Health Report 1997-99-solomon Islands

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 ==============================================================

Ministry of Health Solomon Islands

NATIONAL HEALTH REPORT 1997-99

EVALUATION OF THE HEALTH STATUS

March 2000 ___________________________________________________________________________________ -1-

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Message From The Minister of Health i. INTRODUCTION SECTION I: GENERAL INFORMATION 1.1. Land (geography of provinces/ SI) 1.2. The demography (Population): 1.2.1. Size & Growth: 1.2.2. Age-group Composition: 1.2.3. Population density:

1.3. The Economy: 1.4. The Health Status by provinces and National:

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SECTION II: INTERNAL REVIEW REPORT

3 2.1. REGIONAL (PROVINCIAL) SERVICE DISTRIBUTION; 3 2.1.1. Type of Services; 3 Table (1) : The Health Care Referral System 3 2.1.2. DISTRIBUTION OF SERVICES: 3 Graph (1) showing distribution of health facilities by provinces: 3 Table (2) showing Health Clinics:Population* and Nurse: Population** Ratio: 3 2.2. INTERNAL STRUCTURAL AND MANAGEMENT ISSUES: 3 2.2.1. Organizational Structure: 3 Fi g ur e1s h o wi n gt h ee x i s t i n go r g a n i z a t i o n ’ ss t r u c t ur e :Mi n i s t r yo fHe a l t h :Na t i o na l and Provincial level: 3 2.2.2. Centralization Vs Decentralization (Vertical versus Horizontal programs): 3 2.2.3. Activities (Inputs): 3 2.2.4. Findings (outputs): 3 2.3. HEALTH FINANCING & BUDGETING AND RESOURCE ALLOCATION FACTORS: 3 Table (3) Total government budget and the allocations from 1988 to 1999: 3 Table (4) Distribution of the Recurrent Health Budget 1991-1 9 9 9( SBD$’ 00 0 ) 3 Table (5) showing selected health accounts indicators for selected countries in the pacific region; estimates for 1997: 3 2.4. Management and Supervision: 3 2.5. STATUS OF HEALTH CARE SERVICES DELIVERY: 3 2.6. DISTRIBUTION OF HEALTH CARE WORKFORCE; 3 2.6.1. SHORTAGE AND MANAGEMENT OF HEALTH WORKFORCE: 3 Table (6) Shows the Gap Between Requirement Projection and Supply Projection on the Medical Profession (Doctors): 3

SECTION III: HEALTH SERVICE PLANNING, MANAGEMENT AND SUPERVISION: 3.1. MANAGEMENT & ADMINISTRATION: 3.1.1. Activities (Input) & Output: 2

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======================================================= Table (7) below shows matrix of strategies implemented since 1997. 3 3.1.2. Analysis: 3 3.1.3. Output & Key Issues: 3 3.2. How Well Do the Solomon Islands Health System Performs? 3 3.2.1. Overall Level of Health: 3 Table (8) showing Basic Indicators for selected countries in the pacific region: 3 Table (9) showing health attainment, level and distribution in selected countries in the pacific region; estimates 1997-99: 3 3.2.2. The distribution of health in the population: 3 3.2.3. Responsiveness of the health system: 3 3.2.4. Performance on health level (DALE) and Overall Performances: 3 Table (10) shows ranking of selected countries in the pacific region on their performances on health level, and the overall performance: 3 3.3. Health Information System: 3

SECTION IV: ACCESSIBILITY AND QUALITY OF HEALTH SERVICES 4.1. Health Care (Curative) Services:

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4.1.2. Activities (Input) 4.1.3. Outputs: Graph (2) showing Ratio of Registered Nurses, Nurse Aides and Total Nurses to Population in 1997-1999: 3 4.1.4. Primary Health Care- Health Facility: Population 3 Table (11) showing Health Clinics:Population* and Nurse: Population** Ratio in 1997-1999: 3 Graph (3) showing ratio of population to a health facilities in the provinces: 3 4.2. PRIMARY HEALTH CARE (CLINICS): WORK LOAD. 3 Table (12) PHC (A): Outpatient Visits by Type of Facility, 1997,1998,1999: 3 4.2.1. OPD visits per Facility: 3 Bar Graph (4) showing workload at Area Health Centers, Rural Health Clinics and Nurse Aid Posts 3 Table(13) showing workload at Area Health Centres, Clinics and NurseAide Posts by provinces 1997-99 3 4.2.2. OPD visit per person per year by provinces: 3 Graph (5) showing average OPD visits per person per year: 3 Table (14) Shows Average OPD Visit Per Person per day and year, by provinces, across all facilities: 3 Table (15) Breakdown of Beds By Hospital (Government Owned Only) by end of 1999 3 Table (16) Breakdown of Beds by Hospitals (Church Owned Only): 3 Table (17) Shows number of available beds to be filled per 1,000 population in the region; 3 Table (18) Shows the Flow of Patients in and Out of the Provincial Hospitals (including private centers): 3 Graph (6) showing flow of patients in and out of the provincial hospitals: 3 4.3. Secondary Health Care: Hospital Utilization: 3 Table (19) shows the Hospital Utilization Rates (number of admissions per 1,000 population) 3 Table (20) shows Hospital Utilization in the National Referral Hospital 3 3

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======================================================= Graph (5) showing hospital utilization of National Referral Hospital 1997-1999 3 4.3.2. Bed Occupancy and Average Length of Stay: 3 Graph (7) showing total admissions by provinces & NRH: 3 Graph (8) showing bed occupancy rates (all beds) by provinces & NRH: 3 Graph (9) showing trend of Average Lengths of Stay in provinces & NRH: 3 4.4. Pediatrics (Child Health) Services: 3 4.4.1. Findings & Outputs: 3 Table (21) shows Hospital Utilization Rates in Paediatrics (Child health care services for <4yrsin the provinces): 3 Graph (10) showing trend of utilization of hospital utilization in pediatrics in the provinces 3 Graph (11) showing trend of bed occupancy rates in pediatrics by provinces & NRH:3 Graph (12) showing trend of ALOS in pediatrics by provinces & NRH 3 4.5. OBSTETRICS & GYNAECOLOGY SERVICES: 3 Table (22) shows Hospital Utilization in Maternity (maternal care services) in the provinces: 3 Graph (13) showing trend of hospital utilization in maternal care services in the provinces: 3 Graph (14) showing trend of Bed Occupancy Rate in Maternal Care by provinces & NRH: 3 Graph (15) showing trend of ALOS in Maternal Care by provinces & NRH: 3 Graph (16) showing trend of ALOS in Maternal Care by provinces & NRH: 3 4.6. Access to Essential Drugs: 3 4.7. Health Infrastructure development: 3 Tabel (23) : Level of Health infrastructure: 3

SECTION V: HEALTH IMPROVEMENT SERVICES: 5.1. THE HEALTHY ISLANDS, HEALTH CITY, INITIATIVES 5.2. Morbidity and Mortality Reduction: 5.2.1. Overview: Graph (17) showing diseases trend in SI from 1997-1999. 5.2.2. Infant Mortality: Graph (18) showing incidence of ARI by provinces 1997-99: 5.2.3. Acute Respiratory Infection (ARI): Graph (19) showing trend of incidence of ARI in SI Graph (20) showing incidence of ARI & Diarrhoea in children <5yrs in Solomon Islands 5.2.4. Diarrhea: Graph (21) showing trend of incidence of Diarrhoeal Diseases 1997-99: Graph (22) showing trend of incidence of diarrhoea by provinces: 5.2.5. Red eyes ( infections): Graph (23) showing incidence of red eyes by provinces 1997-99: 5.2.6. Yaws: Graph (24) showing incidence of Yaws in SI Graph (25) showing incidence of Yaws by provinces 1997-99. 5.2.7. Ear infections: Graph (26) incidence of ear infections by provinces & SI: 15.2.8. Vaccine preventable diseases: 5.2.8.1. National Disease Surveillance: 4

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======================================================= Graph (27) showing incidence of vaccine preventable Illnesses in SI 1997-99 3 Graph (28) showing incidence of vaccine preventable illnesses by provinces in 199799: 3 5.2.9. Sexually Transmitted Infections: 3 Graph (29) showing incidence of STI in Solomon Isl: 3 Graph ( 30) showing incidence of STI by provinces: 3 5.2.10. MALARIA: 3 5.2.10.1. Activities & Findings: 3 5.2.10.2. Accomplishments: 3 Figure 2: Annual Incidence rate of malaria in Solomon Islands 1969-1999 3 5.2.10.3: Incidence in the provinces 3 Figure 4: Trends in the annual incidence rate of malaria in Honiara and the provinces 1992-99: 3 5.2.10.4. Diagnosis & Treatment: 3 5.2.10.5. Key Issues & Problems Experienced: 3 5.2.10.6. Analysis of the Program: 3 5.2.11. TUBERCULOSIS: 3 5.2.11.1. Activities (Input): 3 5.2.11.2. Findings (Outputs): 3 5.2.12. Mental Health Services 3 5.2.12.1. ACTIVITIES (INPUTS) 3 5.2.12.2. Findings (Outputs): 3 Table (A): Total Cases Admitted to 3 Na t i o n a lPs y c hi a t r i cUn i t , Ki l u ’ u f iHo s p i t a l( o n l y )I N1 9 9 7 , 1 9 9 8 , &1 9 9 9 . 3 5.2.12.3.Analysis: 3 5.2.12.4. Major Issues/ problems & recommendations: 3

SECTION VI: ENVIRONMENT HEALTH SERVICES: 3 3 3 3 3 3 3 3 3 3 3 3

6.0. HEALTH AND ENVIRONMENT 6.1. General protection of the environment 6.2. Air (pollution) 6.3. Water quality 6.4. Solid waste disposal 6.5. Food safety 6.6. Housing 6.7. Work place 6.8. Water supply and sanitation 6.8.1. Indicators 6.8.2. General

SECTION VII: HEALTH PROMOTION & EDUCATION: 7.0. Overview: 7.1. Community Health Education Activities 1997-99: 7.2. Evaluation of health education & promotion programs:

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SECTION VIII: REPRODUCTIVE HEALTH AND FAMILY PLANNING:

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======================================================= 8.1. Maternal Mortality: 3 Table (23) showing Maternal Mortality Rate/ 100,000 births 3 Table (24) Maternal Deaths by Provinces 1996-1999 (excluding those in the hospitals): 3 Table (24) Proportion of Total deaths by National and Provinces (ie. No. of. maternal deaths / total deaths reported by Clinic Monthly Reports in %: 3 8.2. Family Planning: 3 Table (25) Family Planning Coverage (%) total users at end of December/wcba x 100): 3 Graph (29) showing FP coverage by end of December 1997,1998 & 1999: 3 Table (26) % Supervised deliveries: 3 Table (27) Antenatal Coverage: First antenatal attendance (% first visit / expected births) 3 Table (30) Total Fertility Rates 1986,1996,1998: 3 Table (28) FERTILITY RATES BY PROVINCES FROM 1997 TO 1999 (births/ 1000 popWCBA 3

SECTION IX: DEVELOPING PARTNERSHIP 9.0. Overview in brief: 9.2. Involvement of International developing or donor partners:

ANNEXURE ANNEX Table (1) showing proportion of population to health workers in 1997-98: ANNEX Table (2) Female, Male, Pediatrics, and Obstetrics Beds-All Hospitals Admissions and Occupancy Rates at 1997,1998,1999 bed capacity ANNEX Tab l e( 3) :To t a lCa s e sAdmi t t e dt oNa t i o n a lPs y c h i a t r i cUn i t , Ki l u ” u f i Hospital (only) 1997,1998 & 1999: ANNEX Table (4): Total Cases seen and treated at the National Psychiatric Unit, Honiara, MOH/HQ in 1997, 1998 & 1999: ANNEX Table (5): Overall Total cases recorded at the National Psychiatric Units Kiluufi Hospital and Honiara in 1997, 1998 & 1999: ANNEX Table (6) Matrix of donor activities impacting directly on the Solomon Islands health sector:

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Message From The Minister of Health Let me repeat the questions Dr.Gro Harlem Bruntland Director-General of WHO raised in her statement in the World Health Report 2000. They were; what makes for a good health system? And how do we know whether our health system is performing as well as it could? The answer to the questions entails the concept and principles behind this National Health Report Review, which focuses on evaluation of the National Health Status of the country for the period 1997 to 1999. This is the second review of the health services following The Comprehensive Review of Health Services Report in March 1996. I am very pleased and would like to acknowledge the efforts by the Undersecretaries and the divisional heads in compiling and providing information for the report. The reporting period of 1997-99 was the most difficult years for the Ministry in delivering health services to the people of the country. The major external factors that a f f e c t e dt hehe a l t hs y s t e m’ spe r f or ma nc ewe r et hee c onomi cd ownt u r n,whi c hwa s severed by the twenty months old ethnic tension. Nonetheless, primary and secondary health care services continued despite difficulties. The report shows that key health indices such as the infant mortality and maternal mortality continue to improve. Naturally, the part of the reason for the improvement is attributed to the performance of the health system of the country. Let me make myself clear that I am neither bias in my statement nor I am compliancy. It is because there are many areas of weaknesses within the health system revealed by the report. And one particular example is the need for us to improve on our capacity to monitor and evaluate our own performances. In this report we have used objective reports from external sources such as WHO annual reports. Another important issue revealed in the report is the issue of health inequalities by provinces. I would say that it confirms the hypothetical assumption that resources are not distributed equally. The level of health status varies a lot by provinces given the fact that the pattern of infectious diseases is similar through out the country. The level of health service delivery activities and accessibility to health facilities varies. Whilst, the overall health indices may look favorable, it is the internal aspect of health service delivery is equally important. All of the above key health issues made up the driving factors for the policies and strategies of the National Health Policies and Development Plans 1999-2003. The report also evaluates the health status against the key performance indicators in the NHPDP. However, due to lack of appropriate data and information the report is not able to evaluate all important indices against the objectives in the NHPDP. This is an issue itself to look into in the near future. The National Health Annual Review is a milestone in a long-term process. The measurement of health systems will be regular feature of annual health reports. Some important conclusions are clear from the report: 7

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=======================================================  There are demographic and behavioral changes. There is some degree of demographic transition. Growth rate and Total Fertility Rate has declined. Infant and maternal mortality rates also declined.  There are also health inequalities at different degrees in areas of distribution of services and resource allocation.  Therefore management and supervision of the health system needs reviewing and improvement. Especially in resources management, which includes manpower, facilities and finance. In conclusion, I hope this report will help policy-makers and operational managers of health institutions and programs of the Ministry and other stakeholders to make wise decisions. We would like the environment created by the report to be of a learning one. My advice is for all health workers to remain committed the essential health services. I commend you for maintaining health services during the height of the ethnic tension all through out the country. May God Bless you.

Hon. Allan Paul, MP Minister of Health Solomon Islands

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i. INTRODUCTION This is a National Health Reports Review of the status of national health services in 1997 to end of 1999. The purposes of the report are;  To report and evaluate health activities of 1997 to 1999.  To ascertain whether standards and the objectives of National Health Policies and Development Plans 1999-2003 is attained.  To evaluate specific health services delivery packages.  Source of information for the purpose of (strategic) management and supervision, planning and monitoring of health services delivery. (Identify priority key health issues and problems through trend and pareto analysis, in order for strategic planning for improvement)  Report on the national (and provincial) population health status Section 1 concerns with the external social changes in relation to geography of the country, demography, socio-economy, and politics, which had significant impact on the health sector in the period 1997-99. Section 2 review the changes within the health sector (Internal Review Report), in relation to health care referral system (structure), distribution of services by health facilities, human resource, and health financing. It also covers issues relating to management and supervision, and the organizational structure. Section 3 evaluates (policy 1), which aimed at improvement of health services planning, management and supervision. Section 4 evaluates (policy 2), which looked at accessibility, quality of care and quality of health services delivery. Section 5 evaluates health improvement programs. Section 6 evaluates (policy 4) trend of morbidity and mortality reduction. Section 7 evaluates (policy 5) environment health services. Section 8 evaluates (policy 6) health promotion and education. Section 9 evaluates (policy 7) reproductive and family planning. Section 10 evaluates (policy 8) development partnership in health development. The scope of the report confine to the activities undertaken in 1997-1999 the resources input, results and achievements in terms of output, and the health status in terms of national health outcome. It also includes statistical figures in raw data, in graphs and analysis of results.

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SECTION I: GENERAL INFORMATION 1.1. Land (geography of provinces/ SI)

The effective delivery of health care is affected by the geographical nature of the Islands. Solomon Islands has a total land area of 28,369 sq. km from a sea area covering 1,632,964 sq. km. It is a widely scattered archipelago of rugged mountainous islands and low lying coral atoll, stretching over some 1,667 km in a southeast direction between Papua New Guinea and the Republic of Vanuatu, and North-East of Australia. On the Islands the location of villages are scattered. Many live along the coast, some inland with sea access and others live inland with limited access to the sea or road. It was found that majority of villages in the country (52.0%) were situated in the coast, 32.9% live inland with no sea access, whilst 15.0% lived inland with sea access. Theses factors determines as well as undermine the plans put in place to deliver health care service delivery efficiently to the remote people, particularly those living more than 3 kilometer from a nearest health clinic. Geography factors have caused threats to health policies, aimed to address issues and problems related to improving accessibility and equality to health care services. In such cases understanding very well the diversity of the people and their needs are important in the strategic planning. Geographical factors therefore correspondences with the weaknesses within the organization. For example, coupled with untimely or non-payment of health services grants, villages living more than 3 kilometers from a health facility or those living inland with no access to roads are not reached by health care mobile teams from rural clinics.

1.2. The demography (Population): 1.2.1. Size & Growth: The population of the country is a major concern to the health care services. Especially with regards to the distribution of limited health resource to meet the vast health

Table (2): Demographic Trends 1995 - 1999

Year

1995

1996

1997

1998

Population Projection

395848 409939 425488 44184 0

1999 45938 0

Source: MHMS Estimate from 1986 Census. The Population figure from

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======================================================= needs of the people. It is evident that our capability in getting families to adopt some ways of understanding and limited the family size is far from reaching our objective targets. Solomon Islands has a population annual growth rate of 3.5%, a total fertility rate of 6.1, crude birth rate of 42 per 1,000 per year, and crude death rate of 10 per 1,000 (1986 1 census) . The estimated population in 1997 and 1999 was 425,488 and 459,380 respectively.

1.2.2. Age-group Composition: Solomon Islands has a young population structure with 43.6% (1996 estimate) of total population in age-group 0-14 years. The number of children 0-4 years continue to increase but at a declining rate. The population of female of childbearing age considerably increases in the past ten years with more children entering adulthood after the 1999 census2. The population of age-group 0-14 by 19993 fell to 41.5% of the total, which is less than age-group 15-44 with 45.2%. The base of the population pyramid slight shrinks whilst it widen in the middle. The health implication of these demographic trends is that the demand for health care service by the age group of 0-4 and female of childbearing age remain high, and the Ministry needs to focus health services towards these category of age group. The ministry is faced with challenges of maintaining primary health care services at the community levels, and meeting the increasing demand for higher level of secondary and tertiary health care services at the capital and other urban areas. Nonetheless, despite this negativism about the trend of demography of the country, there has been some positivism in terms of the natural decline of certain age group. The trend of population is expected to increase but at a declining rate. The growth rate is expected to decline to 2.9 between the period 2000-2050, and further to 2.6 by 20104. Later in the paper the analysis shows that whilst age group of children under 4 yrs increase and puts more pressure to bed capacity of all provincial centers, the trend of WCBA decline giving opportunity for realignment or rationalization of health care services. The variations between the trends of population of children and women of childbearing age (15-49) came about because of declining infant mortality rate and fertility rates.

1.2.3. Population density: It is estimated that the population density will increase from 16 in 2000 to 21 in 2010. The increasing population density will have effect on the morbidity characteristics. 1986 1

Trend of Population Density 2000 2010

Statistics Unit, MHMS, 1999.

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National Census (1999). Take note that the details of the census was not available during the compiling of the report. The majority of the data and infroamtion are based on 1986 estimates. 3 Ibid 4 SPC (2000). Oceania Population 2000, Demography/ Population Program, Secretariete of Pacific Community, Noumea, New Caledonia 11

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======================================================= 15 16 21 Source: Demography/Population Program, Secretariat of the Pacific Community, Noumea.

1.3. The Economy: The subsistence and semi-subsistence economy is still the major means of survival for most families, but these traditional means of economic and social support in the rural areas are weakening. Participation in the cash economy and formal employment opportunities are limited. The main primary sector exports are copra, timber, cocoa, palm oil and fish. The current pattern of economic development is dominated by largescale logging, mining, fisheries and agricultural projects financed by foreign capital. The economy grew at an average 5% per year in the first half of the 1990s mostly due to strong growth in forestry, fishery, construction, transport and communications. The economy is dominated by commodity production, principally export of logs, fishing, palm oils and kernels and copra. Per capital Gross National Product was estimated at US$560 in 1992 ranking the country as a Least Developed Country (LDC). Gross Domestic product in 1995 was 7.0% (an increase of 5% from 1993 levels). The trade balance recorded its first surplus of $47 million in 1995 and $118 million the year after courtesy of the boom in log exports and declining imports. Log exports went from $104 million in 1992 to $221.7 million in 1993 and $366 million in 1996. The persistent trade deficit prior to the advent of the log boom shows the heavy reliance on imported manufactures, machinery, and transport equipment. In 1995 Australia accounted for 41.4 per cent of total imports, Japan 11.8 per cent, Singapore 9.3 per cent and New Zealand 9 per cent. Services payments has been higher than receipts since 1990 although substantially offset by official transfers by the main donors in 1995 and 1996, being the European Union (European Development Fund, STABEX) and Australia (AusAID). In 1999, the adverse effects of the unrest were partly offset by official transfers from Development Partners. By the end of 1999, the conflict was already having its toll on the economy. The pressure on the economy continued in the first half of 2000 until the coup on June 5th. The coup only accelerated an already worsening situation in the Solomon Islands economy witnessed since mid 1999. Now however, the important sectors of the economy have been knocked out leading to a substantial weakening of the structure of the whole economy. So the effect of the social unrest on the Solomon Islands economy is much more severe and damaging than any crisis the country had ever experienced in the past. The impact of the crisis on the Solomon Islands is yet to be fully realized. It would take several years before the damage to the economy is fully felt. Likewise, it would take even more years before the economy is restored and rebuilt to its pre tension levels. In some respects, the Solomon Islands society may have changed forever as a result of the social unrest on Guadalcanal.

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1.4. The Health Status by provinces and National: Table 1

Solomon Islands Basic Health Indicators 1997 to 1999

INDICATORS Number of health facilities Total Population

Population <1 year Population 1-4 years Population women 15 –49 years Population annual growth rate Population density Life expectancy Infant Mortality/1000 live births Under 5 Mortality rate/1000 Maternal Mortality Rate/100,000 Total Fertility rate/WCBA(1549) GNP (USD) %GNP on Health Expenditure per health Doctor per population R/Nurse per population Population access to safety water Population access to proper sanitation Contraceptive prevalence [iv.] Ante-natal coverage [iv.] Supervised delivery [iv.] Birth <250g [iv.] Expected births [v] Total deaths [v] Total Births [v] Maternal Deaths [v] % Family Planning Coverage [v] % Antenatal Coverage [v] % Postnatal Coverage [v] % Detected malnutrition [v] Touring Satellite Clinics [v] Touring Schools [v]

1996 334

1997

410,36 15,209 56,432 87,294

252 425,488 15,772 58,516 90,486

3.5 in 86 [i.] 14

15

67 in 1976

38 in 1986

26 in 1995 [iv.] 549 in 1986

209

6.1 in 1986

1999 411 459,380

3.3 [ii] 16 M-62, F-64 28 [iii]

4.7*

870 11.6 11 65% in 1995 [iv.]

70% [vi.]

9% in 1996 [vi.] 25% in 1995 92% in 1995 85% in 1995 20% 17,235 863 7,235 8 7.7

17,868 884 7,360 5 8.5

74.4 36.6 1.6 2,309 890

68.9 39.9 1.5 2,068 720

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======================================================= Village Health Meetings [v] 1,600 1,767 EPI [v] - BCG 58.1 % 69.4 % - Measles 63.8 % 65.2 % - DPT3 71.9 % 68.6 % - TT2 + Booster 56.1 % 54.8 % - Polio 3 69.0 % 69.2 % - Hepatitis B 3 68.3 % 69.6 % - DPT1 / DPT3 drop out 4.6 % 5.3 % - BCG / Measles drop - 9.8 % 6.0 % out Sources: [i.] 1986 National Census [ii] WHO World Health Report 2000, Annex Table 2 Basic indicators for all [iii] 1999 National Census [iv.] Th eS t a t eo f Wo r l d ’ sCh i l d r e n2 0 0 0 , UNI CEF, Ne wYo r k [v.] EPI figures are from the Health Information system, Statistics Unit MHMS5i [vi.] RWSS/MOH Report (2000).

Despite shortcomings in demographic and epidemiological information, it is generally held that major improvements in the health status of Solomon Islanders have been achieved over the past two decades. The reported Infant Mortality Rate (IMR) has been reduced from 67 deaths per 1000 live births in 1978 to 44 per 1000 in 1995. Other statistics, such as lower crude death rates and longer life expectancy, provide additional indicators of improved health status. While the IMR has decreased, infectious diseases and chronic under-nutrition continue to dominate morbidity and mortality in children. There is growing evidence, much of it clinical and anecdotal, that non-communicable diseases of youth and adults are becoming increasingly important as a traditional lifestyle is replaced by one that is more westernized, with sedentary habits and diet. This is reflected in an increasing rate, albeit relatively undocumented, of diabetes, hypertension, obesity, cancers and respiratory diseases. This in turn has implications for resource utilization as the demand increases for longterm care, tertiary interventions and costly technologies. The MHMS is committed to preventing disease, protecting life and promoting healthy lifestyles and choices. The National Health 5

EPI figures used in the table are recorded by the HIS monthly reports. A verification report was done in Malaita 1999 to encountered under and over estimation reporting. 14

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======================================================= Policies and Development Plan 1999-2003 articulate a systematic approach to further d e v e l opa nds t r e ng t he nt heMi ni s t r y ’ sc a pa c i t ya ndc a pa bi l i t y .

SECTION II: INTERNAL REVIEW REPORT 2.1. Regional (Provincial) Service Distribution; 2.1.1. Type of Services; Table (1) : The Health Care Referral System

Level

Authority

Institution

1996*

1999

6

National

1

1

5 4 3 2 1 Total

Provincial Area Council Wards Wards Village

National Referral Hospital Provincial Hospitals Area Health Center Rural Health Clinics Nurse aides Posts VHW Posts

7 14 123 61 128 334

9 23 95 129 154 411

Source: *The Comprehensive Review of Health Services Report, 1996, MHMS, p.3.

Smaller hospitals such as Tulagi, Lata, Kirakira, Buala, Helena Goldie, Atoifi and Sasamuga Hospitals offer slightly lower level of service than bigger hospitals like Gizo, Kiluufi and National Referral Hospital in Honiara. The levels of (health care) services are delineated by the draft Guide to Role Delineation of Health Care Services in Solomon Islands 6. However, the Guide document is to be further developed into a meaningful resource management. Primary health services are primarily delivered at community level both at the urban and rural areas. Accessibility of health services has improved with the upgrading of health facilities and establishing additional through out the country. Approximately 70% of rural communities are within an hours walking distance from a health facility (The Comprehensive Review of Health Services Report, March 1996). Health facility to population in at least 50% of the provinces in 1996 was 1:800 compared to 1,131 in 1992. About half of the population (national average of 53.7%) lived within 3 kilometers from a health facility (1996). However still a sizeable population lived more than 5 km away (19.4%). The majority of people (58.2% Nat. aver.) walk to health facilities and therefore the cost to them in monetary terms is negligible. Nevertheless, remote provinces such as Temotu and Choiseul are vastly affected by distance and cost of travel to nearest clinic respectively.

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MHMS (1998). Guide To Role Delineation of Health Care Services in Solomon Islands, Draft, Unpublished Paper, Honiara. 15

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======================================================= From table (3), the number of health facilities has increased by 23% (77 additional facilities), which implied that 26 facilities have been established per year in the three periods 1997 to 1999. The increase is seen with Area Health Centers, Nurse Aide Posts, and Village Health Aides. During the period of 1997-99, the number of population cared for by a health facility clinic declined from 1:1,737 in 1997 to 1:1,643 because of the slight increase in the number of health facilities especially the rural health clinics.

2.1.2. Distribution of Services: Graph (1) showing distribution of health facilities by provinces:

Majority of basic health facilities are based in bigger provinces with larger populations (such as Malaita, Western, Guadalcanal, so that basic health care services are within the reach of the people. However, the level of services differs between areas. Higher level of service are available at the Central Hospital Honiara, which the National Referral Hospital. This is achievable when the need arises through the referral system or travel to Honiara at own will. Chart (1) Showing Distribution of Health Faciltites by Provinces

Makira Ulawa 11%

Temotu 3%

Choiseul 9%

W estern 20%

Choiseul Western Isabel Central Islands Guadalcanal Malaita Makira Ulawa Temotu

Malaita 29%

Isabel 10%

Guadalcanal 9%

Central Islands 9%

Table (2) showing Health Clinics:Population* and Nurse: Population** Ratio:

1997 Provinces No. of .Clinics Facilitie s Choiseul 21 Western 38 Isabel 28 Central 31 Islands Guadal. 20 Malaita 56 Makira 28 Temotu 12 Honiara 8

1999 Clinic Nurse: No. of Clinic: : Pop Pop Clinics Pop

Nurse: Pop

998 1,609 716 725

1998 Nurse: No. Pop of . clinic s 1,311 24 38 717 28 1,604 31

900 1,637 740 746

1,200 1,016 609 1,445

24 38 28 31

926 1,707 763 767

890 1,201 668 1,321

3,928 1,833 1,119 1,613 8,314

2,806 1,488 1,045 745 2,293

3,902 1,875 1,160 1,656 8,954

2,826 1,500 984 686 2,311

21 56 28 12 8

4,070 1,926 1,201 1,705 9,643

2,442 1,477 909 758 2,488

Clinic: Pop

21 56 28 12 8 16

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 17 of 122

======================================================= Ren Bell 3 803 482 3 826 413 3 850 Solomon I 245 1,737 249 1,774 249 1,845 * not including VHW posts ** Registered Nurses only

2.2. Internal Structural and management Issues: In short, the major internal problems are as follows:  The inability to adapt to environmental changes and, to manage and cope with change.  Financial sustainability  Institutional sustainability  Ineffective and inefficient management of health resources.  Ineffective implementation of health programs and projects  Quality assurance 2.2.1. Organizational Structure: The organizational structure of the Ministry of Health has been unchanged for the past two decades. There is very little accountability as most decisions and powers are centrally control by central agencies such as Department of Finance, Department of Planning, and Department of Public Services. Nonetheless, delegation of disciplinary power was given down to the Permanent Secretary (impartially) with out much legal underpinning. Internally there is confusion between policy and operational roles, between statutory and ministerial obligations. The job descriptions are ill defined without much performance indicators and proper staff appraisal in a consultative and learning incentives, which would be helpful in performance management of departments and individual. Having going through the structural difficulties with financing of health care services, training and development of health workers, recruitment and appointment, and disciplinary actions, it raises the question; whose values do we (public servants) exists? Is it the rules and procedures that matter? Or is it our customers? Our local population? These questions need answer that concerns with accountability and external autonomy to the Ministry of Health. Or even to other sister ministries. The existing health structure and its relation with the public service needs careful review and changes.

17

425

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 18 of 122

=======================================================

18

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 ==============================================================

Fi gur e1s howi ngt hee x i s t i ngor ga ni z a t i on’ ss t r uc t ure: Ministry of Health: National and Provincial level:

MINISTER Permanent Secretary NATIONAL LEVEL

Undersecretary Health Care Health Care / Curative Health Services Paradigm

Undersecretary Health Improvement CAO

Health Improvement & Protection Paradigm

Supporting Services Administration Accounts

PROVINCIAL LEVEL Provincial Health Services Curatve Health Services

___________________________________________________________________________________ - 19 -

Health Improvement & Protection Programs

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 20 of 122

=======================================================

20

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======================================================= 2.2.2. Centralization Vs Decentralization (Vertical versus Horizontal programs): Health services in Solomon Islands remained a centralized function of the Government with implementing agencies in the province under the Provincial Agreement Act. Health financing and manpower supply are centrally controlled and disbursed. Health services delivery to the people uses the primary health care approach. There is mixture of horizontal and vertical health programs. Most public health programs such as the Malaria Control Programs, Environmental Health and Rural Water Supply programs, and health education programs are typical vertical programs.

2.2.3. Activities (Inputs): The Health Strategies of the Ministry is stipulated under the National Health Policies and Development Plans. Whilst the specific programs and activities are in the individual work plans. These activities and programs are funded by the Health Recurrent Budget from the Government as wells as grants and external financial sources from international developing pa r t ne r s .TheMi ni s t r y ’ se f f or tt os us t a i nt hemi ni ma lr e a s ona bl el e v e lofc a r et ot hepe opl e of the country supported by the limited resources of health workforce, financing and infrastructure. 2.2.4. Findings (outputs): There were two changes to the Minister of Health during the report period. In mid 1997 around August, the Ministry had a new Health Minister (Hon. Dickson Waraohia, MP for East AreAre) He is a member of the national coalition Government by the name of Solomon Islands Alliance For Change (SIAC). After two and half years, a reshuffle took place, which took effect January 2000. The then Health Minister was Hon.Dr.Steve Sanga Aumanu, MP for Baegu Asifola, Malaita Province. The Ministry official changes its name from Ministry of Health and Medical Services to MINISTRY OF HEALTH in 1999. Bills and 1997 Cabinet Papers

1998

1999

1.Parliamentary Bills

(a) Passed

1.Pharmacy Practitioners Act (Amendment 2.Pharmacy & Poisons Act (Amendment) 3.Pure Food Act 4. Nursing Council 21

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 22 of 122

======================================================= Amendment (1997) (b) Draft Stage 1.Mental 2.Tobacco Products Health Act Control Bill (draft) (proposed amendment) 2.Cabinet Papers Not available 1.Indicative Health Sector 1.Revised Local Program on Development Supplementation Stategies 1997-2001. (23.3.98, Scheme (LSS) for Cab(98)59). foreing doctors employed by the S.I.G. (10.2.99, Cab(99)15). 2.Resolutions on Health for 2. Submission for st All into 21 century 5% increase of SDA Reproductive Rights and to Operating Responsibilities conferences, Theatre & Eye 11-12.2.98,Canberra,Aust. Nurses in the (22.4.98, Cab(98)83N). country. (18.2.99, Cab(99)16 3. MHMS to have its own 3. Report on the transport servicing & pooling Study Tour to Japan system. (28.4.98, Cab(98)87). & Brisbane by Minister of HMS. (30.4.99, Cab(99)64I). 4. Decision to terminate 4.The impact of the Solomon Islands doctors with current ethnic SIMA Medical Centre from tension on the Public Service be withdrawn Hospital services at and direction to resolve the the Central issues. This matter was (National) Referral deferred but never discussed Hospital. (27.7.99, again. (28.4.98, Cab(98)88). Cab(99)89). 5. The MHMS 5 year National Health Policies and Development Plan 1999-2003). (27.7.99, Cab(99)113 6. Report of the Review and Restructuring of the MHMS as part of the phase two of the public sector reform

22

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 23 of 122

======================================================= program. (2.8.99, Cab(99)120). 7.Proposed Solomon Islands Health Sector Development Project. (15.9.99, Cab(99)159). 8.Solomon Islands Health Sector Development Project Previous Paper. (13.10.99, Cab(99)159. Early 2000: Reform in the Health Sector Assisted by AusAID, (22.2.00, Cab(99)231). Change of name from the Ministry of Health & Medical Services to MINISTRY OF HEALTH (MOH) (29.2.00, Cab(99)27).

2.3. Health Financing & Budgeting and Resource Allocation Factors: The national government provides the major source of (recurrent) funding for health services at both the provincial and central levels. Successive governments have always considered health services as an important political priority and a right of its citizen. This has been reflected in the high proportion of government allocation to health. Table (3) Total government budget and the allocations from 1988 to 1999:

Year Total Govt. Rec. Budget SBD$M s 1988 101.2

Health Rec. Budget SBD$M 12.7

Share to Health (%) 12.5

23

Health Revenues SBD$M 0.1

Per capitaSBD$ Nominal

Rea l

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 24 of 122

======================================================= 1989 125.2 14.8 11.8 0.2 42.5 1990 146.6

18.3

12.5

0.2

47.9

1991 162.8

20.5

12.6

0.2

57.4

1992 208.8

24.3

11.6

0.2

62.4

1993 231

26.9

11.6

0.2

71.7

1997 412.5

48.8

11.8

1998 532.5 1999 441.0

54.3 56.7

14.4 16.3

76.8

27. 5 27. 2 29. 9 28. 1 28. 9 28. 4

Source: Account Section, MOH (2000. Table (4) Distribution of the Recurrent Health Budget 1991-1 9 9 9( SBD$ ’ 0 0 0 )

Sections Total Central Total Province Total National %Provincial %Central % National

1991 6632

1992 15907. 8 6994.4

1993 16758. 9 8180

185331. 1 35.8 64.2 100.0

22307. 2 28.7 71.3 100

24939. 3 32.8 67.2 100

11901.1

1994 24525. 1 10044. 2 34569. 3 29.1 70.9 100

1995 23776. 8 14928. 3 38705. 1 39.6 60.4 100

1997

1998

1999

18963. 6 31290. 5 37.73 62.26 100

21209. 2 34070. 1 38.36 61.63 100

21306. 1 35439. 6 37.21 61.89 100

Source: Account Section, MOH (2000).

One of the fundamental problems contributing to the management of finance is the lack of appropriate mechanisms or technology to monitor and evaluate the performance management of the health budget. It is almost impossible to measure both the operational and the impact of the health care services at the central and provincial level. Item budgeting r a t he rt ha n‘ ou t pu tba s e d’bu dg e t i ngi sa ppl i e d.Thebu dg e ts t r u c t ur ei sdr i v e nbyt he De pa r t me ntofFi na nc e ’ sobj e c t i v e smor et ha npr ov i di ngoppor t u ni t yf orbi gs penders like health to be accountable in cost saving incentives and cost-recovery. The health budget therefore does not reflect the health care services, so as the allocation of resources in the health sector 7. To reflect the above argument the National Referral Hospital alone consumes significant portion of 28.3% of the total health budget in 1999, followed by Ministry of Health Headquarter 15.2%, Pharmacy services (drugs & equipment covered here) 12.2%, whilst 10 provinces (including Honiara City) accounts for 37.21, which is SI$52 (USD10) per-capita in province (excluding drugs costs). The level of health services grants 7

John Izard (1999). Solomon Islands Health Finance Review, ADB Consultant, MHMS/HQ, Honiara, May.

24

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======================================================= to the provinces dropped from 43.5% in 1986 to 28.7% in 19928. In 1997 to 1998, it raised (since 1993) and stays around 37-38%. The implications of the current budget setting and allocation are an issue to be addressed in the near future plan. De s pi t et heGov e r nme nt ’ sc ommi t me ntt ohe a l t ha sr e f l e c t e dbya ni nc r e a s et o1 6 . 3 % of total government budget from previous years, there is the need to review the issue of health financing and management of health care delivery, particularly at the NRH. The Government in its Solomon Islands Policy and Structural Reform in 1997 set the direction towards increasing proportion of the recurrent health budget to community and public health programs, provincial health services, environmental services, and health education and promotion.

Table (5) showing selected health accounts indicators for selected countries in the pacific region; estimates for 1997:

untries

stralia ew Zealand ji lomon ands G anuatu

HEALTH EXPENDITURE (%) Public Total Private Out-ofexpendit expenditur expendit pocket e as % of ure on ure as % expenditur total health e as % of expenditur of total as% of health total e on health. GDP expendit expenditur ure e on health 7.8 8.2 4.2 3.2

72.0 71.7 69.2 99.3

28.0 28.3 30.8 0.7

16.6 22.0 30.8 0.7

PER CAPITA HEALTH EXPENDITURE (U Public Total Out –ofTotal Public expend health expenditur pocket Expendit -iture in inter expendit e at official expenditur ure in national ure on exchange e internatio dollars health as rate at official nal dollars % of rate total public expendit ure 15.5 1730 287 1601 1153 12.7 1416 312 1911 999 8.3 115 35 214 148 5.2 19 ……. 83 83

3.1 3.3

77.6 64.3

22.4 35.8

22.4 35.8

7.5 9.6

36 47

8 17

77 85

Normal type face indicates complete data with high reliability Italics indicate s incomplete data with high to medium reliability …. . d a t anot available Source: WHO (2000). The World Health Report 2000, Annex Table 8, pp. 192-95.

From the 1997 estimates by WHO, Solomon Islands incurred 3.3% of the GNP on health, as compared to Fiji (4.2%GNP) and Australia (7.8%GNP). The question therefore is raised 8

Approved Recurrent Estimates and Solomon Islands Government Budget.

25

59 55

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======================================================= is; Are we doing better we the current share of 3.2 % of the GNP? It is evident later in the report that by WHO standard to some extend, Solomon Islands health system has a cost-effective delivery package through the primary health care approach. It is assumed and implied here then that we are utilizing the limited input of financial resources and transforming it into higher level of performance on health. This is not saying that the internal structure and functions of the health system is perfect. As the report will reveal later there are numerous health issues and problems related to structure and function needs to be reviewed and addressed.

2.4. Management and Supervision: The foremost important health issue in the period of 1997-99, is the lack proper and detailed monitoring and evaluation of health care service delivery. This is partly due to lack of appropriate health management information, and lack of skilled manpower and facilities (technology). Productivity and financial performances has never being careful monitored and done, therefore problem solving and strategic planning is difficult. Proper accounting data for financial management is lacking or inadequate. The budget is far from a reflection of the health services delivered. There is no cost-sensitivity or incentives in placed. The budgeting procedure is traditionally cost-based. There is need to improve the financial management system at the central ministry and hospital levels. Health policies are not evaluated seriously. There is no evidence based policy development. There is no mechanism in place to access whether human resource for health is meeting the requirements of the country in terms of defined needs. It is difficult at this point in time to have proper needs-analysis result because of lack of trained personnel and logistic support facilities such as efficient health information system. Staffing of services and facilities is often the basis of personnel deployment in the Solomon Islands.

2.5. Status of Health Care Services Delivery: The Comprehensive Review of Health Services in 1995-96, made attempts to evaluate the current status of health care service delivery in Solomon Islands, highlighted some concerns and weaknesses as well as strengths. About 59.7% of the respondents found that health facilities are located conveniently for them. It was noted that patients wait longer (1-2 hr.) Honiara Clinics than provincial clinics (< 1hr). Malaita, Isabel, Makira and Rennell & Bellona wait only for 15 minutes. Therefore waiting hours is an issue for urban hospitals and clinics to address. The presence of a health worker at the health facility at the time of patient presentation ranges from 63.7 to 88%, the lowest in Makira. Generally with the existing health care service network, more than half, 61.8% (national average) satisfied with the waiting time. It is also noted that most patients in Honiara (55.6% respondents are not satisfied. Although majority of 81.2% is satisfied with attitudes of health workers, it is a concern still in Makira, Temotu and Honiara. Despite difficulties, 65.5% are satisfied with availability of medicine whilst sizable population of 31.7% are dissatisfied. The logistics of

26

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 27 of 122

======================================================= getting medicines to clinics is not easy. Natural forces such as bad weather and untimely shipping and ordering had threatened availability of medicines to the rural population. It is evident that there was a tremendous pressure in maintaining health care service delivery in 1997 to 1999. The level of output increased in relation to number of people receiving health care services at the Area Health Centers, Rural Health Clinics and Nurse Aide Posts. (See table 13 below). The increase was highest in Malaita followed by Western Province and Guadalcanal. It is also noted that the usage of health care services per person also increased. However, there was marked differences between provinces in average outpatient visits per person per year (See table 14 below). An individual of Western Province visited the clinics more, followed by Choiseul and Malaita. In 1999 the impact of the ethnic tension is evident, that the average number of individuals using the health care services dropped from twice (or more) to once (1.58) per person. The exact reasons for the variations are to be fully investigated. The shortage of local doctors is an ongoing concern. Of the 31.4% wanted to see a doctor at first presentation only 1.2% actually saw a doctor. This implied that many people are moving towards a higher level of service. The demand to see doctor will increase. Whilst the number local doctors graduating from medical schools in Fiji and Papua New Guinea increases, retaining them within the public sector will become a health care management issue.

2.6. Distribution of Health Care Workforce; The rural population of eighty seven percent is currently served with a small proportion of relatively less qualified health workers especially in clinical areas and diagnostic services. In 1999, 70% of the health work force is in the provinces and the Honiara City, engaged in primary health care. With the increasing need to decentralize more specialized services along with the need to improve quality of care, it is seen that hospital based services require improvement. About twenty four percent (24.3%) of the total health work force is in the National Referral Hospital. However, deployment of qualified well-trained health workers and professionals centrally biased with 59.5% of the total qualified well-trained health workers in the Central Hospital. More than seventy percent (72.9%) of total number of doctors in Solomon Islands are located at the National Referral Hospital. In relation to registered nurses, 32.5% of nurses are also in the NRH, while 67.5% are in the provinces including HCC. Nevertheless, there is hospital-bias in relation of deployment of Registered Nurses in the provinces by more than half (59.2%), excluding CIP, GP, CP, and HCC who are without public hospitals. It is the universal picture that the nurses constitute the major component of the health workforce. The implications are the need to strengthen the primary health care in terms of human resource development.

2.6.1. Shortage and management of health workforce: The Shortage of qualified staff especially doctors is a known cause of the internal weaknesses, whilst allocation and development of nursing is a problem. Table (6) shows the gap between required numbers of doctors with the projected supply. It is also been observed 27

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 28 of 122

======================================================= that local doctors are leaving the public service to private sectors because of dissatisfaction with the conditions of the service. The issue of retaining qualified local doctors is a priority on the paper (policy) but low practically. Annex table (1) shows that the population to doctor ratio is very high.

Table (6) Shows the Gap Between Requirement Projection and Supply Projection on the Medical Profession (Doctors):

0

1

Total

0

HTC

0

RBP

0

CIP

1

G.P

0

MUP

1

TP

1

C.P

0

I.P

0

M.P

0

W.P

NRH

General Surgery Orthop ed. Paediatr i Obst& G. Int.Phy si Radiolo g Patholo g. Anaesth Eye Psychiat rist A&E/ GP Manage r/CEO Total

3 1

0

0

0

1

1

1

1

1

0

0

0

5

0

0

0

1

1

1

1

0

0

0

0

4

2

1

1

1

1

1

1

0

0

0

0

8

0

0

1

1

1 0 0

1

1

1

1

1

1

0

1

0

0

0

0

0

0

0

0

7 0 1

3

2

3

1

1

1

1

1

1

1

1

16

0

1

1

1

1

1

1

1

1

1

1

10

8

5

7

7

7

6

7

3

2

2

2

56

28

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 29 of 122

=======================================================

SECTION III: HEALTH SERVICE PLANNING, MANAGEMENT AND SUPERVISION: 3.1. Management & Administration: Health services is predominantly centralized in terms of overall health policy development, planning, management, training and evaluation of health services. Implementation of the National Health Policies is being left to respective divisions and departments that made up the Ministry of Health. However, MOH is trying its best to do away with the above management approach and to empower the heads of department and middle managers to play more part in decision making in areas of management, planning, monitoring and evaluation of health services. In enabling that to work the fundamental basic structure must be conducive. Roles of job descriptions of staff must be understood and clarified. It is a difficult task. However, contingency plans were made since 1997. In this report below subsequent feedback is made actions taken to achieve the objectives. TheMi ni s t r y ’ sPol i c y Goals is to improve the capacity of the ministry to plan, implement, and evaluate the health services in the country. 3.1.1. Activities (Input) & Output: Table (7) below shows matrix of strategies implemented since 1997. Priority Areas

Input (Strategies)

1.National Health Policy Developments:

1.1.National Health Indicative Strategies

1.2.Medium Term Development Strategy

1.3.National Health Policies and Development Plans 1999-2003 2.Health Sector Reform

2.1.Restructuring MOH Restructuring the health sector so that it becomes efficient and effective in the delivery of health services. Main focuses on [1]

Output Indicators The national health indicative strategies were produced by the MOH. The MTDS was formulated with participation of MOH and all other Ministry Sequent of events leading to the final draft of the NHPDP

-Institutional strengthening project. -Draft Restructured MOH. -Revised staffing structure. -Revised budget structure.

29

1997

1998

1999

Senior Health Officers Conference met in August 1998

Finalization of draft. Printing of the document is delayed.

-An institutional strengthening project completed and submitted to the Multidevelopment partners meeting held in Honiara.

-An ADB consultant, Mr. John Izzard, reviewed the MOH Budget structure.

accomplished

accomplished

Review Or situational analysis done

-Draft restructuring document

-A NZ consultant reviewed the Health Care Legislation. Joy

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 30 of 122

=======================================================

3. Strengthening t heMHMS ’ capacity to plan, budget, evaluate, monitor and evaluate health services delivery

institutional strengthening [2] Staffing restructure [3] Budgeting restructure [4] Health care legislation review. Review functions, job descriptions, activities involved, work load analysis. 3.1.-All posts filled with appropriate qualified staff. -Office automated & equipped. -Training of staff

-Revised Health Care Legislation

-All posts filled. -Office automated. -FMS -RAF. -Regular financial reporting. -

3.2.Establishemnt of proper Financial Management System

-Properly structured financial management system and guideline on monitoring and cost analysis and budgeting and resource allocation. -Monthly financial reporting by accounts section. Regular (annual) National health Financial reporting and cost analysis. -Development of a appropriate resource allocation formula based on demand, needs and population -Accurate and timely reporting (response rate. -Hospitalinformation system.

3.3.Strengthening of the health information system by improving coordination and integration of information data, and software. Expand hospitalinpatient data.

completed but needs further refinement and modification.

Liddicoat (September 1999).

Not accomplished

Not accomplished

Not accomplished

Not accomplished

Not accomplished

Not accomplished

-Response rate from clinics: (a) 78.8%, (b) Pop. covered in reporting 88.2% -Response rate from Hospital; poor.

30

(a) 79.1% (b) 91.2%

Poor. Not accomplished

The health s e c t or ’ s intention to restructure was approved by the Cabinet.

(a) 76.7% (b) 87%

Poor. Not accomplished

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 31 of 122

=======================================================

4.Partnership Development

5.Improve access & quality health care

6. Develop policy on (public) health Financing

4.1.Review current mechanisms 4.2.Develop partnerships and collaboration with private sector 5.1.Strengthening level of health care at NRH & provincial hospitals through: -Continuous training,

Not accomplished Not accomplished

4.1.Draft Guideline completed 4.2.MOU established

Not accomplished

Not accomplished

Not accomplished

Not accomplished

Physical upgrading in progress

-Upgrading of equipment,

No. Of trained personnel Upgrading of equipment

-Upgrading of infrastructure

Infrastructure rehabilitation

6.1.Review current regulations so that alternative health financing could be developed.

- Cost recovery (user pay) policy

Not accomplished

-Increased revenue collection at the National Referral Hospital; -Increase budget allocation to health improvement & protection.

Not accomplished

6.2.More emphasis to Health Improvement programs.

Not accomplished

Physical upgrading in progress

In progress

In progress

In progress

Not accomplished due to lack of funding

Not accomplished due to lack of funding

Not accomplished due to lack of funding

Draft Guide to Role delineation t completed Not accomplished

Not accomplished

Not accomplished

Not accomplished

-Increased of 10% to the health budget to health improvement & protection.

-Donor inputs in public health programs.

3.1.2. Analysis: The activities and input at the policy and executive level of the Ministry of Health are driven by eight health policies that form the platform to ensure that the system achieves the following key outcomes9; - Improves overall level of health - Equal distribution of health in the population - Overall level of responsiveness and distribution of responsiveness, - Distribution of financial contribution. The key strategic inputs the Ministry undertook in the three years period was setting future directions through three key policy frameworks. They were the National Health Indicative Strategies, which formsa ni nt e g r a lpa r toft heGov e r nme nt ’ sMe di u m Te r m De v e l opme nt Strategy (MTDS).

9

WHO (200) Measuring Goal Achievements in the World Health Report 2000; Health Systems: Improving Performances, Chapter 1, pp27-35.

31

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 32 of 122

======================================================= The development of the National Health Policies and Development Plans begun in 1997 with sequence of events leading up to the finalization of the document in 1999. These events include review of the status of health services in the country, which coincides with the Senior Health Officers Conference in August 1998. The structural and management issues were clearly raised by the conference as the major health issue the Ministry needs to prioritize in the future health developments. The Ministry then drew up a Cabinet paper e x pr e s s i ngt hes t a t e me ntofi nt e ntf ort he‘ he a l t hs e c t orr e f or m’ ,whi c hwa s ,a ppr ov e dt he Cabinet in 1998. 3.1.3. Output & Key Issues: The level of output of the activities of the Ministry is assessed to be very low, and affected by the political and social problems experienced. The effect of the ethnic tension has been the major threat, which corresponds to the weaknesses of the health sector to effectively carry out the planned health reform. Most leading activities were not accomplished. Overseas developing partners were requested to assist and support the proposed reform by the health sector, during a conference in 1998 organized by the Government. The key factors for the ineffective implementation of the national policy strategies are listed below; Time issue. -There is very little time for technical or professional developments such as developing standards and specific policies, integrating more with staff and other stakeholders internally and externally. It is therefore clear that coordination at the executive and divisional management level needs to be addressed. Clear guidelines and job descriptions need to be developed or re-enforced if already present. It is helpful if clear performance management process is developed with staff from the executive and downward.  Delay at the Central Agencies: - There is significant delay in administration procedures by central agencies. Human resource management procedures such as recruitments have been very slow. This is not critize the central agencies but this is how health development is been affected.  Lack of funding:- Theov e r a l lGov e r nme nt ’ sc a s hf l ow pr obl e ma f f e c t e dt he Mi ni s t r y ’ sc a pa c i t yt oi mpl e me ntma nage, and evaluate its programs. Supervisory visits were not done. The capacity to implement project and plans of the Health Development Budget is none, either due to lack of funding or no one to implement the plans at operational level. It is also because of lack of proper costing of plans into a budget, which omits important health priorities. The budget process is traditionally cost or itemized-based, and not program or output-based.  Lack of knowledge and skilled personnel. The lesson here is that new concepts must be transferred to the divisional heads and subordinates and reinforced in a learning manner. However, the rationale to re-l ooka tt heMi ni s t r y ’ sor g a ni z a t i ona ls t r uc t u r e and function is understood to some level. Workshops and conference were the major venue for communication. Involvement of key staffs were involved right at the planning level. This approach will be further promoted with the health sector.

32

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======================================================= Outcome: Whilst above issues are subjective, the objective perspective organization is also crucial and are related. In measuring the achievements of the Solomon Islands Health System the above key outcomes are used in this report. The WHO guide is applied in this context. The Mi ni s t r y ’ sf or wa r dpl a nni ngi se ns u r et ha twec ou l ds e et hepr oblems and achievements ourselves and not for someone else to do it for us. However, at this stage we could only rely onot he r s ’ j u dg me nt .

3.2. How Well Do the Solomon Islands Health System Performs? 3.2.1. Overall Level of Health: The three conventional and partial health status is used. By end of 1999 the estimated annual growth rate declined to 3.3% as compared to 3.5% in 1986. The probability of a child dying under 5 years (per 1,000) in the Solomon Islands is higher (47-49/1,000) than Fiji (19-25) but less than Papua New Guinea (106-129). Similarly, adult Solomon Islander has a higher probability of dying at between age 15-59 years (227-274/1,000pop) compared to Fiji (141247) but less than Papua New Guinea (325-325) and Vanuatu (239-333)). According to the basic indicators by WHO, Fijians live longer at Life Expectancy of female 69.2 and male 64.0, than Solomon Islands, female 64 and male 62. Solomon Islanders expected to live longer than Papua New Guineans and Vanuatuans See Table xxx). Table (8) showing Basic Indicators for selected countries in the pacific region:

Countr ies

Annua l growth rates (%) 199099

Total fertility rates

Probability of dying (per 1,000) Under 5 yrs

Probability of dying (per 1,000). Between 15 and 59 yrs 1999

Life Expectancy at (yrs) 1999

1990

Male

Male

Male

1999

Femal e 5

Femal e 53

Austra 1.1 1.9 1.8 7 94 76.8 lia Fiji 1.2 3.1 2.7 25 19 247 141 64 S.I 3.3 5.7 4.7 49 47 274 227 62 PNG 2.3 5.1 4.5 129 106 377 325 53.4 Vanuat 2.5 4.9 4.2 64 57 333 239 58.7 u Source: WHO (2000): The World Health Report 2000; Annex Table 2, pp.156-163.

33

Femal e 82.2 69.2 64 56.6 63

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 34 of 122

======================================================= Another measure that combines death rates and disability and reflects the overall status of population health as the ratio to the burden of diseases is Disability-Adjusted Life Expectancy (DALE). It is been used by WHO to judge if good health is achieved. The estimates for 1997-99 by WHO revealed Solomon Islands ranked 127 compared to Tonga and Fiji at 75 and 106 respectively. Vanuatu and PNG at 135 and 145 respectively. Table (9) showing health attainment, level and distribution in selected countries in the pacific region; estimates 1997-99:

Ran k

Countries

Total pop. @ birth

Disability-adjusted life expectancy (years)

Males 2

Australia

73.2

At birth 70.8

Females At 60 16.8

At birth 75.5

At 60 20.2

Expectation of disability at birth (years) Males Female s 6.0

6.7

Tonga 62.9 61.4 11.5 64.3 13.3 6.8 Fiji 59.4 57.7 8.3 61.1 9.8 6.3 Solomon 54.9 54.5 8.8 55.3 9.2 7.5 Islands 135 Vanuatu 52.8 51.3 8.0 54.4 9.2 7.4 145 PNG 47.0 45.5 8.2 48.5 8.7 7.8 Source: WHO (2000): The World Health Report 2000; Annex Table 5, pp.176-183

8.6 8.1 8.7

75 106 127

8.6 8.1

Preventable health conditions remain predominant causes of illness burden to the people (as the recipients of services) and the Government as the major supplier of health services. 3.2.2. The distribution of health in the population: Health services reached the population through the Primary Health Care programs, and the referral systems in relation to health care services delivery. The primary health care mechanism forms the template for service delivery in order to achieve Health For ALL by 2000. It is through these means that forms the platform or structure for responsiveness to the peoples’ di f f e r e nthe a l t hne e ds . 3.2.3. Responsiveness10 of the health system: S ol omonI s l a ndshe a l t hs y s t e msha v es howne v i de nc eofme e t i ngpe opl e ’ ss a t i s f a c t i on.A national survey done in 199511 . There was a high percentage of level o satisfaction with the overall performances of the health facility. High level of satisfactions was also found in selected activities such as waiting time (mainly in rural health facilities and not in Honiara), 10

WHO (Health Report 2000): Responsiveness is no tme e t i ngp e o p l e ’ sn e e dsbu tho ws y s t e msp e r f o r ms relative to non-h e a l t ha s p e c t s ,me e t i ngo rno tme e t i ngpo pu l a t i o n ’ se xp e c t a t i o n.Co mmo nc o mp l a i n t so f public are attitudes of health workers towards their patients and waiting times. 11 Ministry of Health, SI (1996). The Comprehensive Review of Health Services Report, pp.66-67

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======================================================= attitude of health workers, explanation of diseases and treatments, availability of medicine, and referral to high level of care.

3.2.4. Performance on health level (DALE) and Overall Performances: Table (10) shows ranking of selected countries in the pacific region on their performances on health level, and the overall performance:

Performance on health level Overall Performance (DALE) Rank Countries Index Rank Countries Index 20 Solomon Islands 0.892 32 Australia 0.876 39 Australia 0.844 41 New Zealand 0.827 80 New Zealand 0.766 80 Solomon Islands 0.705 120 Vanuatu 0.665 96 Fiji 0.653 124 Fiji 0.632 127 Vanuatu 0.559 146 Papua New Guinea 0.546 148 Papua New Guinea 0.467 Source: WHO (2000): The World Health Report 2000; Annex Table 10, pp.200-203

Overall Efficiency (overall performance)

Efficiency in health attainment(performance on health level/ DALE) in selected countries in the pacific region Papua New Guinea

Papua New Guinea Vanuatu

Fiji Fiji

Vanuatu New Zealand

Solomon Islands

Australia

New Zealand

Solomon Islands

Australia

0

20

40

60

80

100

0

20

40

60

80

100

%

%

It is therefore evident that the Solomon Islands Health System has performed reasonably well in the past decades. On the developments on health alone, S.I is ranked 20 ahead of two developed country in the pacific, Australia and New Zealand. Even on overall performances SI is ranked 80 out of 1991 members states of WHO.

35

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 36 of 122

======================================================= S y s t e m’ sWe a k ne s s e s : Whilst the WHO guide to systems has revealed satisfactory performances, there are major weaknesses observed in the health systems. Theses weaknesses are mainly related to political status of the provincial government system and their commitment to health, health financial management and accountability, and administration process in relation to human resource management, and other bureaucratic procedures, and the ability of the Ministry of Health in monitoring and evaluating health services. Other problems are practical issues related to untimely payment of health grants to the provinces.

3.3. Health Information System: Thek e ys ou r c e sf orhe a l t hi nf or ma t i oni st he‘ He a l t hI nf or ma t i onS y s t e m( HI S ) ’ .I ti st he monthly clinic report on health activities by provincial hospital outpatients, Area Health Centers, Rural Health Clinics, and Nurse Aide posts. It reports on the activities of health institutions, as the inputs in service delivery as well as output and outcomes to some extend. Annual reports are other area of health information feedback from the provinces and divisions and programs. It is (hope) through annual reports that feedback on issues related to health resources management is reviewed. Issues and problems are raised and discussed. It was an important avenue for problem identification. Besides, conventional health indices such as morbidity rates experienced in the provinces, other management information is also included, though limited. Staff inventory, facilities and equipment inventories are some of the information included. The major issue with Annual Health Reports is that there are no standards and required formats for directors and heads of programs and divisions to follow when reporting. Thus, the substances of the reports are often very descriptive without analytical meaning for evaluation and improvement purposes. Nonetheless, this report uses a lot of trend analysis as a means of evaluation of the health activities and program outputs and outcomes. There is overall failure of reporting by responsible health authorities in the provinces and divisional level in 1997-99. Nonetheless, there are few authorities producing reports annually. A few filled in gaps left by their predecessors. These few people are commended for their efforts. Other sources of information are external to the Ministry. They are National Census, WHO, Unicef, UNFPA, SPC and other organization. Nearly all the above are form of estimates with good accuracy. 3.3.1. Response Rates of Monthly Clinic HIS Reports: -Response rate from clinics

1997 1998 1999 78.8%, 79.1% 76.7%

Pop. covered in

88.2%

Solomon Islands

91.2%

87%

36

It is clear from the table that the level of responding declined in the past three

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 37 of 122

======================================================= years, 1997-99. The 20 months old ethic tension did had some significant impact on clinics report besides other reasons needing further review and improvement. % of Reporting from Clinics by provinces Choiseul Western Isabel Central Islands Guadalcanal Malaita Makira Temotu Rennell Bellona Honiara

1997 66.3 85.1 64.0 76.8 73.7 83.8 91.7 83.3 52.1 100

1998 67.0 81.5 64.8 85.5 82.0 77.0 95.6 82.1 64.6 100

1999 76 75 66 81 79 73 81 67 35 83

Source: Health Information System, Annual Feedback 1997,1998,1999, Statistics Unit, MOH

Graph showing % of reporting of Monthly Clinic Report by provinces 120 100

%

80 60 40 20

SI

on ia

ra

a H

R

C

G

en ne

ua

ll

Be llo n

u m

1998

Te

1997

ot

ira ak M

al ai ta

l

M

da

lc a

sl an lI

en tr a

na

ds

el ab Is

te es W

C

ho is

eu

rn

l

0

1999

It is clear that level of reporting of monthly clinic HIS report varies between provinces. Honiara recorded the highest reporting percent followed by Makira Provinces. Those provinces below 80% line need more effort put in reporting.

3.3.2. Response Rate of Annual Reports: Provinces & Reporting Officers Western

1997

1998

1999

Nil

Yes By B.Sasa

Yes By Hosp. secretary

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 38 of 122

======================================================= Choiseul Yes Nil Nil By B.Sasa Isabel Yes Nil Nil By Dr. Roy CIP Nil Nil Nil Guadalcanal Nil Nil Nil Malaita Nil Nil Nil Makira Yes Yes Yes By Dr. Bala By Dr. Bala By Dr. Bala Rennell Bellona Nil Nil Nil Temotu Yes Nil Yes * By Dr. By Drs. Togamae & Araathon Tovosia Honiara Town Council Nil Nil Nil National Psychiatric Unit Yes, by Yes, by D.Boara Yes, by D.Boara (NPU) D.Boara By Programs & 1997 1998 1999 Reporting Officers Malaria Yes Yes Yes Reproductive Health Nil Nil Nil RWSS Nil Nil Yes, by Peter Woperes * Disease Prevention & Yes, by Yes, by Yes, by K.Konare Control center K.Konare K,.Konare Health Education Yes, by Yes, by A.Lovi Yes, by A.Lovi A.Lovi Social Welfare Nil Nil Nil NRH & Reporting Officers NRH – Overall Report Rehabilitation

1997

1998

1999

Nil Yes, by C.Laore

Nil Yes, by V.Hugo

Nil Nil

Pathology Surgical

Yes, by A.Dofai Yes, by Dr.D.Pikacha

X-ray Private Sectors & Reporting Officers

1997

1998

Helena Goldie Hospital

Yes, combined report by Dr.D.Pikacha Yes, by S.Savakana 1999

Yes, by Yes, by Yes, by Dr.J.Xlow Dr.J.Xlow Dr.J.Xlow Atoifi Hospital Yes* Note: * implies that report submitted were incomplete or partially. Not all activities are reported on.

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 39 of 122

======================================================= Obviously, the levels of reporting by responsible officers are very low. This is an area for improvement. It is an opportunity to commend those officers who had taken all efforts to put in an annual health report. There is also need for proper reporting format to enable responsible officers to know what kind of information is required in the reports. The r ei snof or ma l‘ Hos pi t a lRe por t i ng ’ a tt hemome nt . Re por t sa r edonea ta na d-hoc basis. Hospital services reporting are crucial part of management, and planning. There was attempts to develop a reporting format for Hospitals but was not implemented for several r e a s ons .I ti st heMi ni s t r y ’ spl a nt oa ddr e s st hei s s u e .The r eha dbe e ns omepr e l i mi na r y reviews done experts12. The findings of the review strongly emphasized putting in place a proper Health Information and Management System. Further development will be done in this area.

SECTION IV: ACCESSIBILITY AND QUALITY OF HEALTH SERVICES 4.1. Health Care (Curative) Services: I ti st heMi ni s t r y ’ sov e r a l l g oa l to provide reasonable minimal level of essential health care to all individuals and families, in an acceptable and cost-effective, affordable way, and with their full involvement. The key strategic areas to achieve the above goals and objectives are;  Staff development & Training: It includes recruitment of skilled staff for hospitals and clinics both at the urban and rural clinics. The undergraduate trainings of nurses, dentist and dental therapists, technicians in different diagnostic services, and doctors are dealth directly by the National Training Unit, Ministry of Human Resource Development & Education in close collaboration with the MOH. The postgraduate (inservice) training of health workers is directly responsible of the MOH in collaboration of other stakeholders such as Public Service Department.  Upgrading of level of services in different health institutions and hospitals: A challenging strategy put in place is the plan to improve level of services as according to the draft Guide to Role Delineation to Health Care Services. At this

12

Watso, P.,J.,WHO Consultant (1999).

39

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======================================================= time of reporting, there still a need to review and improve on this strategy. This report is not in a position to present an evaluation of the level of services.  Upgrading of health infrastructure, facilities and equipments: This has been a very difficult task faced by the MOH in the past period mainly because of lack of funding. Lack of data does not allow this report to provide a report on this particular development. 4.1.2. Activities (Input) Training of health workers including doctors, nurses, and paramedics continued in 1997, 1998, and 1999. Again, because of lack of information, this report is not able to provide details of how many health workers are trained and their placements. The School of Nursing at SICHE could only take 35 students and not 50 as requested by the MOH. There is a slight increase in the number of new health facilities especially clinics by end of 1999. The MOH plan to rehabilitate and repair all health infrastructure never been implemented because of lack of funding. 4.1.3. Outputs: Annex Table () summarizes the ratio of health workers to population. By end of 1999 there population per doctor in practice was 1:10,488. (Not including the private practitioners). The number of doctors to the population is declining as compared to 1:7031 in 1995. The MOH target is to improve the doctor:population ratio to 1:4,500. This is an area needing special consideration by the Government. The ratio of registered nurses to population remains constant at 1:836 as in 1995. However the total nurses (RNs and Nurse Aides) to population ratio is 1:489. See Annex Table ( ) shows the proportion of health workers in 1997-99. The target of the Ministry by 2003 is 1 registered nurse to five hundred populations (1:500). The productivity of the Health Institutions (hospitals) is measured in terms its utilization rates, bed capacity (Bed Occupancy Rates) and ALOS, and number of total admissions, which is outlined in Annex Table ().

40

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 41 of 122

=======================================================

Graph showing Registered Nurses, Nurse Aides & Total nurses to Population, 1997-99 7,000 6,000 5,000 4,000 3,000 2,000 1,000

1997

1998

1999

From the above graph (2), Guadalcanal and Malaita have higher number of population to a nurse. In 1999 in Malaita the number of population to a nurse increases due to the ethnic tension when there was a huge influx into Malaita. Honiara has the highest population to a nurse but a readily accessible to all level of health care in the capital. However, it remains a management problem for the outpatient services in Honiara.

4.1.4. Primary Health Care- Health Facility: Population The other measure of accessibility is health facility to population. From the table and the graph, the current standing is that in Solomon Islands 1,643 population is for a health facility. However, this does not directly imply physical access to the health facility because of the variations in the geographical locations by provinces. The health facility to population varies by provinces.

41

NA To tal

RN

NA

RN

To tal ISL AN DS

SO LO MO N

NA To tal Be llo na

RN

Re nn ell

NA To tal Ho nia ra

RN

NA To tal Te mo tu

RN

NA Ma To t kir a U al law a

NA To ta Ma l lait a RN

NA To Gu ta ad alc l an al RN

NA To tal Isl an ds RN Ce ntr al

NA To tal Isa be l RN

NA To t We al ste rn RN

0 Ch ois eu l RN

Population to 1 nurse

Graph (2) showing Ratio of Registered Nurses, Nurse Aides and Total Nurses to Population in 1997-1999:

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 42 of 122

======================================================= Table (11) showing Health Clinics:Population* and Nurse: Population** Ratio in 1997-1999:

1997 Provinces No. of .Clinics Facilitie s Choiseul 21 Western 38 Isabel 28 Central 31 Islands Guadal. 20 Malaita 56 Makira 28 Temotu 12 Honiara 8 Ren Bell 3 Solomon I 245

Clinic: Pop 998 1,609 716 725 3,928 1,833 1,119 1,613 8,314 803 1,737

1998 Nurse: No. Pop of . clinic s 1,311 24 38 717 28 1,604 31

199913 Clinic Nurse: No. of Clinic: : Pop Pop Clinics Pop

Nurse: Pop

900 1,637 740 746

1,200 1,016 609 1,445

24 38 28 31

834 1,651 729 696

800 1,162 638 1,199

2,806 1,488 1,045 745 2,293 482

3,902 1,875 1,160 1,656 8,954 826 1,774

2,826 1,500 984 686 2,311 413

21 56 28 12 8 3 249

2,870 2,190 1,107 1,576 6,138 792 1,643

1,722 1,670 838 700 1,584 396 836

21 56 28 12 8 3 249

Notes: 1. The above table and graph does not including VHW posts (therefore it includes Nurse Aide Posts and Rural Health Clinic run by Registered Clinics. 2. The nurse: population refer to Registered Nurses only

Guadalcanal has very high population to a health facility. The reasons would be related to closure of some health facilities as a result of the ethnic tension. There is an offset phenomenon observed between Guadalcanal and Malaita. Whilst Guadalcanal experienced a decline in number of population to a health facility, Malaita experiences an increase. This is directly link to the ethnic tension in 1998-99.

13

National Census 1999 population figures used.

42

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 43 of 122

======================================================= Graph (3) showing ratio of population to a health facilities in the provinces: Graph showing ratio of population to a health facility Solomon I Ren Bell Honiara Temotu Makira

1999 1998 1997

Malaita Guadal. Central Islands Isabel Western Choiseul 0

2000

4000

6000

8000

10000

Population

4.2. Primary Health Care (Clinics): Work Load. Despite lack of data, the percentage of OPD visits seen at clinics is within the average of 80% as compared to OPD visits in the provincial hospitals and NRH. Table (12) PHC (A): Outpatient Visits by Type of Facility, 1997,1998,1999:

Facility

Choiseul Hospital Clinics* Total Western Hospital Clinic Total

1997 No OPD . Visits 1 21 22 2 48 50

35,678 12,767+ 186,703

%

1998 No OPD . Visits

%

1999 N0. OPD Visits

1 24 25

7,776 42,679

1 24 25

49,145

2 50 70

7,874+ 165,223

2 55 0

178,397

Isabel

43

%

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 44 of 122

======================================================= Hospital 1 8,053 16.6 1 1 Clinics 30 40,588 83.4 31 35,891 30 34,883 Total 31 48,641 32 31 Central Islands Hospital 1 1 1 (Tulagi MiniHosp) Clinics 24 44,678 24 47,173 24 Total 25 25 25 Guadalcan al Hospital Clinics 29 172,420 31 193,356 34 134,064 Total 29 31 34 Malaita Hospital 2 2 2 Clinics 56 207,042 56 186,725 56 223,893 Total 58 58 58 Makira Hospital 1 Nk 1 Nk 1 Nk Clinics 29 45,730 29 54,685 29 43,341 Total 29 29 29 Temotu Hospital 1 9,480 23.1 1 1 Clinics 12 31,553 76.90 12 30,304 12 33,143 Total 13 41,033 13 13 Rennell Bellona Clinics 3 3,687 3 4,819 3 3,543 HTC Clinics 9 99,062 64.0 9 108,050 78 9 87,848 63.0 1 NRH 55,798 36.0 1 30,494 22 1 51,242 37.0 Total 10 154,860 10 138,544 139,090 * excluding Village Health Workers Posts but include Area Health Centers 4.2.1. OPD visits per Facility: It is clear from the graph below that Area Health Centers have higher workload than Rural Health Clinics and Nurse Aid Posts. Area Health Centers in Malaita have the highest workload, which reached its highest peak in 1999. Guadalacanl and Western also showed higher level of workload. All other provinces including HTC had OPD visits per AHC per day at an average of less than 100 for that period 1997-99.

44

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======================================================= For Rural Health Clinics, except for Guadalcanal in 1998, all provinces had an average of OPD visits per RHC per day of less than 50. The trend of OPD visits per facility per day varies by provinces.

Bar Graph (4) showing workload at Area Health Centers, Rural Health Clinics and Nurse Aid Posts

45

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 46 of 122

======================================================= by Bar graph showing workload at Area Health Centers, Rural Health Clinics and Nurse Aid Posts by provinces NAP RHC AHC Rennell Bellona RHC Honiara Town Council NAP RHC AHC Temotu NAP RHC AHC Makira NAP RHC AHC Malaita NAP

1999 1998 1997

RHC AHC Guadalcanal NAP RHC AHC Central Islands NAP RHC AHC Isabel NAP RHC AHC Western NAP RHC AHC Choiseul

0

50

100

150

200

OPD visits per facility

Provinces.

46

250

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 47 of 122

======================================================= Table(13) showing workload at Area Health Centres, Clinics and NurseAide Posts by provinces 199799

1997 Provinces

Choiseul AHC RHC NAP Western AHC RHC NAP Isabel AHC RHC NAP Central Islands AHC RHC NAP Guadalca nal AHC RHC NAP Malaita AHC RHC NAP Makira AHC RHC NAP Temotu AHC RHC NAP Honiara Town Council RHC Rennell

Facility

2 7 12 4 16 18 3 10 15 4 15 12

1998 Av.OPD Visits/fac / Day

35678 49 14 8 186,703 128 32 28.5 40,588 37 11 7 44,678

Av.OPD Visits/staf f /day

Facility

2 9 13 4 16 18 3 10 15

30.7 8 10 172,420

4 15 12 4 10 7

3

157.9 47.4 67.7 207,042 189.6

20

28.4

33 3

17.2 45,730 41.9

12

10.5

14 1

9.0 31,553 86.7

5

17.3

6

14.4 99,062

9

30.2

3 10 7

3 20 33 3 12 14 1 5 6

9

3687 47

1999 Av.OPD Visits/fac / day

42,679 58.5 13.0 9 165,223 113 28 25 35,891 33 10 6.5 47173

Av.OPD Visits/staf f /day

Facility

2 9 13 4 16 18 3 10 15

32 8.6 10.8 193356

4 15 12

132.4 53.0 75.8 186,725 170.5 25.6 15.5 54,685 49.9 12.5 10.7 30304 83.0 16.6 13.8 108,050

4 10 9

32.9 4819

9

Av.OPD Visits/fac / day

49,143 67.5 15 10.4 178,397 122.5 30.6 27 34,883 32 9.5 6.4

134064

3 20 33 3 12 14 1 5 6

92.1 36.8 40.9 223,893 205.0 30.8 18.6 43,341 39.7 9.9 8.5 33143 91.1 18.2 15.2 87,848 26.8 3543

Av.OPD Visits/staf f /day

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 48 of 122

======================================================= Bellona AHC 1 10.1 1 13.2 1 9.7 1 10.1 RHC 1 13.2 1 9.7 NAP 1 10.1 1 13.2 1 9.7 TOTAL 867,141 814905 AHC 24 99.3 25 89.3 25 RHC 105 22.9 107 20.9 107 NAP 117 20.4 119 18.8 121

4.2.2. OPD visit per person per year by provinces: Graph (5) showing average OPD visits per person per year:

Graph showing average OPD visits per person per year 3.5 3 OPD visits

2.5 1997 1998 1999

2 1.5 1 0.5

W

C

ho

is eu l es te rn C I en s tra abe l lI sl an G ua ds da lc an al M al ai ta M ak ir R Te a en ne mo tu ll Be llo na

0

The measure of average OPD visits per person per year indicates the utilization of the health facility for that particular year. On average, in Western Province one person makes around 23 visits per year. Compared to Guadalcanal 1.5-2.4, and Malaita 1.7-2.0.

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 49 of 122

======================================================= Table (14) Shows Average OPD Visit Per Person per day and year, by provinces, across all facilities:

1997

1998

1999

Provinces

Pop.

Av.OPD Visits/pe rson/ Day

Av.OPD Visits/spe rson /yr

Pop

Choiseul Western Isabel Central Islands Guadalca nal Malaita

20969 61146 20074 22461

0.0046 0.0083 0.0056 0.0055

1.7 3.1 2.02 1.9

21596 62982 20714 23113

0.0071 0.0047 0.0056

78563 0.006

2.2

81941

10265 0.0055 3 31343 0.004 19360 0.00447 66508

2.0

2410

1.53

Makira Temotu Honiara Town Council Rennell Bellona TOTAL

0.0042

1.46 1.63

Av.OPD Visits/pe rson/ Day

Av.OPD Visits/spe rson /yr

Pop

Av.OPD Visits/pe rson/ Day

Av.OPD Visits/spe rson /yr

2.6 1.73 2.04

22241 64869 0.0076 21376 0.0045 23784

2.75 1.63

0.0065

2.34

85461 0.0043

1.58

10501 3 32471 19903 71628

0.0049

1.78

2.075

0.0046 0.0042

1.69 1.5

10785 0.0057 7 33638 0.0035 20459 0.00445 77141

2479

0.0053

1.94

2550

1.39

0.0038

1.29 1.62

Table (15) Breakdown of Beds By Hospital (Government Owned Only) by end of 1999

Services and Level of Services (LOS) Medical (Beds) TB beds LOS Paedistrics LOS Surgical (incl.

National Referral Hospital, Honiara, Guadalcanal 56

Kiluufi Hospital, (Malaita)

Gizo Hospital (Western)

Kirakira (Makira)

Lata Buala Hospital (Isabel) (Temotu)

Total

11

15

19

8

8

117

52 L3 45 L4 56

Nk L2 22 L2 20

Nk L1 10 L2 15

12 L1 16 L2 18

12 L1 8 L2 8

Nk L1 8 L2 8

L1-3 109 L2-4 125 (incl.orthop)

L3 (12)

L2 0

L2 0

L2 0

L2 0

L2 0

L2-3 12

L4 50

24

14

21

8

15

Orthop. for NRH only)(Beds)

LOS Orthopaedic (Beds) LOS Maternity (Obst

49

149 (incl.Gynae)

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 50 of 122

======================================================= Gynae 17 LOS L6 L5 L4 L4 L4 L4 Private 12 Ward Others 42 6 2 Total Beds 330 130 60 86 46 39

L4-6 12 44 568

Source: MHMS, 1998; LOS - Level of Service

Table (16) Breakdown of Beds by Hospitals (Church Owned Only):

Services and Level of Services (LOS) Medical (Beds) Paedistrics Surgical (Beds) Orthopaedic (Beds) Maternity (Obst Private

Sasamuga Hospital (Choiseul)

Atoifi Hospital, (Malaita)

Nk

24

Helena Goldie Hospital (Western) 12

Nk Nk

22

12 12

0

0

0

Nk

14

14

Total

0

From table (15) the Honiara based National Referral Hospital is operating at a higher level of services with specialist mostly levels 3 to 6. Malaita and Western followed at levels 2 to 4, while Makira, Isabel and Temotu operate mostly at levels 1 to 4.

Guadalcanal, Central Islands, Rennell and Nk 2 Bellona and Choiseul Provinces use the National Referral Hospital as their main hospital. Choiseul Province uses Gizo Hospital as its first point of referral. These provinces with an overall population of 124,400 (1997 estimates) depend on the primary health care as the major means of receiving health care services. About 29.3% of the total population of Solomon Islands depends on Primary Health Care (PHC) services. The Comprehensive Review of Health Services Report (1996) reiterated the need for improvement of PHC is furthered by the fact that hospital utilization rates at the provincial level varies by provinces. This variation is attributable to the external factors as well.

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 51 of 122

======================================================= Table (17) Shows number of available beds to be filled per 1,000 population in the region;

Choiseul

Western

Isabel

Malaita

Makira

Temotu NRH ((A)include Guadalcanal, Central Islands & Rennell Bellona Provinces) (B) National

Public Hospitals Private ( Church ) Hospitals Overall

-

0.9

1.8

1.2

2.6

2.25

1.6

0.85

-

0.92

-

-

(a) 2.95 (b) 0.72 -

1.6

1.77

1.8

2.13

2.6

2.25

As above

Table (17) shows marked variation in number of available beds to be filled by 1,000 in the provinces and Honiara. In 1999 the number of beds available in the provinces like Chosieul, Western, Isabel, and Malaita is less than NRH. Makira and Temotu even they available beds less than NRH, they are higher than Choiseul, Western, Isabel and Malaita. It is expected in ten years time, should nothing is done, beds: population ration will decrease further as the population increases. Thus, indicates that the bed: population ratio is an issue to be addressed. Table (18) Shows the Flow of Patients in and Out of the Provincial Hospitals (including private centers): NRH

Choiseul

Western

Isabel

In Flow

1,411

310

1,058

18

Out Flow

23

27

93

Central Islands 354

3

37

Guadalca nal 0

57

Malaita

Makira

Temotu

1,804

463

181

129

52

63

Rennell Bellona

HTC

0

0

9

6

Graph (6) showing flow of patients in and out of the provincial hospitals:

2,000 1,500 1,000

In Flow Out Flow

500

Provinces

HTC

Temotu

Makira

Rennell Bellona

51

Malaita

Guadalcanal

Central Islands

Isabel

Western

-500

Choiseul

0 NRH

No. of Referral Cases

Chart Showing Flow of Patients In and Out of the Provincial Hospitals

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 52 of 122

=======================================================

Table (10) and Chart (2) shows Malaita (Kiluufi Hospital) have the highest number of patients in and out, but more referrals in than out. Followed by National Referral Hospital and Western. In 1999, there were 1,411 patients referred in to the National Referral Hospital, Honiara, through both the Outpatient (Referral) and directly from provincial hospitals. Referrals out are all to overseas hospitals. Of the total 23 referrals, 69.6% (16) went to St. Vincent Hospital in Sydney, 21.7% (5) to various hospitals in New Zealand, and 8.7% (2) to Brisbane. Self-sufficiency in all provinces in terms of basic level of health care is indicated by many referrals in than out. Malaita and, Western have relatively higher referrals out than all others because various reasons such as frequent regular shipping and fights. In Temotu the increasing number of referrals out is due to absence of a medical professional. The reason for more referrals to NRH from the two major centers is the presence if induce demand by (more) doctors in Gizo and Auki. It is obvious that the level of sufficiency in providing higher tertiary care is very low in the National Referral Hospital as indicated by the type of cases referred overseas.

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======================================================= 4.3. Secondary Health Care: Hospital Utilization: Table (19) shows the Hospital Utilization Rates (number of admissions per 1,000 population)

Provinces/ Hospitals National Referral Hospital* Choiseul (Sasamuga) Western (Gizo)** Isabeli (Buala) Malaita ( Ki l u ’ u f i ) * * Makira (Kirakira) Temotu (Lata) Solomon Islands **

1997 34.8

1998 32.5

1999 37.6

58.0

59.2

64.1

33.8

29.9

28.6

44.7

49.4

34.7

37.9

39.7

33.7

34.0

29.6

30.5

44.1

44.8

53.2

34.4

34.9

36.1

Average

35.1

*The provinces included under the catchment population for NRH are Guadalcanal, Central Islands and Rennell Bellona, including Honiara. Theses provinces have no hospitals but assumed NRH as the center for admissions. The Catchment population for NRH is therefore 169,942 (1997), 179,161 (1998) and 188,936 (1999) respectively.

** excluding private hospitals

The overall trend of utilization of the hospital services in the country is between short ranges of 34 to 36 admissions per 1,000 populations. However there are differences within the region. Choiseul and Temotu the two furthest provinces are experiencing trend of utilization whilst Western is declining and the others (NRH, Isabel, Malaita and Makira) experiencing fluctuations. However, NRH utilization increased markedly in 199 but Isabel declined in 1999. The utilization pattern did not follow or correspondence with the patient flow in table (10) because the majority of inflow of patients to the provincial hospitals went as far as outpatient department (OPD) only. In other words, they did not needed to be inpatient.

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======================================================= Table (20) shows Hospital Utilization in the National Referral Hospital

NRH

Medical Surgical Pediatrics Maternity

1997 4.3 4.8 22.8 82.7

1998 2.7 4.3 22.4 86.2

1999 4.43 5.3 31.0 77.6

Graph (5) showing hospital utilization of National Referral Hospital 1997-1999

Chart showing hospital utilization of National Referral Hospital 1997-1999 100 90

No. of adm/1,000pop

80

82.7

86.2 77.6 Medical Surgical Paedatrics Maternity

70 60 50 40 31

30 20

22.8

22.4

4.8

4.3

10 5.3

0 1997

1998

1999

54

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======================================================= 4.3.2. Bed Occupancy and Average Length of Stay: Graph (7) showing total admissions by provinces & NRH:

No. of admissions

Graph showing tota admissions by provinces & NRH 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0

7102 5916

5830 3,766

3,746

3,531

Western Isabel Malaita

1,426

1,278

1,216

Choiseul

Makira Temotu 1997

1998

1999

NRH

Years

Kiluufi Hospital in Malaita recorded highest number of admissions in the years 1997 to 1999. Followed by `Western and Choiseul. The data contained in the table above, alone, does not exclusively indicate the workload and productivity but other information below further our understanding on the resource use implications.

55

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======================================================= Graph (8) showing bed occupancy rates (all beds) by provinces & NRH: Graph showing bed occupancy rates (all beds) by provinces & NRH

90 80

79.5 75

70 62.7 62.1

64.7

40

46.3 45.8 40.7 36.7

48.4

30

29.2

%

60 50

65.9

63.3

58

55.1

45 41

40.5 36.9

20

32.9

Choiseul Western Isabel Malaita Makira Temotu NRH

19.6

10 0

1997

1998

1999

Choiseul

62.1

75

79.5

Western

46.3

55.1

58

Isabel

36.7

36.9

41

Malaita

62.7

64.7

65.9

Makira

29.2

19.6

32.9

Temotu

40.7

40.5

45

NRH

45.8

48.4

63.3

Years

All provincial hospitals experience an increasing bed occupancy rate. Choiseul (Sasamuga) records the highest, followed by Malaita and Western Province. The pressure on beds capacity to the increasing demand is an issue to be addressed in the in the future. Choiseul also has the increasing average length of stay in the hospital. It may be due to limited r e s ou r c e si nt e r msoff a c i l i t ya ndma npowe rt oe ns u r epa t i e nt ’ spr obl e msa re diagnosed and underwent treatment quicker. Other quality issues can also implied for example infection rate. However, this report is not going in detail.

56

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======================================================= Graph (9) showing trend of Average Lengths of Stay in provinces & NRH:

Graph showing trend of Acerage Lengths of Stay in provinces & NRH

12 10.7

ALOS (no. of days)

10

10 9.3 8.4 8

8

6.5

6

5.8

8.2 7.6 7.5

8.3

6

5.9

7.1 7

4

Choiseul Western Isabel Malaita Makira Temotu NRH

2 0

1997

1998

1999

Choiseul

6.5

7.5

7.1

Western

6.1

7.2

7

Isabel

5.8

6

5.9

Malaita

8.4

8.2

8.3

Makira

8.6

6.4

7.8

Temotu

8

7.6

7

9.3

10

10.7

NRH

Years

All provincial hospitals have recorded fairly a constant ALOS within the period 1997-1999. NRH has the highest ALOS. The specific reasons are known and need to be investigated. However, it implies the efficiency and effectivity of the hospital. An area of concern to managers since the hospital incurred a significant portion of the budget 14.

4.4. Pediatrics Services:

(Child

Health)

CHILD HEALTH CARE SYSTEM

14

Health Budget , MHMS

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======================================================= The National Health Policies and Development Plan articulate a systematic approach to f u r t he rde v e l opa nds t r e ng t he nt heMi ni s t r y ’ sc a pa c i t ya ndc a pa bi l i t y .I npa r t i c u l a rt hePl a n recognises the need to:  Improve level of paediatrics services  Strengthen primary health care services in rural areas and to more fully utilise existing facilities and resources; and  Engage in health reform, particularly in the areas of capacity building in management and supervision, human resources development, infrastructure development, health information and services planning and health financing. The National Health Policies are further translated into operational activities that focus on vulnerable populations which include women and children. The Reproductive Health Di v i s i oni sr e s pons i bl ef orpr og r a mst ha tr e l a t e dt oc hi l dr e na ndwome n’ she a l t h.Ce r t ain policies and guidelines has been developed, these include:  Nutrition Policy (1992)  Breastfeeding Policy (1995)  EPI Policy (1995)  Paediatric Treatment Protocol (2nd Edition 1995) Disease-specific Programs There are also disease-specific programs currently implemented in the Solomon Islands include:  ARI / CDD  Malaria Control  EPI  Growth Monitoring / Breast feeding (Nutrition)  Vitamin A supplementation Coordination and Provision of Care The Ministry of Health is the sole Ministry responsible for regulation, policy formulation and provision of health services in Solomon Islands. The Ministry operates 75% of health facilities, church organisations 17% and industry (plantation clinics) 8%. There is a growing private general practitioner and malaria diagnostic service in Honiara. The Ministry operates within a health care referral system which consists of a network of six different levels of health facilities from village health worker posts to the National Referral Hospital. This referral system forms the structural backbone of the health care system in the country. All hospitals in the country (both public (618 beds) and private (190 beds)) account for a total 808 hospital beds. There are a total of 326 health centres / clinics through out the public health care system and 6 general practitioners, mostly working in the urban centres of Honiara.

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======================================================= Decentralisation of Care: Provinces such as Guadalcanal, Central Islands Province, Rennell and Bellona and Choiseul use the National Referral Hospital as their base hospital. The Choiseul Province uses Gizo Hospital as its first point of referral. These provinces with an overall population of 124,400 (1997 estimates) depends on the primary health care as the major means of receiving health care services. About 29.3% of the total population of Solomon Islands depend on Primary Health Care (PHC) services, exclusively. However, the Comprehensive Review of Health Services Report (1996) reiterated the need for improvement of PHC as utilisation rates at the provincial level are low at around 60%. Basic health care are further provided in the Area Health centres and Rural Health Centres, covering a population of less than 500 people. 4.4.1. Findings & Outputs: Table (21) shows Hospital Utilization Rates in Paediatrics (Child health care services for <4yrsin the provinces):

Hospital utilization in paediatrics varies by provinces. Temotu experienced an increasing utilization from 1997 to 1999. Whilst, other provinces were fairly stable.

1997 Choiseul Western Isabel Malaita Makira

1998 43.2

72.7 61.6 39.1

1999 42.9 71.9 55.2 35.9

74.1 56.8 35.9

Graph (10) showing trend of utilization of hospital utilization in pediatrics in the provinces

No. pediatrics adm/1000pop

120 101.3

100 80 60

72.7 70.5 61.6

40

81 74.1

Choiseul

71.9

Isabel

56.8

55.2

Malaita

44

43.1

Makira

35.9

20 0 1997

Western

1998 Period 1997-1999 59

1999

Temotu

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 60 of 122

======================================================= The Ministry has offered a guide15 of 75% bed occupancy rate for the six provincial hospitals. This is because of the higher hospital utilization in some provinces. It also allows 25% of the bed capacity some safety net should an epidemic of childhood illnesses arise. Malaita and Chosieul recorded a bed capacity of 71 –88% BOR. Western and Isabel had bed capacity in pediatrics of the range 45-71% BOR. Makira has the lowest range of BOR. In practical sense it means that for Malaita in 1999 of the total of 22 pediatrics beds, 17 beds are always filled at any one time. In Western of the total 10 pediatrics bed, 7 beds are always filled at any one time as compared to Makira only 4 beds of the total 16 pediatrics beds are filled. Graph (11) showing trend of bed occupancy rates in pediatrics by provinces & NRH:

100 90 80 Choiseul

70

%

Western

60

Isabel

50

Malaita

40

Makira Temotu

30

NRH

20 10 0

1997

1998

1999

Choiseul

75.6

74.8

74.1

Western

45.6

62.9

71.1

Isabel

46.2

70.1

61.5

Malaita

71.2

88

77.3

Makira

25

14.2

23.8

Temotu

55.8

54.1

68.6

62.4

58.5

NRH

Years

15

National Health Policies and Development Plans 1999-2003; an objective.

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 61 of 122

======================================================= The average length of stay in paediatrics in the provincial hospitals ranged from 4 days to 7 days. Graph (12) showing trend of ALOS in pediatrics by provinces & NRH Graph showing trend of ALOS in pediatrics by provinces & NRH

ALOS (no. of days)

30 25 20 15

Choiseul

10 7.1

6.9 6.7

5

6.9 5.9

Western Isabel

4

0

1997

1998

1999

Choiseul

6.8

6.9

6.9

Western

5.9

5.7

5.6

Isabel

5.3

6.5

5.6

Malaita

6.9

7.1

6.9

Makira

6.7

4

5.9

Malaita Makira Temotu NRH

Years

4.5. Obstetrics & Gynaecology Services: TheMi ni s t r y ’ sov e r a l l g oa l i st oi mpr ov ea ndu pg r a det heq ua l i t yofobs t e t r i c s& gynecological services in the country. The key performances areas are:  Upgrading and improving the level of services in key hospitals and primary health care centers.  Training and staff developments of doctors and nurses  Protection of mothers during pregnancy  Improve collaboration and coordination with MCH/FP programs There are objective guides the Ministry has established16 at the policy level for obstetrics care in the hospital settings. The six provincial hospitals should incorporate 75-80% bed occupancy rate. This is to allow 20-25% bed safety. In practical sense it would mean for example in Gizo Hospital of the total 14 maternity beds, the management would ensure that 3-4 beds are always spared for emergency. However, this is not a strict ruling but a management tool.

16

Ibid

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======================================================= 4.5.1. Findings & Outputs: Table (22) shows Hospital Utilization in Maternity (maternal care services) in the provinces:

1997 Choiseul Western Isabel Malaita Makira

1998 30.5 32.3 61.9 35.9 45.6

34.7 60.8 35.9 49.2

1999 35.1 57.6 36.8 45.7

Graph (13) showing trend of hospital utilization in maternal care services in the provinces:

Chart showing trend of hospital utilization in maternal care services in the provinces

No.of maternity adm/1000pop

80 70

64.7 63.7

61.9 57.6

60 50

1997

45.6 45.7

40

30.5

30

1998 1999

36.8 35.9

35.1 32.3

20 10 0 Choiseul

Western

Isabel

Malaita

Makira

Temotu

Graph (14) showing trend of Bed Occupancy Rate in Maternal Care by provinces & NRH:

100

92.1 87.8

90 80

82.3

81 76 72.9

70

73.3 67.6

Western

% BOR

60 50 40 30

Isabel

55 53.1 51.6 46.4 40.7

51.7

49.5

37.3

38 37.2

Malaita Makira Temotu NRH

27.3

20

17.9

10

1997

0 1998

1999

Choiseul

53.1

72.9

73.3

Western

51.6

51.7

49.5

Isabel

27.3

17.9

38

Malaita

82.3

76

92.1

0

Choiseul

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======================================================= Graph (15) showing trend of ALOS in Maternal Care by provinces & NRH:

14 13

12

11.8 10.6

ALOS (no. of days)

10

8

Choiseul

7

6.9

6

6.1 6 5.7

5.6 5.5 5.1

4.2

4

2.9

4.8

5.9 5.5 5

4.1

4.1 3.9

Western Isabel Malaita Makira Temotu NRH

2.5

2

0

1997

1998

1999

Choiseul

5.6

6.1

5.9

Western

5.1

4.8

5

Isabel

5.5

5.7

5.5

Malaita

6.9

6

7

The average length of stay in maternal care is higher in the provinces in the range from 3.9 to 11.8 days. Makira for some reason have the highest average length of stay.

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======================================================= Graph (16) showing trend of ALOS in Maternal Care by provinces & NRH:

14 13

12

11.8 10.6

ALOS (no. of days)

10

8 7

6.9

6

5.6 5.5 5.1

4.2

4

2.9

6.1 6 5.7

5.5

4.8

5

4.1

4.1 3.9

5.9

2.5

2

0

1997

1998

1999

Choiseul

5.6

6.1

5.9

Western

5.1

4.8

5

Isabel

5.5

5.7

5.5

Malaita

6.9

6

7

Makira

13

10.6

11.8

Temotu

4.2

4.1

3.9

NRH

2.9

2.5

4.1

Years

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=======================================================

4.6. Access to Essential Drugs: The National Pharmacy Services in its objective to increase access of essential to the local c ommu ni t y , c onc u r swi t ht heWHO’ sDr u gAc t i onPr og r a m( DAP) , whi c hs e e k st o strengthen the capacity in developing and implementing national drug policies and policy plans in order to ensure the availability and accessibility to all people of essential drugs of acceptable quality and rational use of drugs. 4.6.1. Inputs: The consolidation of the draft National Drug Policy (completed in 1997) include the following tasks: Activities (Input) 1. Technical Assistance from WHO 2. Review of Essential Drug List (EDL). 3. Review of the Standard Treatment Guideline (STG). 4. Review of Pharmacy Legislation

Output WHO requested in 1999. Subcommittees or taskforces formed to review the EDL. Two follow up meetings held. In 999 As above A NZ consultant did preliminary review in 1999. However, the review is focused on the MHMS restructuring and not direct to the National Drug Policy.

Progress/ Comment Not accomplished. Negative response Not accomplished. No review documents ready or completed. As above No follow up work is done.

Work force Distribution: In 1999 there were total of 28 established pharmacy workers17, which is about 2.4% of the total of the total health work force. Majority of the pharmacy personnel are posted at the National Referral Hospital whilst 32% (9) are posted at the provincial level. 4.6.2. Output: The Pharmacy Practitioners Act was passed and enacted through the date of issue on 10th July 1997. The Act is to regulate the practice of pharmacy in Solomon Islands. The Act is an i mpr ov e me ntoft hePha r ma c ya ndPoi s on’ sAc t1 9 9 1a ndhe r e byr e pe a l sc e r t a i npr ov i s i ons of the pharmacy and Poisons Act, and to provided for matters connected therewith or incidental thereto.

17

Public Service Division (1999). Approved Recurrent Established Establishment Register, SIG. Honiara, pp. 125-158.

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======================================================= Access to essential drugs indicators:  From the current data, there is an absolute figure of 70% of rural population having access to essential drugs.  The remaining 30% access to drugs by outreach visits and the existing health care referral system. In terms of therapeutic access, there is availability and access of basic essential drugs developed and marketed for the health problems and conditions occurring in the country. The increasing concern to the government now is the affordability of drugs (financial access) purchased overseas. With the financial crisis difficulty in ensuring a timely payment of essential drugs overseas are experienced. Antimicrobial resistance to drugs: There is no formal study on the antimicrobial resistance to drugs despite the fact that there are resistance to chloroquine clinically.

4.7. Health Infrastructure development: TheMi ni s t r y ’ spol i c yonhe a l t hi nf r a s t r u c t ur ei st oc ons ol i da t ee x i s t i nghe a l t hi nf r a s t r uc t u r e and facilities rather than establishing new ones. However, exemptions are made for new facilities that would meet the criteria set in the policy governing health infrastructure18.

18

The draft of the Policy governing infrastructure is completed.

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======================================================= Tabel (23) : Level of Health infrastructure: Choiseul 97 98 overnment ospitals 0 0 HC 2 2 HC 6 8 AP 11 12 HW 10 11 rivate/ GO: ospital 1 1 HC HC 1 1 AP 1 1 HW otal 32 36

Western

Isabel

Central Islands Guadalcanal

99

97

98

99

97

98

99

0 2 8 12 11

1 4 16 18 40

1 4 16 18 40

1 4 16 18 40

1 3 10 15 9

1 3 10 15 9

1 3 10 15 9

1

1

1

1

1 1 36

80

80

80

97 1* 0 4 15 12

1 1

1 1

1 11 1

40

40

40 34

98

99

97

98

Malaita 99

MUP

97

98

99

1* 0 4 15 12

1* 0 3 4 10 15 7 12 3

4 10 7 0

4 10 9 0

1 3 20 33 54

1 3 20 33 54

1 3 20 33 54

34

1 6 4 0 34

1

34

1 5 4 0 31

1

1 1

1 5 3 0 32

1

1 1

112 112 112

97

Temotu 98

99

97

98

1 3 12 14 14

1 3 12 14 14

1 1 5 6 0

1 1 5 6 0

1 1 5 6 0

0 1 1 1

0 1 1 1

44

44

13

13

13

3

3

By end of 1999, there are 9 hospitals. Five (5) provincial government hospitals, 2 church hospitals (Helena Goldie Hospital in Munda, Western Province, and Atoifi Hospital in East Kwaio). Two (2) are designated as provincial (Mini) Hospital, and they are Tulagi and Sasamuga). Twenty-three (23) AHC (Area Health Centers, 95 Rural Health Clinics, 129 Nurse Aides and 154 (Village Health Workers Posts). Total of 356 health facilities (not including the VHW posts. VHW posts are not included in the count because of the instability of their existence in the provinces. Since their establishment of the VHW early in 1990s, they are not recognized as formal health delivery structure because of the relatively very low skill but deemed as first aid community health workers. Nonetheless, they have received great support and assistance by way of funding through some provincial health services, training and supply of essential medical supplies. However, the conditions of most health infrastructure in the country have deteriorated in the past ten years. The plan to rehabilitate these facilities is not possible due to lack of funding. The previous rehabilitation was done in 1992-94,which was funded by EEC. Some provinces were not included. Other adhoc-based assistance in rehabilitation was done in varies sites in the provinces, which were funded by the Canadian Aid. The phase 3 rehabilitation of the National Referral Hospital started in 1998 with the funding from the Government of Republic of China, and still in progress . Ki l u ’ u f i Hos pi t a l ha ds ome renovation done with the assistance from Rotary Club. A national health infrastructure plan was drawn by the MOH in collaboration of Ministry of Development Planning in 1999 but was not implemented because of the lack of funding. The ethnic tension significantly affected the possibility of acquiring funding.

67

Rennell Bellona 99 97 98

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=======================================================

SECTION V: HEALTH IMPROVEMENT SERVICES: Whilst health care and health improvement are technically overlapped and not separated, for monitoring and evaluation purposes they are considered independently in the report. The key role of the health improvement side of the health sector is prevention of diseases and protection of health (not merely absence of disease but also well physical, social and mentally).

5.1. The Healthy Islands, Health City, Initiatives19 The Healthy Islands, Health City Initiatives is a new approach to ensure multiple stakeholders involvement in health developments to prevent illnesses and protect health in the world. The settings represent social systems, which are deeply binding, involve frequent and sustained interactions, and are characterized by multiple forms of membership and communication. Settings, as a context for relationships, may also exert direct and indirect effects on health, and acting on community-level influences may need to parallel interventions with individuals. The Fourth International Conference on Health Promotion, held in Jakarta in 1997 affirmed t he“ s e t t i ng s ”a ppr oa c ha sa ne f f e c t i v es t r a t e g yf orhe a l t h pr omot i on. TheJ akarta Declaration also recognized that a multiplicity of interventions was most effective. Diverse health realities, along with diverse social, economic, and political realities, demand that health protection and promotion efforts take into account the contexts for intervention as well as the evidences base for effective interventions. Recognizing that Healthy Islands/Cities initiatives is using the settings approach to promote and advocate for supportive environment for health, Solomon Islands became a party to the “ Ya n u c aI s l a n dDe c l a r a t i o n ”in 1995. This was reaffirmed in “ Th eRa r a t o n g aAg r e e me n t ”in 1997. In adopting this approach, Solomon Islands use the Malaria Control Program as the entry point. It was shown through this approach that in 1999 the total number of cases recorded was only 63,853 or the annual incidence rate was 145 cases per 1000 population, a decline of over 67 percent. An intensified malaria control program in Honiara launched by WHO and the Ministry of Health in 1995 has reduced the incidence rate from 1072 cases per 1000 population (1992) to 187 cases per 1000 population in 1999. This is a significant reduction of 82% in the capital city. Deaths due to malaria have also declined by 50 percent since 1995. 19

Dennie Iniakwala (2000). Report by Dr. D. Iniakwala during the Workshop on Health Islands Iniatiative, unpublished paper.

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======================================================= Solomon Islands joined other Pacific Island Countries in endorsing the Palau Action Statement in March 1999, Korror, Republic of Palau. The Palau Action Statement calls for countries to set short-term targets and to increase efforts to involve private sector, especially in the areas of healthy work place, including tobacco and alcohol consumption. It also calls on Countries, in collaboration with the World Health Organization (WHO) to address the issue of alcohol abuse and tobacco consumption. Other activities following the Palau Meeting: Following the Palau meeting in March 1999, the following short-term targets were adopted by the Ministry of Health:    

Establishment of the Honiara Healthy City Co-ordination Committee (HHCCC) Establishment of the Honiara Youth Taskforce Honiara Tree Planting Legislation to Control Tobacco promotion, sale, and consumption

Establishment of the Honiara Healthy City Co-ordination Committee (HHCCC): In June 1999, the HHCCC was established with members drawn from the Ministry of Health, Honiara City Council, Business, Media, Education and Police sectors. Series of meetings were held to coordinate activities in Honiara that related to healthy environment. This includes issues like waste management, tree planting, malaria control and general cleanliness. Establishment of the Honiara Youth Taskforce: Youth issues such as alcohol abuse has been on the rise, especially in Honiara and other urban centers. A youth taskforce was established in May 2000. The taskforce is comprises of representatives of all yout hg r ou psi nHoni a r a , i nc l udi ngt hec hur c he sa ndNGO’ s . The 1999 census indicated that almost 42 percent of the population were under 15 years and the majority of the population was under 25 years. Yet this large population had been consistently ignored. The National Youth Policy (NYP) defines youth as those between the a g e sof1 4a nd2 9y e a r sol d.Li k et heWome n’ sPol i c y ,t heNYPc u t sa c r os sv a r i ou ss e c t or s . Two major objectives of the NYP to ensure gender equity and equality for all young people in the access to education and training, and the promotion of health programs with special focus on unwanted pregnancies, STD/HIV/AIDS and other youth social problems. The NYP also aims to promote population education, including family life education, through the formal education curricula. Given the high growth rate of the population, high rate of school drop out and/or push outs, and slower pace in new job creation, youth in Solomon Islands are particularly disadvantaged in getting employment in the formal sector. In all respects the ethnic tensions have worsened the situation of youths. Most of the youngsters in the displaced families are

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======================================================= not only disadvantaged from pursuing further education or securing job in the formal sector, but are now vulnerable to the various kinds of dangerous life styles. As the social unrest intensified by mid 2000, it became difficult to organize or convene any meeting as most the youth are either join the militants or left Honiara. Honiara Tree Planting: Honiara Tree Planting has been organized by Chamber of Commerce and assisted by the Honi a r aCi t yCou nc i l ,You t hGr ou psa ndot he rNGO’ s .ByMa y2 0 0 0 ,s e v e r a lt r e e swe r e planted along the Honiara main road and was launched by the Governor General. Young people volunteered to look after the trees and several business houses offered to support the tree panting at various points along the main street. Due to the ethnic unrest, this activity was halted and although resumed by November 2000, it is difficult to continue because of lack of interest and destruction of the plants and inability to maintain law and order in the City. Legislation to control tobacco promotion, sale and consumption: A draft Tobacco Product Control Bill approved by Cabinet in September 1999. This was revised following a review, which identified certain gaps and deficiencies. The re-drafted bill was sent to the Attorney General Chambers to be reviewed by the Legal Draftsman. Since the social crisis intensified, the priority for government bill changes and hence the delay in completing the final draft before it can be tabled in the parliament. It is anticipated that following the passage of the bill, tobacco control activities will gain momentum especially in the areas of promotion, sales and consumption.

5.2. Morbidity and Mortality Reduction:

5.2.1. Overview: The conventional indicators such mortality and morbidity rates are used as the measure of the status of population health due to lack detailed measurements to capture the meaning of health as def i ne di nWHO Cons t i t u t i on( “ He a l t hi sas t a t eofc ompl e t ephy s i c a l ,me nt a la nd social well-be i nga ndnotme r e l yt hea bs e nc eofdi s e a s eori nf i r mi t y ” ) . Howe v e r ,t he measurement is also viewed to imply the demand for health primary care services in the provinces.

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======================================================= Graph (17) showing diseases trend in SI from 1997-1999. Graph showing diseases trends in Solomon Islands from 1997-99 (No. of new cases per 1,000 population). 700

ARI (ALL)

600

ARI(Severe) Diarrhoea(All)

500

Diarrhoea(with bloo&dysentry) Fever Red eyes

400 Yaws Skin diseases Ear infections

300

Neonatal tetanus Tetanus

200

W hooping cough Suspected Polio Measles

100

Penile discharges Vaginal discharges

0 1997

1998

1999

Sources: HIS Annual Reports 1997-99, MOH (not ICD10 based).

Acute Respiratory Infections (ARI) is the commonest illness recorded in the three years period 1997 to 1999. Fever is the commonest conventional symptom suffered and presented with at the primary health care centers such as the Area Health Centers, Rural Health Clinics, Nurse Aide Posts and Village Health Workers Aid Posts. Followed by eye infections, yaws, diarrhea and Sexually Transmitted Diseases. VaccinePreventable diseases are very low but remains potential threat to the children. 5.2.2. Infant Mortality:

The infant mortality rates (IMR), reflect major improvements during the past 2 decades, dropping from 70/1,000 per live births in 1976 to Infant Mortality Rate / 1000 live births 28/1,000 live-births, in 1976 1986 1999 1999. Infant mortality rate in Solomon Islands IMR / 1000 70 38 28 is acceptably below The Five Top Causes of Death in Infants (%) Global Strategy for Health for ALL by year Cause 1994 1997 1999 2000 guiding target of IMR 50 per 1,000 live Complications of Delivery 32.6 13.6 42.9 births. The major causes Pneumonia 8.7 34.6 9.5 of mortality are Malaria 13 3.7 14.3 Diarrhoea 13 7.4 9.5 complications of Meningitis 4.3 12.3 7.1 childbirth; pneumonia, Others 28.4 28.4 16.7 malaria, diarrhoea and meningitis which, accounted for 83% of infant death in 1999. It can also be noted that the most common cause of infant death in 1999 was those related to complications of childbirth. The childhood (<5 years) mortality rate is not known, however, the most common cause of deaths in children under 5 years is malaria, followed by Five Top Causes of Deaths in Children 1-5 yrs (%). pneumonia and diarrhoeal diseases. This trend is consistent through the last five years. Malaria accounts Cause 1994 1997 1999 Malaria Pneumonia Diarrhoea/Dysentry16.7 Accidents Meningitis / Septicaemia Others

41.7 16.7 10.3 8.3 8.3 8.3

33.3 12.8 16.7 7.7 5.1 30.8

25.0 16.7 7.9 16.7 17.0

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======================================================= for 25% of deaths in 1999 compared to 16.7% each for diarrhoeal diseases and pneumonia. Review of the causes of admissions and deaths in children at the National Referral Hospital also reflect the similar trend of the National Referral Hospital (Paediatric Ward) causes morbidity and mortality in the % Selected Causes of Admissions (1998-1999) Admissions Malaria Pneumonia Meningitis Gastroenteritis TB

0-5 years 1998 1999 10.7 15.7 19.7 20.7 5.4 14.8 13.8 5.3 0.8 0.5

National Referral Hospital (Paediatric Ward) % Selected Causes of Deaths (1998-1999) 0-5 years Cause of Deaths 1998 1999 Malaria 8.3 18.1 Pneumonia 12.5 15.1 Meningitis 4.2 6.0 Gastroenteritis 0 9.0

community. Malaria and pneumonia still remain the predominant causes of deaths in under-five years old children in the paediatric ward of the National Referral hospital. Neonatal sepsis is the predominant cause of National Referral Hospital (Neonatal Ward) % Selected Causes of Morbidity and Mortality in Neonate (1998-1999) morbidity and while pre-term is Morbidity Mortality the predominant cause of death 1998 1999 2000 1998 1999 in the neonatal ward of the Neonatal Sepsis 6.6 6.9 9.6 4.8 11.5 Jaundice 9.5 10.6 8.2 4.8 7.7 0 National Referral Hospital. Pre-term 5.9 6.9 10.9 14.3 26.9 Other major concern is the Aspiration 6.8 3.6 6.3 9.5 3.8 increasing morbidity related to Reactive VDRL 22.3 24.5 19.9 0 7.7 meningitis, rheumatic fevers and LBWt 11.7 7.2 12.9 4.8 0 septicaemia in children. Meningitis has been the third most common cause for admission and deaths in under fives in the hospital. Malnutrition in children under 5 years of age is an increasing concern for the Ministry of Health. There was a high prevalence of moderate under nutrition among children 0-4 years. About 23 % were underweight, and the prevalence of under nutrition was highest between 9 and 24 months. Growth faltering commenced at 4-5 months and continued thereafter.

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======================================================= Graph (18) showing incidence of ARI by provinces 1997-99:

G r a p h s h o w in g in c id e n c e o f A R I b y p r v o in c e s 1 9 9 7 1999

Incidence/ 1,000pop

600 500 400 300 200 100

C h o is e u l W e s te r n

C IP

Is a b e lG u a d a lc a n aM l a la ita A R I (A L L )

M a k ir a

A R I( S e v e r e )

Graph (19) showing trend of incidence of ARI in SI

Incidence rates/ 1,000pop.

Graph showing trend of incidence rates of ARI in Solomon Islands 1997-99

500 400 300 200 100 0

1997 1998 1999 ARI (ALL)

ARI(Severe)

All provinces recorded around 300 cases per 1,000 population and above, within the three year period (see table) below. Isabel, Malaita, and Renell Bellona recorded highest cases per 1,000 population in 1997, whilst Choiseul, Western Province, CIP and Temotu in 1999. Of all provinces, Rennell Bellona recorded the highest incidence of severe ARI in 1997. It was not confirmed at that time whether it was an epidemic. Graph (20) showing incidence of ARI & Diarrhoea in children <5yrs in Solomon Islands

73

1999

T e m o tu H o n ia ra R e n B e ll

5.2.3. Acute Respiratory Infection (ARI): The Acute Respiratory Infection has been the commonest illness in children and adults. In the period 1997 to 1999 incidence of ARI range from 350 to 450/ 1,000 populations. However, severity impact of the illnesses is well below 25 cases /1,000 population.

1998

1997

1999

1998

1997

1999

1998

1997

1999

1998

1997

1999

1998

1997

1999

1998

1997

1999

1998

1997

1999

1998

1997

1999

1998

1997

1999

1998

1997

0

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 74 of 122

No.of cases/1,000pop <5yrs

======================================================= Incidence of ARI in children under 5 years Graph showing incidence of ARI and Diarrhoea in chidlren <5 yrs in SI old is very high. The highest of the three 1200 years was recorded in 1000 1997. 800 600 400 200 0

1997

1998 ARI (ALL)

1999

Diarrhoea(All)

5.2.4. Diarrhea: Graph (21) showing trend of incidence of Diarrhoeal Diseases 1997-99: Chart showing trend of incidence of Diarhoeal Diseases 1997-99

50 40 No. of new cases/ 1,000 pop

30

1997 1998 1999

20 10 0 Diarrhoea(All)

Diarrhoea(with bloo&dysentry)

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 75 of 122

======================================================= Graph (22) showing trend of incidence of diarrhoea by provinces:

120 100 80 60 40 20 0 ll en Be

ra

R

on ia

ot u

H

m

ira Te

M

ak

ai ta al

M

an al

l G

ua d

al c

Is

ab e

IP C

W

C

es

eu

te rn

l

1997 1998 1999

ho is

No. of cases/1,000pop

Graph showing trend of incidence of Diarrhoea by provinces 1997-99

Rennell Bellona recorded the highest incidence of diarrhoea, in 1997. Western experienced high cases in 1997 and 1998 than other provinces.

5.2.5. Red eyes ( infections): The trend of eye infections increased in 1998 and 1999. Graph showing incidence of red eyes (infections) in SI: 45

Western, Choiseul and Malaita recorded higher incidence of eye infections.

40 No.of cases/1000 pop

Unfortunately the report is not able provide the incidence of blindness.

35 30 25

The National Primary Eye Care program by the Eye Department of the National Referral Hospital went very well

20 15 10 5 0 1997

1998

1999

years

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======================================================= during the period of 1997-99. Their provincial visits were regular with good coverage of the provinces. Financial constraints were the limiting factor. The primary eye care training continued with provincial nurses trained in eye care.

No.of new cases/ 1,000pop

Graph (23) showing incidence of red eyes by provinces 1997-99: 80 70 60 50 40 30 20 10 0

1997 1998 1999

By end of 1999 there were smaller eye care units at Gizo, Kiluufi and Kirakira Hospitals, which provide basic primary care service to the provinces.

ua b da el lc an al M al ai ta M ak ir Te a m o H tu on ia R ra en Be ll

IP

C

Is a G

W

C

ho

is e

u es l te rn

Ranges of tertiary eye care services were also made available through the Pacific Islands Project by the Royal Australasian College of Surgeons and funded by AusAID. The Phase 2 of the PIP started in 1 May 1998, after which ophthalmology visits to Solomon Islands took place in 15-May 1998, and 15th-May 1999. In 1997, of the total 133 eye swab examined by the Bacteriology unit of Medical Laboratory, NRH, 12% (i.e.16) were due to N.gonorrhoea, Staph.aureus 8%(11), Klebsiella 4.5% (6), pseudomonas 6.8% (9), heamophilus sp. 6% (8), strept. Pneumoni 3.8% (5) and E.Coli 6% (8).

5.2.6. Yaws: Yaws remain a health problem through out the country. Temotu, Western, Malaita and Makira reported higher number of new cases per 1,000 populations. There was no yaws campaign in the past years. Graph (24) showing incidence of Yaws in SI Graph showing incidence rates of Yaws in SI 60 50 40 No.of new 30 cases/ 1000 pop 20 10 0

S1

1997

1998 years

76

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 77 of 122

=======================================================

Graph showing incidence of Yaws by provinces 120 100 80 60 40 20 0

1997 1998

IP Is ab G ua el da lc an al M al ai ta M ak ira Te m ot u H on ia ra R en Be ll

C

n es te r

W

eu l

1999

ho is C

No. of new cases/ 1,000 pop

Graph (25) showing incidence of Yaws by provinces 1997-99.

5.2.7. Ear infections:

Graph showing incidence rates of ear infections in SI

Graph showing incidence of Ear infections by provinces, 1997-99

70 60 No. of 50 new 40 cases/10 30 00 pop 20 10 0

1997 1998 1999

ho is eu l G ua C I da P lc an a M l ak i H ra on ia ra

120 100 80 60 40 20 0

SI 1997

C

No. of new cases/ 1,000 pop

Graph (26) incidence of ear infections by provinces & SI:

1998

1999

years

Ear related problems were fairly constant between 40-60 cases per 1,000 population in the past three years 1997-99, but varies by provinces. Western, Temotu and Honiara reported higher number of cases. In 1997 total of 112 ear swabs were examined at the Medical Laboratory, NRH, of which 11.4% (i.e. 98) specimen were culture positive. Majority of the culture positives (50%) were due to pseudomonas (49), proteus (25), klebsiella (14), E.Coli (7), and Staph.aureus (7).

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=======================================================

15.2.8. Vaccine preventable diseases: 5.2.8.1. National Disease Surveillance: Guadalcanal recorded 29 cases of whooping cough in 1998 and 4 cases in the previous by nurses at the rural clinics. Malaita also reported one each cases of neonatal tetanus and tetanus respectively. However, all these two cases were not clinically confirmed. Thus, there was doubt in the accuracy of the reporting. Graph (27) showing incidence of vaccine preventable Illnesses in SI 1997-99 Graph showing incidence of vaccine preventable diseases in SI, 1997-99

Source: HIS, MOH

0.07 0.06

Incidence rates

0.05 Neonatal tetanus Tetanus

0.04

Whooping cough 0.03

Suspected Polio Measles

0.02 0.01 0 1997

1998

1999

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======================================================= Graph (28) showing incidence of vaccine preventable illnesses by provinces in 1997-99:

Graph showing incidence of vaccine-preventable diseases by provinces 0.4

Incidence rates

0.35 0.3 Neonatal tetanus

0.25

Tetanus

0.2

Whooping cough Suspected Polio

0.15

Measles 0.1 0.05 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999

0

ChoiseulWestern CIP

Isabel Guadalcanal Malaita Makira TemotuHoniaraRenBell

5.2.8.2. Immunization Coverage: Immunization coverage has remained high but decreasing over the last six years. It is believed that this could be due to % Immunization Coverage Rate (Cases) the over estimation of the BCG Hep B3 DPT3 Polio3 Measles TT2

1994

1995

1996

1997

1998

1999

76 67 68 68 61 56

77 71 69 68 68 71

73 72 77 72 67 63

73 73 72 70 68 54

72 71 69 69 64 55

64 62 61 60 59 50

Immunization Coverage Survey in Malaita (%)

BCG Hep B3 DPT3 Polio3 Measles

1999 99.1 99.1 86.7 84.6 58.8

population. This has been verified through an immunization coverage survey in Malaita province in 1999. The overall immunization coverage has remained over 80% compared to the reported coverage.

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=======================================================

5.2.9. Sexually Transmitted Infections: Graph (29) showing incidence of STI in Solomon Isl:

Sexually transmitted Infection remains a public health problem. There is underreporting of cases.

Graph showing incidence of Sexually Transmitted Diseases in S1, 1997-99 (by symptoms)

Rennell Bellona, Temotu and Honiara reported higher number of STI symptoms.

No. of new cases/ 1,000 pop

3 2.5 2 SI 1997 1.5

SI 1998 SI 1999

1 0.5

In 1998, total of 2,235 genital 0 Penile discharges Vaginal discharges Genital ulcer specimens (pus swab) were collected from STI clinics in Honiara20. Of the total specimen collected 13.4% (300) were positive for N. Gonorrhoea. Fifty-five (55) positive specimens were penicillin resistant (i.e. 18.3%).

20

Medical Laboraory, National Referral Hospital (1998): Annual Health Report.

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======================================================= Graph ( 30) showing incidence of STI by provinces:

Graph showing incidence of STD by provinces, 1997-99

16

No.of cases / 1,000 pop

14 12 10 8 6 4 2

1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999

0

Choiseul Western

CIP

Penile discharges

IsabelGuadalcanalMalaita Makira Temotu Honiara RenBell Vaginal discharges

Genital ulcer

5.2.10. Malaria: 5.2.10.1. Activities & Findings: Solomon Islands continue to make a good progress in the last three years with malariacontrol activities21, 22. In 1999 the incident rate is down to 144/1000 pop, which is 64 points y e tt or e a c h8 0 /1 0 0 0popa st hepr og r a m’ sobj e c t i v et a r g e tf or2 0 0 3 .I ti mpl i e sf u r t he r achievement of 16 points down with in the next four years. In 1999, in Honiara alone there is a significant reduction of over 80 % . Rates of net re-treatment through out the country remain high. They stand at more than 80% in all provinces. This indicates that the modified re-treatment methods introduced in the past few years have been successful. For the country as a whole, more than 70% of the population is now pr ot e c t e dbyne t s .Thepr og r a m’ s objective is to have 95% of the population protected by nets in three years time. It implies further strengthening and improvement of compliance towards bednets.

21

Kevin Palmer (2000). Mission Report, Solomon Islands 12-19 Feb.2000, Regional Office For the Western Pacific of WHO, Manila 22 SI Malaria Control Program (1999). Annual Report 1997,1998,1999. Unpublished Paper, MHMS.

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=======================================================

5.2.10.2. Accomplishments: In 1992 there were 153,359 cases of malaria or 440.5 cases per 1000 population. In 1999 the annual incidence rate was 144 cases per 1000 population a decline of over 67 % compared to 1992 (Figures 1, 2 and 3). Figure 2: Annual Incidence rate of malaria in Solomon Islands 1969-1999

1999

1996

1993

1990

1987

1984

1981

1978

1975

1972

450 400 350 300 250 200 150 100 50 0

1969

Annual Incidence Rate/1000 population

Annual Incidence Rate of malaria in Solomon Islands 19691999.

Year Figure 2 Annual malaria incidence rate in Solomon Islands since 1992 441

Annual incidence rate per 1000 population

450 400

353

347

350

301

300 250

207

200

160

150 100 50 0

82

165

144

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======================================================= Figure 3

Total number of malaria cases in Solomon Islands 153

160 141

Total number of cases (000)

140

131

126

118

116

120 100

85

80

63

65

1988

1989

73

68

64

60 40 20 0 1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

Year

5.2.10.3: Incidence in the provinces Figure 4 shows the trend in the annual incidence rate recorded in the provinces. The incidence rate has decreased in all provinces except Central and Malaita. Figure 4: Trends in the annual incidence rate of malaria in Honiara and the provinces 1992-99:

Trends in the Annual Incidence Rate of malaria in Honiara and the provinces 1992-1999.

AIR/1000 population

1200 1000 800 600 400 200 0 HON

CP

IP

83

WP

MP

Provinces

GP

MUP

TP

CHP

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 84 of 122

======================================================= Figure 5 shows the trend observed in the percentage of Plasmodium falciparum cases. Since 1992 the parasite formula index had reversed from being predominantly P. falciparum to a mixed situation with Plasmodium vivax being predominant in several provinces. But in 1998 and 1999 an increase in P. falciparum cases in all the provinces was recorded. P. vivax continues to the dominant species in Isabel provinces. Further studies are in progress to arrest this trend. Figure 5 Percentage of P. falciparum infection 70

60

50

40

30

20

10

0 %

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

62

62

70

63

62

60

63

61

52

55

66

69

The Slide Positivity Rate (SPR) had declined from 39% in 1992 to 20% in 1999 (Fig 6). Figure 6

SLIDE POSITIVITY RATE IN SOLOMON ISLANDS

40 35 30 25 20 15 10 5 0 1988

1989

1990

1991

1992

84

1993

1994

YEARS

1995

1996

1997

1998

1999

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 85 of 122

======================================================= 5.2.10.4. Diagnosis & Treatment: The prompt diagnosis and appropriate treatment of all malaria cases continues to be the most important component of the National Malaria Control Programme. Accomplishments: Malaria cases are diagnosed either clinically (based on symptoms) or by microscopic examination. Where microscopy is available, slides are taken from all fever cases and suspected cases of treatment failure. The proportion of suspected cases diagnosed by microscopic examination has increased as the number of microscopists in the country has increased from 67 in 1992 to 135 in 1999. Blood slides are read immediately and the results used for the treatment of patients. All malaria microscopists have been trained to carry out in-vivo drug sensitivity tests as a way to constantly monitor the effectiveness of the drugs being used. This network was strengthened through increased supervision and further training courses in 1997-98. A network of twenty surveillance agents was established in February 1997 in Honiara. It has been successful in supplementing the already effective diagnosis and treatment services provided by Central Hospital and nine Town Council clinics. The agents are able to detect and treat cases that do not seek treatment and to follow-up cases to ensure that each case is fully treated. They have also been able to identify and treat malaria cases that are new arrivals or visitors thereby reducing the source of imported cases. The mass blood examinations conducted in Honiara during 1996 - 1999 were effective i nde t e c t i nga ndt r e a t i ngal a r g enu mbe rof“ i na ppa r e ntma l a r i ai nf e c t i ons ” .Theope r a t i on in 1996 covered approximately 9,000 people living in the most highly malarious parts of Honiara. More than 6,000 slides were taken, 13% were positive. During 1997and 1998 the population covered was expanded to approximately 32,000, 19,000 slides were taken, 13% were positive. In 1999 this programme was integrated along with the routine surveillance operations. Mass blood examinations are done regularly in residential schools at the beginning of every year. Mass blood examinations are conducted in other provincial areas as a na ddi t i ona l me a nsofr e du c i ngt heov e r a l l “ pa r a s i t er e s e r v oi r ”i nhi g hi nc i de nc ev i l l a g e s .

5.2.10.5. Key Issues & Problems Experienced: Major problems are related to the lack of timely receipt of monthly grants by provinces from central government. In many cases are more than six months late. This means that for short periods work comes to a halt, and in many provinces money is borrowed from the mosquito-net fund just to maintain basic operations. All this is a consequence of the poor economic situation that the government is facing, partly as a result of recent ethnic tensions.

5.2.10.6. Analysis of the Program:

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======================================================= The strength of the program since 1997 and even before that is the continued support from WHO and other developing partners such as AusAID, Rotary Club and SPC. Whilst the above boosted the integrated malaria control program the improvement of Malaria Reporting System is also noted. As an accomplishment of its own, a computerized malaria information system (MIS) was introduced in Honiara and Guadalcanal Province in 1995. The system allows weekly reporting of malaria cases, automatic generation of monthly reports, and analysis of cases by age, sex and locality. The system was upgraded in 1997 to incorporate databases for mass blood surveys, spraying, and mosquito net distribution. With this system, the Program is able to track reported cases and maintain a history of spraying and mosquito net distribution for each household . In early 1998, a modified version of the MIS was setup in Western and Choiseul provinces and later extended to all other provinces. These provincial systems will eventually be linked into a national reporting and management network. A system for the regular collection and quarterly reporting of information on malaria deaths will be established in every province. This will include the establishment of a standard format for the investigation of deaths. This mortality information will be reported quarterly. The introduction of pre-packed drugs for both vivax and falciparum malaria, and the introductions of primaquine in Honiara on a trial basis for the treatment of vivax malaria have both very successful. This will soon be expanded to cover the entire country. As mentioned above great effort is still needed to expand the usage of bed-net to cover the entire population.

5.2.11. Tuberculosis: TB and leprosy control programs are long established in the country. In 1990 the program was boosted by JICA completing the traditional donors such as WHO and Pacific Leprosy Foundation New Zealand 5.2.11.1. Activities (Input): The strength of the National TB and Leprosy Control Program rests on a small TB/Leprosy unit under the umbrella of the Disease Control and Prevention Center (DCPC) of the Ministry of Health. The latter with only a establishment strengthen of 4 health workers, the support and efficiency provided by the Provincial TB/Leprosy Coordinators and fellow nurses at the area health centers, rural health clinics, nurse aide posts and village health aid posts is crucial and has been very good. Further boost to the program was the inception of the Short Course Chemotherapy in 1996 and 1997, after a short trial in northern region of Malaita Province in 1995. The program has been supported (at adhoc basis) by the Research Institute of Tuberculosis (RIT) in Tokyo, a WHO collaborating center for monitoring TB epidemiology in the Western Pacific Region. The program has been reviewed by external

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======================================================= reviewers followed by a national conference, which deliberated, on the findings for the purpose of strategic planning. Continuous health workers training and regular provincial tours were done to increase knowledge and skills of both the health workers and the community on the problem. One of the main agenda of the trainings and supervisory visits is the introduction and sustaining of the Direct Observation Therapy Strategy (DOTS). It is apparent that the DOTS coverage has been increasing and notes to be successful in the past three years.

5.2.11.2. Findings (Outputs): Supervisory Tours: 1997

Coverage (%)

1998

Coverage (%)

1999

Coverage (%)

Nk

Nk

8/10

80

8/10

80



. In 1999, the Cure rate for the National Tuberculosis Control Program has also increased from 30% in 1996 to 83.3% in 199823. However, cure rate is just below 85% mark by WHO. The treatment successive rate is 92.0%. Nonetheless, individual provinces like Western (87.5), RBP (100), Temotu (100), Makira (100), Choiseul (94.7), and Isabel Provinces (92.3) have cure rates more than 85% (higher than WHO mark). The provinces needing further improvement are Guadalcanal (72.7), Malaita (79.3) Honiara City Council( 50), and CIP (83.3). The above results are unweighted against the number of case holdings.



There has been a significant decline over the past 13 years (1986-1999) irrespective the fluctuation in between the period, from 102.1 new cases detection rate (NCDR) per 100,000 pop down to 64.2/ 100,000 pop. (I.e. 225 new cases detected end of 1999). Of the total new cases 72% are PTB and 28% others.



Relapse of cases of TB amongst children is less frequently notified nowadays. Due to high treatment successive rate and BCG coverage.



It is apparent that the BCG coverage is underestimated in the Health Information System. According to the Disease Prevention and Control Center (DPCC?MOH) the accurate estimate would be more than 80%.



It is puzzling to variation to conversation rates between hospitals. Sasamuga, HGH, Kirakira, Buala and Atoifi Hospital have 100% completion rate end of 2 months inpatient. Whilst, Lata, NRH, Kiluufi Hospitals have less than 80% end of 2 months, but 100% end of three months (a month extra of treatment).

23

Ken Konare (1999).

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5.2.12. Mental Health Services It is the Ministry mission to increase accessibility to basic mental health services through the pr i ma r yhe a l t hc a r ea ppr oa c h. I ti sa l wa y sac onc e r nt ha tpa t i e nt s ’ r i g ht sa r er e t a i ne da nd r e c og ni z e dbyt hec ommu ni t y . TheNa t i ona l Ps y c hi a t r i cUni ta tKi l u ’ u f i Hos pi t a l , a ndt he Honiara psychiatric unit are the only two service providers. However, irregular provincial tours do occur. 5.2.12.1. Activities (Inputs) The Honiara Psychiatric unit had an average staffing level of three psychiatric nurses. The Honiara unit did outpatient services, screening, counseling and referral of patients of patients needing admissions. In 1997 only two provinces were toured. Subsequent years were affected by the ethnic tension. The unit also did visits to the Rove Central Prison. The National Psychiatric Unit is the main admitting center for inpatients. The staffing level is always around 18 (including 3 domestic workers, a cook and a driver). The condition of the unit has run down in the past years and needs urgent repair. The Ministry had great difficult in recruiting a psychiatrist because of several reasons. Firstly, there were no applicants despite several advertisements overseas. Secondly, there is lack of commitment from higher authorities, as recruitments were freezed by the Public Service. Thirdly, the issues of financial constraints were some of the answers the Ministry received. Nonetheless, the psychiatric nurses were trained and had the capacity to manage the NPU and the Honiara Unit. This report highly commend the Principal Nursing Officer, Psychiatric Services and the staff for maintaining the basic level of service with out a qualified psychiatric, after the only one left in 1997.

5.2.12.2. Findings (Outputs): Table (A): Total Cases Admitted to Na t i ona lPs y c hi a t r i cUni t ,Ki l u’ uf iHos pi t a l( onl y )I N 1997,1998,& 1999.

Total Admin New M F Total new Old M F Total old Point prevalence rate Per 10,000 pop

1997 1998 358 177 79 50 38 42 117 92 164 36 75 49 239 85 8.4 4.0

1999 84 19 11 30 34 29 54 1.8

88

. Table B: Total Cases seen and Treated by the National Psychiatric

Unit, Honiara, MHMS,HQ, in 1997,1998 & 1999

Total Cases Seen New M F Total new Old M F

1997 354 79 41 117 162 75

1998 1999 598 830 130

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======================================================= Table C:

5.2.12.3.Analysis:

Overall Total Cases recorded at the National Psychiatric Unit, Kiluufi Hospital & Honiara in 1997,1998,& 1999.

The access to mental health services is fairly limited in terms of mental health workers to rural population.

Total Admin & seen New M F Total new Old M

Secondly, it is evident that the pressure on mental health services is increasing. The total number of cases seen (as outpatient in Honiara Psychiatric Center) and admission a tt heNa t i ona lPs y c hi a t r i cHos pi t a lKi l u ’ u f i Hospital increased from 663 in 1997 to 915 in 1999, with an average of 764 per year.

1997 1998 1999 663 715 915 158 79 237 276

222

117

Thirdly, it also implied the impact of mental health illness on the local community has increased. By 1999 in a population of 10,000 people 19.9 (about 20) people have came down with mental health problem. An increase from 15.6/ 10,000 population in 1997. 5.2.12.4. Major Issues/ problems & recommendations: Thema i ni s s u ei st heMi ni s t r y ’ sc a pa bility to sustain both institutionally and financially, the psychiatric health services in the country in light of the limited resources.

Secondly, the issue of increasing accessibility through the primary health care approach has been preferred. A problem experienced with the psychiatric outreach health visits to other provinces was the irregularities of tours because of untimely payment of grants (imprest), and limited qualified staff. Recruitment of a psychiatric was difficult process, which is partly du et ol a c kofg ov e r nme nt ’ sc ommi t me ntt ot hes e r v i c e s . Thus, the drive towards primary health care approach is crucial in light of the current limited resources in terms of manpower and funding. It would also be helpful for a detailed epidemiological study on mental health illnesses to be carried in the next few years to ascertain the attributable factors, so as to enable existence of a preventable and health promotion program.

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SECTION VI: ENVIRONMENT HEALTH SERVICES: 6.0. HEALTH AND ENVIRONMENT24 6.1. General protection of the environment The Solomon Islands Government recognizes the importance of our environment to the health, welfare and economic development of this country. The Cabinet has endorsed in 1991 the National Environmental Management Strategy, which is implemented by the Environment and Conservation Division of the Ministry of Forestry, Conservation and Environment. The strategy itself is a step forward to ensuring sustainable economic development and environmental management for the Solomon Islands. The Environment and Conservation and Environmental Health Divisions collaborate in ensuring environmental impact assessments are conducted to assess impacts on development using local staff or overseas consultants. 6.2. Air (pollution) The Environment and Conservation and Environmental Health Divisions have realized that there are potential effects air pollution can cause to the environment. At this stage the country does not have the means to undertake air quality monitoring. 6.3. Water quality The Water Resources Management Division of the Ministry of Forestry, Mines and Minerals is responsible for the monitoring of water resources in the country. The Division has trained personnel and the Government has made equipment available with assistance from overseas donors. The facilities for quality control for both bacteriological and chemical analysis is inadequate, this is particularly true for chemical analysis. The country is adopting the safe standards for drinking water recommended by WHO. 6.4. Solid waste disposal Solid waste disposal is becoming a problem in urban places like Honiara particularly for toxic wastes such as hospital and industrial wastes. There is a need for a new dumpsite to be identified for Honiara as soon as possible and need for improvement in the management techniques of the dumpsite. 24

WHO, Honiara Office. Evaluation of the Implementation of the Strategy For Health For All By The Year 2000, 3rd evaluation, Solomon Islands.

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6.5. Food safety Food safety has been strengthened through the enactment of the Pure Food Act and the Consumer Protection Act by Parliament to be implemented by the Environmental Health Division of the Ministry of Health and Medical Services and the Consumer Affairs Divisions of the Ministry of Commerce Employment and Trade. The Environmental Health Division has participated in the Codex Alimentarius Commission through the South Pacific Commission. All inspectors of the two ministries have been trained to perform food inspection. The Public Health Laboratory with the MHMS has limited scope in the food analysis due to lack of adequate facilities and qualified staff. The HTC Health Inspectors have been trained in the HACCP and have been running a program for selected food establishments in Honiara since 1995. The HTC has had an educational program for the mothers in town in the hygienic preparation of food for sale to public. This program has often been disrupted by lack of financial support. There has never been a major outbreak of food borne disease recorded in the country and the situation is considered at present relatively safe. 6.6. Housing The housing situation in the rural Solomon Islands is that every family has a house built of local materials, which is adequate in construction. Some well to do Solomon Islanders living in rural villages have built themselves buildings of permanent structure. In urban places such as Honiara and other centers the employers provide houses for the workers both with the public and private sectors. There are people who are unfortunate not to have a house whereby they have to find a home with a friend or shift to the outskirts of the township to settle in the slums. This is increasing in Honiara. Some persons have access to loans from financial institutions to build their houses; this does not apply to most people in the rural villages since they are not on regular earnings. 6.7. Work place Those who are on regular employment both in the public and private sectors are protected under the Labor Act, which provides the conditions of service regarding wages, and housing and other benefits to which a worker is entitled. This is being implemented by the Labor Division.

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======================================================= The Safety at Work Act protects workers who are likely to be subjected to risks of occupational health and is being implemented by the Labor Division of the MCET. The Workers Compensation Act is currently under revision, particularly with regard to the medical conditions covered under the Act. For environmental issues such as air, radiation and chemicals the country does not have the necessary equipment and expertise to deal with these and to a large extent depends on overseas consultants should the need for such risk assessment arises.

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======================================================= 6.8. Water supply and sanitation 6.8.1. Indicators 1. Percentage of the population with safe drinking water available in the home, or with reasonable access: By 1999, 70% of people have access to safe water as compared to 64% in 1996 (estimate from RWSS, MHMS). 2.

Percentage of the population with adequate excreta disposal facilities available:

By 1999, it is estimated that 25% of the population have access to proper sanitation as compared to 9% in 1996 (estimate from RWSS, MHMS) 6.8.2. General In 1979 the Environmental Health Division of the Ministry of Health commenced the implementation of a construction program to build safe and secure water supplies for rural villagers throughout the country. Up to 1990 Governments of Australia and New Zealand and the UNDP and WHO were major contributors. In 1990 the Solomon Islands Ministry of Health and Medical Services prepared a report on progress and direction of the Rural Water Supply and Sanitation (RWSS) program, which was submitted, to the Governments of Australia and New Zealand. In February 1995 a project design document was prepared which describes a five-year RWSS project to run from 1995 to 2000, with project funding from GOA, GNZ and the Solomon Island Government. A Project Memorandum of Understanding was signed on 31 August 1996. The project is expected to increase the percentage of population with safe water to 70% by the year 2000 and the population with adequate sanitation facilities to 25%. The project will also build capacity in the Environmental Health Division (RWSS) through: training of staff, establishment of database management system, construction of a new office and establishing several new provincial Office/Store complexes, improving storage facilities and stock recording system, and provision of additional transport equipment. Emphasis will be given to strengthening community awareness and participation so that communities have the capacity to manage their own water supply and sanitation systems. The village health/RWSS committees will be reactivated or established to play a central role in the planning, management and maintenance of WSS facilities. The RWSS project will receive funding from three sources: the Governments of Solomon Islands, Australia and New Zealand. The projected funding is expected to be SBD 40.4 million with SBD 11.5 million from GOSI, SBD 27.6 million from GOA and SBD 1.2 million from GONZ. The major constraints faced by the Government are: 93

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======================================================= 1. 2. 3. 4. 5.

Lack of trained professionals Inadequate organization and management 4. Lack of community involvement Insufficient health/hygiene education Inadequate cost recovery framework

Table showing expected water supply and sanitation service coverage achievements –RWSS Project 1996-2001. Present Expected Yearly Expected end of Project RWSS Situation Achievement (Year 2001) 1996 Situation Total Population 407,634¹ 467,770³ Rural Population 346,490² 397,605 Water Supply Coverage 64% Increase 1% p.a. 70% Population served 222,742 Approx. 11,00 p.a. 278,323 WS Maintenance/Repair Coverage reduction (16%) Decrease 1% p.a. (10%)5 Population not served 55,686 Approx. 3,300 p.a. 41,748 Sanitation Coverage 9% Increase 3% p.a. 25% Population 31,180 Approx. 13,500 p.a. 99,400 Notes: 1. 2. 3. 4. 5.

Figure from Medical Statistics Division, MHMS (Review of national Health Plan 1990 –1994) Assumes 85 per cent of population in rural areas. Assumes 3.5 per cent population growth per annum. Assumes 25 per cent of installed systems require maintenance. Assumes 15 per cent of installed systems will require maintenance.

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SECTION VII: HEALTH PROMOTION & EDUCATION: 7.0. Overview: TheMi ni s t r y ’ smi s s i oni st oe nc ou r a g ea ndhe l pt hepe opl et oi mpr ov eand promote their personal hygiene, live healthy lifestyle and take responsibilities for their own health. The strategic approach is the transition into a wider –sector approach, integrating as much as possible with the communities, non-government organizations. One of the key steps forward is to review the existing structure and roles of the Health Education Division of the Ministry of Health to be more proactive in advocating health pr omot i on.Bye ndof1 9 9 8 ,t he r ewa sadr a f t‘ He a l t hPr omot i onPol i c y ’dr a wnu p.I ti sy e t to be finalized, as further work is needed to ensure the strategies are clear and practical. As part of the move towards health promotion, a Memorandum of Understanding was developed with the Yooroang Garang, School of Indigenous Health Studies, University of Sydney, who trained health workers in skills of addressing community health issues related to indigenous people of Australia. Having studied the courses the Ministry agreed that there are numerous similarities between the attitudes and behavior of the aboriginals and the people of Solomon Islands. Thus, three staff of the Health Education & Promotion Unit were enrolled. The program is yet to be evaluated.

7.1. Community Health Education Activities 1997-99: The key health education activities for the communities are school visits and village meetings. From the graph below, the trend of village meetings increased from 1997, whilst schools visits decline. Western Province did more school visits and village meetings than all other provinces. A major problem to these programs is lack funding to allow regular visits.

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SI

ChoiseulWestern Isabel

CIP Guadalcanal Malaita Makira Temotu Honiara RenBell

Graph showing Health Education Activities (School visits & Community meetings) by provinces

1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997 1999 1998 1997

At the national level in 1998, there were total of 101 trainings and workshops planned. Of which 76 (75%) were actually implemented. Thirty-eight (38%) percent were integrated health workshops and thirty four percent (34.2%) were MCH/FP/Sexual Health Trainings.

Meetings in the villages Schools visited

School Health Education and Promotion: 0

1000

2000

3000

A Health Promoting School Policy was developed and endorsed by the Cabinet in latter half of 1998. The health education and promotion department have executed its school health education program in line with school activities. They provide general health awareness talks ensuring that the environment is conducive and safe, provision of the needed health information and collaborating with surrounding communities. The activities have been classified under; school health instruction, school health inspection, school health services and school community organization. No. of activities

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======================================================= 7.2. Evaluation of health education & promotion programs: Whilst there were no formal review and evaluation of health education programs by the MOH, the Health Education & Promotion Division took a forward step in the formation of a‘ Na t i ona lHe a l t hEduc a t i ona ndPr omot i onRe s e a r c ha ndEv a l ua t i onCommi t t e e ’ .The c ommi t t e e ’ st e r msofr e f e r e nc ei nv ol v e sc oor di na t i ngr e s e a r c ha nde v a l ua t i onofe x i s t i ng health education and promotion activities and programs. Unfortunately, the committee has been defunct since the ethnic tension escalated. Howe v e r ,i ti st hedi v i s i on’ sk e ypr i or i t yt o evaluate the programs in order to improve the health outcomes through providing information and advocating for healthy life style.

SECTION VIII: REPRODUCTIVE HEALTH AND FAMILY PLANNING: TheMi ni s t r y ’ spolicy on reproductive and family planning is to promote and maintain the development of a health family, reduce, maternal and peri-natal, and infant mortality, and raise the standard of living for mothers and children. The key performance areas of the division responsible is to ensure that every mother has the best opportunities for appropriate timing and spacing of pregnancies, safe delivery of a healthy infant in an environment conducive to health with adequate antenatal care, sufficient nutrition and preparation of breast feeding her child.

8.1. Maternal Mortality: There is marked improvement in reduction of the maternal mortality rate from 549/ 100,000 live births to an estimate of 154/ 100,000 in 1999. It took about 13 years to reduce the level in 1986 by more than half. The policy standard in the National Health Policies and Development Plans 199-2003 is to reduce the maternal mortality rate by 50% at the end of the five year planned period. Most causes of maternal mortality are preventable. Table (23) showing Maternal Mortality Rate/ 100,000 births

1986[i.] 549

1997[ii.] 209

1998[iii.] 203

1999[iv.] 154

Sources: [i.] 1986 census, [ii.] Reproductive Health Division/MOH 1997, [iv.]based on HIS/MOH

Table (24) Maternal Deaths by Provinces 1996-1999 (excluding those in the hospitals):

Solomon Islands By Provinces:

1997 H=5, C=9 Total =14

1998 H=7, C=9, Total = 16

1999 H=11,C=1, Total=12.

Home Clinics Total Home Clinics Total Home Clinics Total

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======================================================= Choiseul 1 3 4 0 1 1 0 0 Western 1 2 3 1 3 4 0 0 Isabel 0 0 0 0 0 0 0 0 Central 0 1 1 0 1 1 2 1 Islands Guadalcanal 3 1 4 5 2 7 4 0 Malaita 0 2 2 0 2 2 3 0 Makira 0 0 0 1 0 1 2 0 Ulawa Temotu 0 0 0 0 0 0 0 0 RenBell 0 0 0 0 0 0 0 0 Honiara 0 0 0 0 0 0 0 0 Source: HIS, MOH, 1997,1998,1999

Graph showing maternal deaths 1997-1999 by provinces 8

No. of maternal deaths

7

7

Choiseul Western

6

Isabel 5

Central Islands

4

4

3

3

4

0 0 0 3 4 3 2 0 0 0

Guadalcanal recorded the highest number of maternal deaths with 7 in 1998. Western had 4 in that same year. There may be underreporting of cases.

Guadalcanal

4

According to the local statistics maternal deaths Temotu 2 2 2 RenBell made up 1.58% of the total Honiara 1 1 1 deaths recorded in the 0 0 communities in 1997, 1997 1998 1999 1.86% and 1.18% in 1998 Years and 1999 respectively (see table below). Despite the lower percent, it is very stressful when mothers die, leaving behind many children to care for by the husband and relatives. Malaita

Makira Ulawa

3

Table (24) Proportion of Total deaths by National and Provinces (ie. No. of. maternal deaths / total deaths reported by Clinic Monthly Reports in %:

Solomon Islands By Provinces: Choiseul

1997 Total MD =14, All deaths=884, =1.58% Total All % MD deaths 4 38 10.5 (0.45)

1998 Total MD = 16, All deaths=861, =1.86% Total All % MD deaths 1 61 1.6 (0.12)

98

1999 Total MD=12, All deaths=1,018, =1.18% Total All % MD deaths 0 66 0

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======================================================= Western 3 196 1.53 4 172 2.3 0 157 ((0.34) (0.46) Isabel 0 38 0 0 33 0 0 40 Central Islands 1 69 1.45 1 55 1.8 3 56 (0.11) (0.12) Guadalcanal 4 116 3.4 7 119 5.9 4 131 (0.45) (0.81) Malaita 2 260 0.77 2 212 0.94 3 365 (0.23) (0.23) Makira Ulawa 0 103 0 1 141 0.7 2 118 (0.12) Temotu 0 51 0 0 48 0 0 70 RenBell 0 11 0 0 10 0 0 3 Honiara 0 2 0 0 10 0 0 12 Source: HIS, MOH, 1997,1998,1999

0 0 5.4 (0.29) 3.05 (0.39) 0.82 (0.29) 1.69 (0.19) 0 0 0

8.2. Family Planning: Family planning contraceptives is widely available in the rural clinics. However, compliance from clients is observed to be declining. According to available statistics there is marked drop in the contraceptive prevalence rate from 25% in 1986 to 18.625 in 1997. Table below clearly shows that level of family planning coverage in population of women of childbearing age is generally low. FP coverage declined in 1999. It varies by provinces. Isabel, CIP and Temotu have higher coverage than other provinces. Table (25) Family Planning Coverage (%) total users at end of December/wcba x 100):

Solomon Islands By Provinces: Choiseul Western Isabel Central Islands Guadalcanal Malaita Makira Ulawa Temotu RenBell Honiara

1997 8.5 1997 6.9 11.2 7.9 6 7.1 10.2 7.9 14.2 3.3 5.6

1998 8.6 1998 5.0 8.2 13.2 15.7 5.8 11.3 6.9 12.3 5.3 5.6

Source: HIS, clinic monthly reports

25

1997 Estimate by Reproductive Health Division, MOH

99

1999 6.5 1999 7.8 9.1 11.4 17.9 5.4 3.9 6 13.5 2.5 2.7

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======================================================= Graph (29) showing FP coverage by end of December 1997,1998 & 1999: Graph showing family planning coverage by December of 1997, 1998 & 1999 20 15 % 10 1997 5

1998 1999

0

Choi Wes Isab Cent Gua Mal Maki Tem Ren Hon seul tern el ral dalc aita ra otu Bell

1997

6.9 11.2 7.9

1998

5

1999

7.8

6

SI

7.1 10.2 7.9 14.2 3.3

5.6

8.5

8.2 13.2 15.7 5.8 11.3 6.9 12.3 5.3

5.6

8.6

9.1 11.4 17.9 5.4

2.7

6.5

3.9

6

13.5 2.5

Table (26) % Supervised deliveries:

1995 85

1997 86**

1998 -

1999 -

Sources: **RHD/MOH, 1997

Table (27) Antenatal Coverage: First antenatal attendance (% first visit / expected births)

Solomon Islands By Provinces: Choiseul Western Isabel Central Islands Guadalcanal Malaita Makira Ulawa Temotu RenBell Honiara

1997 68.9 1997 59.4 79.8 54.6 55.1 66.0 70.6 54.6 53.8 46.5 78.0

1998 71.9 1998 61.7 75.3 60.4 73.6 72.4 72.8 71.7 48.4 38.5 80.5

1999 65.9 1999 65.2 74.5 68.8 68.9 52.1 73.6 56.2 60.2 31.1 68.8

Table (30) Total Fertility Rates 1986,1996,1998:

Years

1986 (Census)

Total 6.1 Fertility Rate Source: UNFPA

1996

1998

5.8

4.8

Total Fertality Rate declined from 6.1 in 1986 to 4.8 in 1998. Majority of six provinces (Choiseul, Western, CIP, Malaia, Makira, and

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======================================================= Temotu) have reached 100 births in 1,000 WCBA population mark during the period 199799. Isabel and Guadalcanal recorded levels below 100/1,000 WCBA pop. However, Guadalcanal is also known to have higher level of maternal mortality rate.

Graph showing fertility rates by provinces 140 120 100 No. of births/ 1,000 wcba

80 60

1997

40

1998

20 0

1997

199 Guad Choi West Isabe Centr Malai Makir Temo Honi alcan seul ern l al Isl. ta a tu ara al 97.3 120.8 93.14 89.3 47.3 115.7 103.6 107.7 0.7

1998 116.8 118.5 81.6 106.1 54.7 115.7 123.1 96.5 199

10.4

96

64.5 12.4

59

0.4

123.9 83.7 111.7 0.12

Table (28) FERTILITY RATES BY PROVINCES FROM 1997 TO 1999 (births/ 1000 popWCBA Province Year Births Fertility rate (births/1000pop WCBA) Choiseul 1997 449 97.3 1998 555 116.8 1999 509 104.0 Western 1997 1,575 120.8 1998 1,591 118.5 1999 1,329 96.0 Isabel 1997 417 93.14 1998 377 81.6 1999 308 64.5 Central Islands 1997 397 89.3 1998 486 106.1 1999 584 124.0 Guadalcanal 1997 773 47.3 1998 932 54.7 1999 1048 59.0 Malaita 1997 2,600 115.7 1998 2,660 115.7 1999 2,917 123.9 Makira Ulawa 1997 682 103.6

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======================================================= Temotu Honiara Rennell Bellona Solomon Islands

1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999 1997 1998 1999

839 591 438 403 480 10 6 2 19 16 10 7360 7,865 7,778

123.1 83.7 107.7 96.5 111.7 0.7 0.4 0.12 39.5 32.3 19.6 81.3 83.7 79.7

*Total births / total pop of WCBA 15-44 x 1000 Source: Health Information System, Annual Health Reports 1997,1998 & 1999, Statistics Unit, MOH. In evaluating the national and provincial reproductive health services and program the following approach could be used: Program Inputs Institutional Capacity

Commitment of the Government Institutional Capacity

Social Development Program efficiency

Program Outputs Service Access (proximity to services) Quality care (drop out) Behavioral changes Fertility rates, contraceptive prevalence Demography changes TFR, Infant mortality rate, Maternal health The Strengths: There are both strengthens and weaknesses of the overall reproductive (& family planning) programs. On one hand the strengthens of the program lies in the institutional capacity through the primary health care and community health network which infiltrated as far as the rural remote areas. There is an existing structure, which has both vertical and horizontal aspect of service delivery. The vertical aspect concerned with policy development, planning, supervision and monitoring, training and staff development (Reproductive Health Division, HQ, MOH). The horizontal aspect concerns with actual service delivery (Maternal Child Health /Family Planning activities in the provincial centers). The program has been very effective in staff development. There were training workshops for different category of health workers in particularly the nurses. Thepr og r a m’ sou t pu tc oul dbev i e we dbyt hef ol l owi ngi ndi c e s :  Clear policy directions and strategies at all levels  Number of nurses trained in family planning  Number of nurses trained in midwifery 102

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=======================================================  Number of training workshops  Service delivery indicators; contraceptive prevalence, F.P coverage, % supervised deliveries, % ANC attendances, The program developed a clear policy, which is documented in the National Health Policies and Development Plans 1999-2003. Underneath the policy are the strategies to achieve the policy objectives. In 1997-1999 number of trainings and staff development were carried out both locally and overseas. Thepr og r a m’ sa nt i c i pa t e dou t c ome sa r ev i e we da s ;  Behavioural changes –Total Fertility rates and contraceptive prevalence  Demographic changes-TFR, Infant Mortality and Maternal Mortality rates. There has been favourable as well as unfavourable outcomes experienced by the program. Firstly, there are definite indications of behavioral changes. The TFR has declined from 6.1 in 1986 to 4.8 in 1998. However, the contraceptive prevalence has dropped according to the available information. Secondly, there are also positive signs that demographic changes are happening. Infant mortality and maternal mortality declined in the past thirteen years since 1986. Weaknesses: However, are the above changes due to the Reproductive Health Programs? Or if these positive changes are taking place in the past 13 years, what were the driving forces for the changes? Special care needs to be taken in answering the question. Firstly, because measurement of changes in behavioral is not only difficult but very lengthy. It would take more than twenty years before any real change in behavior is seen. Simple questions like ‘ wha twa st hei mpa c toft hev i l l a g et a l konf a mi l ypl a nni ngwedi di nt hev i l l a g e ?Oneof weaknesses of many public health programs including the reproductive health is the lack of proper monitoring and evaluation of programs involving behavioral changes. There is need for epidemiological researches to help answer some of the above hypothetical questions. Secondly, there is no evaluation done on the program efficiency and cost-benefit of the programs. Thirdly, lack of coordination of multiple donors has been a weak point. There are inequalities among provinces in areas of maternal health outcomes and accessibility to MCH/FP care. These are important issues and lessons for provincial health service planning. Potential Threats: In the past experiences, there were threats to the reproductive health programs, which correspond to the above weaknesses of monitoring and evaluation. The institutional capacity to evaluate the program efficiency is due to lack of resources such as funding and skill to do it. There were also other obvious threats to the program. Service delivery was significantly

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======================================================= affected by external influences such as geography, and low socio-economical factors. The ethnic tension, which started around 1998, had adverse impact on the service delivery. Traditional custom beliefs and high illiteracy rate among the target customers has been recognize as negativism to the performances of the service. Unfortunately, it is apparent that unwanted competition is been experienced with the Department of Development Planning, which assumed the policy role of population control. Lack of clear strategies of the National Population Policy does not help the program as the major stakeholder. TheGov e r nme nt ’ sc ommi t me ntt or e pr oductive health is literally there. The National Population Policy was drafted with little integration in implementation as expected. Involvement of relevant sectors is yet to be seen.

SECTION IX: DEVELOPING PARTNERSHIP 9.0. Overview in brief: The Minis t r y ’ sv i s i oni nde v e l opi ngpa r t ne r s hi pi st oi nv ol v epa r t i c i pa t i onofwi der a ng eof people in the community both local and international. Health affects every person one or another therefore the policy aims at enhancing collaboration between different stakeholders. There is a need to give formal recognition to community organization through development of a Memorandum of Understanding (MOU) between the Government and other Health Services providers. Mechanisms of operation are to be included and must be clear and well understood by various parties to the MOU.

9.1. Involvement of Non-Government Organizations locally: The private sector is a key player in health developments in the country. Organizations such as Red Cross, Solomon Islands Planned Parenthood Association, Family Health Center, Rotary Club, World Vision and Solomon Islands Development Trust and the Churches such as Seventh Day Adventists, United Church of Solomon Islands, Roman Catholic, SSEC and Church of Melanesia continued to supplement and complement health developments through their activities.

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Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 105 of 122

======================================================= Even business firms have shown initiative to assist the National Referral Hospital in minor projects. In 1999, Mr. Robert Coh a well-known businessman in Honiara established an informal relationship with the National Referral Hospital. Kiluufi Hospital through the ‘ Fr i e ndsoft heHos pi t a lCommi t t e e ’ha v ei nv ol v e di nu pg r a di ngoft hehos pi t a l .S u c h informal partnership is very fruitful. Churches: Despite any formal memorandum of understanding with the Church hospitals in terms of performance management process, service delivery to the people served is great. The SIG continue to provide subsidy and assistance to church health services in return for the services provided to the people of the country. The SIG continued to inject annual funding to church hospital budgets. The secondment of government salaried staff to churches also continued. Provision of essential medical supplies continues free to church hospitals. SIG also support staff development and training of church health services staff.

9.2. Involvement of International developing or donor partners: The international donor agencies through their bilateral and unilateral diplomatic relationship with the SIG continued to play vital and crucial role in health development in the country in the years 1997 to 1999. Annex Table ( ) outlines the donor agencies input in the health development of the country in the past years. Assistance and support are in the following areas;  Human resource trainings and staff development (scholarships- undergraduate and postgraduate)  Technical Assistances  Specific health projects & programs -Rural Water Supply & Sanitation -Vector Borne Disease control programs (including malaria, hepatitis B) -AIDS/ STD  Community health projects and programs  Rural health infrastructure Most form of assistances was either in-country or regional basis. There is no direct injection of fund into the national health recurrent budget. There was a big shift from capital assistance, which was accounted for about one and half of total assistance in 1989-199326.

26

World Bank Pacific Countries (1994). The Solomon Islands Health Sector Issues and Options (June 2, 1994), East Asia and Pacific, Country Department III Population and Human Resources, section 86, p.31.

105

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 106 of 122

======================================================= 1988 1990 1992 1994 1996 1997 1998 1999

Gov. recurrent budget 101.2 146.6 Health recurrent budget 12.7 18.3 % Health recurrent budget 12.5 12.5 Donor 10.6 % Donor 37%

208.8 24.3 11.6 20.3 46%

106

255 34.4 13.5 21.9 39%

311.4 39.2 12.6 11.9 23%

340.9 47.6 14.0 16.3 26%

375 54 14.4 27.0 33%

348.7 56.7 16.3 10.1 15%

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 107 of 122

=======================================================

ANNEXURE ANNEX Table (1) showing proportion of population to health workers in 1997-98:

Province

Choiseul Total pop Doctor : Pop Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Western Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Isabel Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Central Islands Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Guadalcanal Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Malaita Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Makira Ulawa Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Temotu Doctor : Pop

27

Health Workers Ratio to Population 1997-1998: Population/person in practice 1997 1998 20,969 21,596 20,969 1311 839 511 61,146

21,596 1,200 864 502 62,982 157455 1,016 829 500 20,714 20,714 609 767 340 23,113 23,113 1,445 770 502 81,941

20,074 20,074 717 772 372 22,461 22,461 1,604 749 510 78,563 39,286 2,806 2,619 1,355 102,653

2,826 2,731 1,389 105,013

1,488 1500 772 31,343 31,343 1,045 871 475 19,360

1,500 1,522 755 32,471 32,471 984 833 451 19,903

The total population figures of 1999 National Census is used here.

107

199927 20,008 20,008 800 800 400 62,739 15,685 1,162 980 532 20,421 20,421 638 704 335 21,577 21,577 1,199 696 440 60,275 60,275 1,722 1,944 913 122,620 40,873 1,670 1,916 895 31,006 31,006 838 795 408 18,912 18,912

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 108 of 122

======================================================= R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Honiara Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop Rennell Bellona Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop SOLOMON ISLANDS Doctor : Pop R/Nurse:Pop Nurse Aide:Pop Total Nurse:Pop

745 1,210 461 66,508

686 905 390 71,628 71,628 2,311 6,512 1,705 2,479 413 0 413

2,293 6,046 1,663 2,410 482 803 268

700 1182 476 49,107 49,107* 1,584 4,464 1,169 2,377 396 792 264 409,042 10,488 836 1,175 489

Source: Annual Nursing Management Report 1997,1998,1999.

* Private practitioners not included.

ANNEX Table (2) Female, Male, Pediatrics, and Obstetrics Beds-All Hospitals Admissions and Occupancy Rates at 1997,1998,1999 bed capacity Prov Hosp Choiseul (Sasamug a) All Beds Male Female Pediatrics Maternity Western (Gizo)** All Beds Male Female Pediatrics Maternity Others Isabel (Buala) All Beds Male Female Pediatrics Maternity Malaita (Kiluufi) All Beds

1997 Beds

Adm

%OR

ALO S

1998 Beds

Adm

%OR

ALO S

35 8 8 9 10

1,216 236 271 364 345

62.1 62.4 64.2 75.6 53.1

60 15 15 10 14 6

1,656 331 350 422 553 nk

39 8 8 8 15 130

1999 Beds

Adm

%O R

ALO S

6.5 7.7 6.9 6.8 5.6

35 8 8 9 10

1,278 258 216 356 448

75.0 63.6 51.8 74.8 72.9

7.5 7.2 7.0 6.9 6.1

35 8 8 9 10

1,426 307 315 352 452

79.5 73.8 74.5 74.1 73.3

7.1 7.0 6.9 6.9 5.9

46.3 44.9 42.3 45.6 51.6

6.1 7.4 6.6 5.9 5.1

60 15 15 10 14 6

1,676 364 312 450 550

55.1 47.9 34.8 62.9 51.7

7.2 7.2 6.1 5.7 4.8

60 15 15 10 14 6

1811 395 450 462 504

58.0 49.9 50.3 71.1 49.5

7.0 6.9 6.1 5.6 5.0

898 223 149 254 272

36.7 48.2 41.0 46.2 27.3

5.8 6.3 6 5.3 5.5

39 8 8 8 15

876 251 138 315 172

36.9 49.9 27.9 70.1 17.9

6.0 5.8 5.9 6.5 5.7

39 8 8 8 15

987 268 198 320 201

41.0 55.2 40.1 61.5 38.0

5.9 6.0 5.9 5.6 5.5

3,531

62.7

8.4

130

3,746

64.7

8.2

130

3,766

65.9

8.3

108

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======================================================= Male Female Pediatrics Obstetrics Makira (Kirakira) All Beds Male Female Pediatrics Maternity Temotu (Lata) All Beds Male Female Pediatrics Maternity TB Isolation

11 20 22 24

746 918 826 1042

186 129 71.2 82.3

10. 10.2 6.9 6.9

11 20 22 24

789 852 995 1110

195 119 88.0 76.0

9.9 10.2 7.1 6.0

11 20 22 24

854 866 897 1149

213 117 77.3 92.1

10 9.8 6.9 7.0

86 18 19 16 21

1065 188 212 218 324

29.2 21.2 22.3 25.0 55.0

8.6 7.4 7.3 6.7 13

86 18 19 16 21

962 211 233 207 311

19.6 22.8 26.9 14.2

6.4 7.1 8 4 -

86 18 19 16 21

1,320 251 265 235 569

32.9 28.3 26.3 23.8 87.8

7.8 7.4 6.5 5.9 11.8

46 8 8 8 8 12 2

854 213 112 239 282 4 4

40.7 86.3 22.7 55.8 40.7 5.0

8 11.8 5.9 6.8 4.2 55

46 8 8 8 8 12 2

892 198 131 282 266 13 2

40.5 71.2 23.3 54.1 37.3 16.4

7.6 10.5 5.2 5.6 4.1 54

46 8 8 8 8 12 2

1089 264 177 363 278 2 3

45.0 93.4 32.8 68.6 37.2 2.5

7 10.3 5.4 5.5 3.9 54

National Referral Hospital All Beds Medical Surgical Pediatrics Maternity Gynae EMS TB Private Ward

Beds

Adm

%OR

ALO S

Beds

Adm

%OR

ALO S

Beds

Adm

%O R

ALO S

330 56 56 45 50 17 42 52 12

5916 723 812 673 2914 444 222 27 101

45.8 31.6 40.2 31.2 46.4 35.9 27.4 7.8 6.5

9.3 8.9 10.1 7.6 2.9 5.0 18.9 54.8 2.8

330 56 56 45 50 17 42 52 12

5830 475 774 699 3201 362 237 43 69

48.4 63.6 86.0 62.4 81.0 71.2 70.6 58.6 36.0

10.0 14.7 45.7 27.7 2.5 4.6 12.2 213.9 22.8

330 56 56 45 50 17 42 52 12

7102 837 995 1019 3027 673 601 62 286

63.3 64.0 77.0 58.5 67.6 73.8 53.3 62.8 26.2

10.7 15.6 15.8 9.4 4.1 6.8 13.6 192.2 4.0

ANNEXTa bl e( 3 ) :Tot a lCa s e sAdmi t t e dt oNa t i ona lPs y c hi a t r i cUni t ,Ki l u” uf iHos pi t a l( onl y ) 1997,1998 & 1999:

NEW

1. Schizophrenia 2. Manic Depression 3.Neurosis 4.Epilepsy with Psychosis

OLD

Total NEW

Male Femal Male Femal e e 1997 16 11 106 39

Total OLD

TOTA L

27

145

172

1998 1999 1997

3 4 2

4 1 1

11 17 15

10 9 9

7 5 3

21 26 24

28 31 27

1998 1999 1997 1998 1999 1997

5 1 16 0 3 2

4 1 2 1 3 2

5 6 2 0 2 8

3 4 2 11 0 4

9 2 18 10 6 4

8 10 4 11 2 12

17 12 22 21 8 16

1998

1

2

1

2

3

3

6

109

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======================================================= 1999 1 0 1 11 1 12 13 5. 1997 6 1 11 2 7 13 20 Psychosomatic Dis 1998 0 2 0 0 2 0 2 1999 6.Somatoform 1997 1 0 1 0 1 1 2 Dis 1998 1999 7.Transient 1997 3 2 2 4 5 6 11 Organ.Psych (organic cause) 1998 12 0 10 6 12 16 28 1999 2 0 2 0 2 0 2 8.Brief 1997 20 11 6 4 31 10 41 Reactive Psych 1998 1999 2 5 2 3 7 5 12 9.Mental 1997 0 retardation with psychosis 1998 1 1 2 3 2 5 7 1999 1 1 1 0 2 1 3 10.Post 1997 3 1 2 0 4 2 6 traumatice Dis 1998 1999 11.Attempted 1997 1 3 0 0 4 0 4 suicide 1998 1999 12Dementia 1997 1 0 2 0 1 2 3 1998 1999 13.Others 1997 4 4 3 11 8 14 22 1998 4 5 1 0 9 1 10 1999 0

110

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=======================================================

ANNEX Table (4): Total Cases seen and treated at the National Psychiatric Unit, Honiara, MOH/HQ in 1997, 1998 & 1999:

NEW

1. Schizophrenia * 2. Manic Depression* 3.Neurosis 4.Epilepsy with Psychosis 5. Psychosomatic Dis 6.Somatoform Dis 7.Organ.Psych (organic cause) 8.Brief Reactive Psych

OLD

Total NEW

Total OLD

TOTA L

Male Femal Male Femal e e 1997 16 11 106 39

27

145

172

1998 1999 1997

17 8 2

7 3 1

186 284 15

74 68 9

24 11 3

260 352 24

284 363 27

1998 1999 1997 1998 1999 1997

10 1 16 22 14 2

3 1 2 13 10 2

38 153 2 23 15 8

30 36 2 26 15 4

13 2 18 35 24 4

68 189 4 49 30 12

81 191 22 84 54 16

1998 1999 1997

2 0 6

2 1 1

36 31 11

3 4 2

4 1 7

39 35 13

43 36 20

1998 1999 1997

1 2 1

1 0 0

6 18 1

0 11 0

2 2 1

6 29 1

8 31 2

1998 1999 1997 1998 1999 1997

0 0 4 14 4 20

0 0 2 8 2 11

0 0 44 18 2 6

0 0 5 13 4

0 0 6 22 6 31

0 0 8 23 15 10

0 0 14 45 21 41

1998 1999

0 0

00 1

0 0

0 7

0 1

0 7

0 8

111

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 112 of 122

======================================================= 9.Mental 1997 0 0 0 0 0 0 0 retardation with psychosis 1998 0 0 0 0 0 0 0 1999 10.Post 1997 3 1 2 0 4 2 6 traumatice Dis 1998 0 0 0 0 0 0 0 1999 0 0 2 0 0 2 2 11.Attempted 1997 1 6 0 0 7 0 7 suicide 1998 1999 12.Postpartum 1997 Psychosis 1998 0 1 0 2 1 2 3 1999 0 0 0 1 0 1 1 13.Substance 1997 Abuse 1998 12 1 14 0 13 14 27 1997 5 1 10 1 6 11 17 13.Others 1997 4 4 3 11 8 14 22 1998 0 0 1 0 0 1 1 1999 4 15 24 13 19 37 56

ANNEX Table (5): Overall Total cases recorded at the National Psychiatric Units Kiluufi Hospital and Honiara in 1997, 1998 & 1999:

NEW Male 1. Schizophrenia 2. Manic Depression 3.Neurosis 4.Epilepsy

OLD

Total NEW

Total OLD

TOTA L

1997

Femal Male Femal e e 32 22 212 78

54

290

344

1998 1999 1997

20 12 4

11 4 2

197 301 30

84 77 18

31 16 6

281 378 48

312 394 54

1998 1999 1997 1998 1999 1997

15 2 32 22 17

7 2 4 14 13

43 159 4 23 17

33 40 4 37 15

22 4 36 45 30

76 199 8 60 32

98 203 44 105 62

112

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 113 of 122

======================================================= with Psychosis 1998 3 4 37 5 7 42 49 1999 1 1 32 15 2 47 49 5. 1997 Psychosomatic Dis 1998 1 3 6 0 4 6 10 1999 6.Somatoform 1997 7 4 6 8 11 14 25 Dis 1998 26 8 28 11 34 39 73 1999 6 2 4 13 8 15 23 7.Transient 1997 Organ.Psych (organic cause) 1998 1999 2 6 2 10 8 12 20 8.Brief 1997 Reactive Psych 1998 1999 9.Mental 1997 retardation with psychosis 1998 1999 10.Post 1997 traumatice Dis 1998 1999 11.Attempted 1997 suicide 1998 1999 12Dementia 1997 1998 1999 13.Substance 1997 Abuse 1998 12 1 14 0 13 14 27 1999 5 1 10 1 6 11 17 14.Others 1997 1998 4 5 2 0 9 2 11 1999

113

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=======================================================

ANNEX Table (6) Matrix of donor activities impacting directly on the Solomon Islands health sector: DONOR AGENCY

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

NEED FOR FORMAL COORDINATIO N

World Bank

Solomon Islands Makira and Guadalcanal Provinces

Solomon Islands Heath Sector Development Project ($4.5 –5.9m loan)

This Project is funded a sa“ Le a r ning and I nnov a t i onLoa n” project is at concept stage. It will pilot style activities with close monitoring and evaluation The project commenced in February 2000 The priority issues to be addressed include

The WB Project is collocated in the MHMS building with the Planning and Health Information staff. The most critical point of overlap with this Design and the WB Project exists in the activities associated with Health Management Information Systems. It was earlier expected that the WB Project would include the development of a Health Management Information System for MHMS but it is now being limited to the pilot projects

Yes –formal co-ordination on planning issues and Health Management information System at least will be essential.

 Maternal care and family planning including the development of midwifery training  Malaria prevention and control  Provincial health program management  Central capacity building and project support which will include Health Management Information System Development to support the Pilot Projects in the above mentioned service delivery

114

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======================================================= DONOR AGENCY

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

AusAID

Solomon Islands Ministry of Finance

Institutional Strengthening

Financial accounting The SIG is intending Yes systems in Ministry to introduce financial and other line agencies delegations to “ s t r a t e g i cl e v e l s ” within MHMS and other ministries. Restructuring of MHMS and capacity building within this project will prepare MHMS for this devolution of authority and accountability. . The development of management delegations and accountabilities will create requirements for financial management information There will need to be appropriate utilisation of the MoF accounting systems in order to accommodate MHMS requirements

AusAID

Solomon Islands Office of the Auditor General)

Institutional Strengthening Project $2.5 M

The principle objective is to improve overall accountability within the Public Sector

AusAID

Solomon Islands,

Scholarships Program $0.6 M

This program supports training of clinical health staff including  Diploma of Nursing at SICHE

115

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

Contact should be maintained, particularly with the matters regarding expenditure control, strengthened audit legislation Close liaison needed, especially in relation to the health workforce planning and HR development

NEED FOR FORMAL COORDINATIO N

Yes

Yes

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 116 of 122

======================================================= DONOR AGENCY

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

 Critical Care Nursing at Qld Uni  Dental Surgery at FSM  Medicine/Surgery at FSM  Post Grad Obs/Gyn at PNG

policies and programs, to be facilitated by the proposed new project.

The Environmental Health, Health Education and water supply and sanitation maintenance aspects of this RWSS project will need to be interfaced with the planning, and policy development aspects of this project. Coordination and learning from experience with maintenance issues will be useful for operational planning and implementation in Provincial Health services. This vector Borne disease control program interlinks with the MHMS

AusAID and cofunded by NZODA

Solomon Islands

Rural Water Supply and Sanitation $10.3m

Provision of Potable Water supply and sanitation facilities for rural communities This project will be drawing to close in 2001.

AusAID (CASP)

Solomon Islands

Malaria Control, Health education and

Annual provision of bed nets, anti malarial pharmaceuticals, larvicide and fogging

116

NEED FOR FORMAL COORDINATIO N

Potential for candidates to be identified for training in support of the operational management initiatives of this project and the workforce planning strategies which will be developed. Yes

Informal

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======================================================= DONOR AGENCY

AusAID

AusAID

AusAID (Regional)

AusAID (Regional)

AusAID (Regional)

LOCATION OF ACTIVITY

Regional program including the Solomon Islands Regional program including the Solomon Islands Regional program including the Solomon Islands Regional program including the Solomon Islands Regional Program including Solomon Islands

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

Education supplies

chemicals

Hepatitis B Project ($2.0m)

Hepatitis B immunisation (19972000)

policy development processes and the effective operational planning and implementation within the Provincial Health services. Hepatitis B immunisation

Vector-Borne Diseases Control Project ($10)

Assists with programmed medical and environmental health services and introduction of vector control mechanisms. Pacific Action The project is for Health designed to provide ($3.4mil) preventive and health promotional support at community, national and regional levels. Pacific Islands Supports and TA to AIDS and STD national programs in Prevention relation to STD and Programme) AIDFS education, prevention, treatment and care. Integrated Funding provide Community through World Vision. Health Project Objective was to Kia/Kotova improve quality of life and Maringe for about 8000 areas councils villagers through the in Isabel development of an Province integrated community health programme.

117

NEED FOR FORMAL COORDINATIO N

Informal

Malaria and other vector-borne diseases

Informal

NCD’ spa r t i c ul a r l y those linked with tobacco and alcohol

Informal

STD and HIV/AIDS

Informal

Village health care, access to watersupply, literacy, improved agriculture and environmental health.

Informal

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======================================================= DONOR AGENCY

AusAID (Regional)

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

Project will cease in 2000 Project implemented by Family Planning Australia 1994-2000

Regional Programme including Solomon Islands Regional Programme including Solomon Islands

Family Planning regional development ($0.63mil) Family Planning regional development (Proposed $2.7mil)

AusAID (Regional)

Regional Program including Solomon Islands

Tertiary Health Volunteer medical Care Provision teams offering Project specialist services and local capacity building through on-the-job training in Plastic and reconstructive surgery, neurology, eye care and paediatric surgery

NZODA

Honiara and Family Health other urban Project ($0.3 areas Mil pa) Solomon Islands

Reproductive health and family planning including program development and IEC production

NZODA

Solomon Islands

Scheme operates through National Training Unit in

AusAID (Regional)

Training Scholarships

Project to be extended to facilitate inclusion of family planning training into formal curriculum for nurses and teachers To be implemented by Family Planning Australia 1999-2004

118

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

NEED FOR FORMAL COORDINATIO N

Strengthening family planning organisation finances training and administration.

Informal

Strengthening family planning organisation finances training and administration. This has policy development implications and rural health service management proposals which are relevant As the majority of these services are provided in the National Referral hospital it will be essential to ensure this program is accommodated and not disrupted by the NRH Management Strengthening Component of this Project Sexual health for urban youth and peer education in squatter settlements to be implemented in association with churches Potential for candidates to be identified for training

Informal

Yes

Informal

Yes

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======================================================= DONOR AGENCY

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

NEED FOR FORMAL COORDINATIO N

Ministry of Education in support of the and is targeted at nurse operational training. management initiatives of this project and the workforce planning strategies which will be developed. NZODA

Solomon Islands

JICA

Solomon Islands

Rural Health Facilities Rehabilitation Project $15 m

ADB

Solomon Islands Village areas

Population and Family Planning

ADB

Solomon Islands

Public Sector Executive

To assist with treatment of patients for which specialist treatment is not available in Solomon Islands Construction and equipping of facilities including a possible new hospital at Choiseul Bay, a larger new hospital at Gizo and selected upgrading of other Provincial Health facilities

Specialist treatment in New Zealand. Need to maintain liaison.

Informal

Project Design and Yes functional brief completed by MHMS. Project has policy development implications and rural health service management proposals which are relevant to Project. Eventual design needs to be understood by this Project and appropriate coordination maintained.

Reproductive Health It is understood this Informal including development project will function in of IEC materials cooperation with the NZODA to minimise duplication and will involve churches. Management Part of a larger Public Yes education programme Sector Reform Project

119

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======================================================= DONOR AGENCY

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

development Program

for Senior Public Servants.

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

operating from the Institutional Strengthening Unit of t hePr i meMi ni s t e r ’ s Department t supported by ADB Frameworks and Linkages exist with a technical assistance for number of SHP projects to promote: components. Healthy Islands, Health Promoting Schools, New Horizons in Health

NEED FOR FORMAL COORDINATIO N

WHO

Solomon Islands

WHO ongoing Role

WHO

Solomon Islands Country Programme

Human Resources Development

Funding of fellowships Potential for candidates to be identified for training in support of the operational management initiatives of this project and the workforce planning strategies which will be developed.

Yes

WHO

Solomon Islands

Malaria control

Informal

WHO

Solomon Islands

Vector Borne Disease Programme ($200k Water Supply and sanitation ($140k)

Funding of workshops, training and fellowships for Health Inspectors.

Informal

WHO

Solomon Islands

Primary Health Health education and Care promotion including development of IEC materials. Provides fellowships, limited

120

Yes

Informal

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======================================================= DONOR AGENCY

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

supplies and materials and WHO office running costs. Provision of contraceptive material for family planning training. Scholarships for midwifery/paediatric nurse training.

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

NEED FOR FORMAL COORDINATIO N

Population awareness activities in Family Planning and Maternal and Child Health No authoritative documentation available

Informal

UNFPA

Solomon Islands

Reproductive Health

UNFPA

Solomon Islands

Dispossessed Youth Project ($44k)

No authoritative document available.

UNFPA

Solomon Islands

IEC Project (80k)

No authoritative document available

European Union

Solomon Islands Health planning Unit and National Census Office Solomon Island National referral hospital

National Census

Demographic and health data collection and analysis.

Census conducted during November 1999 with preliminary reports anticipated in mid 2000

Phase III upgrade of National Referral Hospital ($1.7mill)

To implement Phase III of the Hospital refurbishment and upgrading.

Solomon Islands

Child Protection

Incorporates child protection, community

Scope of works Yes anticipated still unclear. Vital that the planing and operational aspects of this capital works are clearly appreciated by this project. Project should be monitored to determine if any cooperation possible SCF normally operates Yes to learn with a government or from NGO

Republic of China

Save the Children

121

Pilot one year project to target unemployment, substance abuse and sexual health.

Yes

Ministry of Health National Health Report Review Evaluation of Health Status 1997-99 122 of 122

======================================================= DONOR AGENCY

LOCATION OF ACTIVITY

PROJECT TITLE & DOLLAR VALUE

BRIEF DESCRIPTION OF PROJECT (including commencement & completion date)

COMPLEMENTARY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENING PROJECT

NEED FOR FORMAL COORDINATIO N

Fund

country Program mainly funded by AusAID

Project

based rehabilitation and a youth outreach programme and family support centre.

NGO partner and provides funding and project management and administrative support

arrangements

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