA SD2 TB Treatment success coverage 100% >90% CDCU Annual PHA Screening and preventive care for cancer68 SD2 Cervical Cancer screening (Pap smear) 6096 >20,143 Programme Annual HCA SD2 Mammography screening for Breast Cancer 773 >2,500 Programme Annual HCA SD2 Colonoscopy screening for bowel cancer 511 >1,000 Programme Annual HCA Mental health

3.8 SD2 Coverage of services for severe mental health disorders (bipolar No baseline >90% Psychiatric Unit Annual HCA affective disorder, moderate-to-severe depression & psychosis). Substance abuse69

3.5.1 SD2 Number of people accessing services for alcohol dependence 124 500 DSAPTR Annual MOH SD2 Treatment coverage for drug dependence 424 1080 DSAPTR Annual MOH SD4 Number of syringes distributed 37,516 DSAPTR/CDCU Annual PHA/MOH/NAC SD2 Total number of active clients on Methadone 1884 2100 DSAPTR Annual MOH SD2 Number on Low threshold Programme 3005 DSAPTR Annual MOH SD2 Number on High Threshold Programme 134 300 DSAPTR Annual MOH SD2 Aftercare and Psycho-social supports 937 100% DSAPTR Annual MOH SD2 No. of communities covered by Community-based programme No baseline All districts DSAPTR Annual MOH SD2 Prevention and Education for substance use (interventions) 79 100 DSAPTR Annual MOH SD2 Number of People engaged in outreach services 5400 DSAPTR Annual MOH UHC Index

3.8.1 SD2 UHC index 71 >80 Statistics Unit Annual MoH 68 Indicators may be revised based on final version of Cancer Strategy. 69 Choice of indicators may be subject to revision based on updated DSAPTR operational plans. 113 | P a g e Table 26 Indicator Matrix: Health Risk Factors Health Risk Factors SDG SD NHSP Indicator Baselin End term Data Source Frequency of Responsible e value value Reporting Entity (2020) (2026) Nutrition SD4 Exclusive breastfeeding rate 0-6 months 20.90% ≥50% Nutrition Unit Annual HCA SD3/4 Prevalence of obesity among school children (9-17 ≥50% 28.60% UPCCD Annual PHA years)

2.2.1 SD3/4 Children under 5 years who are stunted 7.60% 3.04% Nutrition Unit Annual PHA

2.2.2 SD3/4 Children under 5 years who are wasted 4.30% 4.30% Nutrition Unit Annual PHA

2.2.2 SD3/4 Children aged under 5 years who are overweight 8.80% 8.80% Nutrition Unit Annual PHA SD3/4 Anaemia prevalence in women of reproductive age no data Reproductive/ Maternal PHA Health Program SD3/4 Anaemia Prevalence in children no data Nutrition Unit PHA Infections SD3/4 Prevention of HIV in key populations AIDS program PHA SD3/4 MSM reporting condom use 14.9% DSAPTR Survey PHA SD3/4 PWIDs reporting using clean needles 58.20% DSAPTR Survey PHA SD3/4 FSW reporting condom use 24.10% DSAPTR PHA Environmental risk factors

6.1.1 SD3 Population using safely managed drinking-water 96% PHA Annual PHA services (2019)

6.2.1 SD3 Population using safely managed sanitation services 99.38% PHA Annual PHA (2019)

7.1.2 SD3 Population with primary reliance on clean fuels and PHA technologies

11.6.2 SD3 Air pollution level PHA Public Health risks SD3 Fraction of food-related services monitored (farms, No data PHA PHA abattoirs, kitchens, etc.) SD3 Sales of tobacco 6032 Seychelles in Figures 2020 PHA SD3 Sales of alcohol 52 Seychelles in Figures 2020 PHA million 114 | P a g e NCDs SD3/4 Proportion of overweight and obesity in school-age 28.6% Zero UPCCD Annual PHA children and adolescents 9–18 years (9-17 years) increase

3.5.2 SD3/4 Total alcohol per capita (age 15+ years) 48% 10% UPCCD Survey 5 years PHA consumption (11-17 Years) relative reduction 3.a.1 SD3/4 Age-standardized prevalence of current tobacco use 15% 30% UPCCD Survey 5 years PHA among persons aged 15+ years (11-17 years) relative reduction SD3/4 Age-standardized prevalence of raised blood 29.5% 5.90% UPCCD Survey 10 PHA pressure among persons aged 18+ years (25-64 years years) SD3/4 Age-standardized prevalence of overweight and 64.5% Zero UPCCD Survey 10 PHA obesity in persons aged 18+ years (25-64 years) increase years Injuries

5.2.1 SD4 Intimate partner violence prevalence 113 Social Affairs Annual Social Affairs

16.2.3 SD4 Sexual violence against children 168 Social Affairs Annual Social Affairs

8.8.1 SD3 Frequency rates of occupational injuries Employment & Annual PHA Occupational Health Table 27 Indicator Matrix: Health Status Health Status SDG SD NHSP Indicator 2019 Baseline End term Data Source Reporting Responsible Entity value value frequency (2020) (2026) Mortality by age and sex SD4 Life expectancy at birth (yrs) HCA SD4 - Men 69.7 72.7 74 Statistics Unit Annual SD4 - Women 78.4 82 83 Statistics Unit Annual SD4 - Both sexes 73.9 77.3 79 Statistics Unit Annual 115 | P a g e SD2/4 HALE (yrs) M: 62.2 M: 62.2 F: M: ? F: ? World Health Annual HCA F: 69.5 69.5 Statistics Report SD2/4 Adolescent mortality rate (per 1000 0.98 0.96 <0.5 Statistics Unit Annual HCA adolescent population) SD2/4 Mortality rate in males aged 15 - 60 5.5 5.2 <4.0 Statistics Unit Annual HCA (per 100 men in age group) SD2/4 Infant Mortality rate (per 1,000 live 16.8 11.6 10 or less Statistics Unit Annual HCA births )

3.2.1 SD2/4 Under-five mortality rate (per 1,000 live 17.4 14.2 12 or less Statistics Unit Annual HCA births)

3.2.2 SD2/4 Neonatal Mortality Rate (per 1,000) 8.7 9 <5 Statistics Unit Annual HCA SD2/4 Stillbirth rate ( per 1000 total births) 5.0 5.1 <5 Statistics Unit Annual HCA Mortality by cause

3.1.1 SD2 Maternal mortality ratio ( per 100, 000 62.3 64.4 <50 Statistics Unit Annual HCA live births) SD2 AIDS-related mortality rate (per 100,000 16.4 10 <5 CDCU Annual HCA population)

3.4.1 SD3/4 Premature NCD Mortality 21.2 21.2 Reduce World Health Annual HCA (Probability off dying from any of by 25% of Statistics Report cardiovascular diseases, cancer, diabetes baseline or chronic respiratory diseases between age 30 and exact age 70 [%]) SD2 Pulmonary embolism related mortality 139 145 Statistics Unit Annual HCA rate ( per 100, 000 population)

3.6.1 SD3 Mortality rate due to road traffic 11.3 11.2 <10 Statistics Unit Annual HCA accident (per 100,000 population)

3.4.2 SD4 Suicide rate (per 100,000 population) 6.1 6.1 <5 Statistics Unit Annual HCA

16.1.1 SD4 Mortality due to homicide (per 100,000 2 1 No Target Statistics Unit Annual HCA population) SD3 Mortality from unintentional poisoning 0 0 0 Statistics Unit Annual HCA SD2/3 Pneumonia related Mortality ( per 100, 158 132 <130 Statistics Unit Annual HCA 000 population) SD2/3 Covid-19 related deaths (per 100 000 0 0 < Statistics Unit/PHEOC Annual HCA population ) SD2/3 Covid-19 case fatality rate (%) 0 0 <1% PHEOC Annual HCA 116 | P a g e Fertility SD4 Total Fertility Rate 2.3 2.3 Below 3 NBS Annual HCA

3.7.2 SD4 Adolescent birth rate ( per 1000 females 69 60 <30 Statistics Unit Annual HCA aged 15-19) SD4 Number of live births in girls aged <15 9 4 Zero Statistics Unit Annual HCA Morbidity SD2 New cases of vaccine preventable Zero DSRU/Programme Annual HCA diseases cases SD2/4 ASR of cancers in males (all sites) (per 274 255 Cancer registry; end- Annual HCA 100,000 persons at risk) term targets to be based on Cancer Control Plan SD2/4 ASR of cancers in females (all sites) (per 302 207 Cancer registry Annual HCA 100, 000 persons at risk) Table 28 Indicator Matrix: Health Security Health Security IHR/ Baseline value End term Data Frequency of Responsible SD NHSP Indicator SDG (2020) value (2026) Source Reporting Entity SD3 Emergency Prepare (IHR Capacities) C1 SD3 Legislation and financing PHA C2 SD3 IHR coordination and national IHR focal-point functions PHA C3 SD3 Zoonotic events and the human–animal interface PHA C4 SD3 Food safety PHA C5 SD3 Public Health Laboratory PHA C6 SD3 Surveillance and Response PHA C7 SD3 Human resources for Emergency Preparedness PHA C8 SD3 National health emergency framework PHA C9 SD3 Health service provision PHA/HCA C10 SD3 Risk communication PHA/MOH C11 SD3 Points of entry PHA C12 SD3 Chemical events PHA C13 SD3 Radiation emergencies PHA SD3 Emergency Prevent (Routine and Emergency Vaccination Coverage) 117 | P a g e SD3 Routine & campaign vaccination for epidemic- and pandemic-prone HCA/PHA diseases (Yellow Fever, Meningitis, Measles, Polio, etc.) SD3 COVID-19 Vaccination 0% >80% per EPI Annual HCA protocol Programme SD3 Detect and Respond SD3 Timeliness of detection and response PHA T0 – Time to Detect PHA T1 – Time to Notify PHA T3 – Time to Respond PHA SD3 New cases of IHR Notifiable diseases and other Notifiable Diseases SD3 Leptospirosis N/A DSRU Annual PHA SD3 Dengue N/A DSRU Annual PHA SD3 COVID-19 Cases 0.8 cases/day < 20 / day PHA/DSRU Month PHA

3.3.1 SD3/4 HIV incidence (newly detected cases) 84 < 50 NAC Annual PHA SD3/4 HCV incidence (newly detected cases) 91 < 1/2 CDCU Annual PHA

3.3.4 SD3/4 HBV incidence (per 100,000 population ) 34 CDCU Annual PHA SD3/4 STI incidence 425 CDCU Annual PHA

3.3.2 SD3 TB incidence rate (per 100,000 population) 9 5 or < CDCU Annual PHA 118 | P a g e List of Annexes

Annex 1: List of National Health Commitments

Annex 2: Seychelles Progress on SDGs

Annex 3: List of in-person Consultations

Annex 4: Tasks and Objectives of the TWGs

Annex 5: Strategic Investment Priorities

Annex 6: Results Chain 2022-2026 NHSP Embedded PDF of annexes: NHSP 2022-2026 Annexes.pdf 119 | P a g e The National Health Strategic Plan 2022-2026 January 2022 For queries, please contact the Policy Unit of the Ministry of Health Sanjeev Pugazhendhi Sanjeev.Pugazhendhi@health.gov.sc Doreen Zelia doreen.zelia@health.gov.sc Juddy Jean-Baptiste juddy.jean-baptiste@health.gov.sc 120 | P a g e