Strong and competent health systems are needed to achieve the health outcomes articulated in the Millennium Declaration. The past decade has seen a steady increase in the funds available for the health sector in large parts of the developing world. In spite of this increase the desired health outcomes are not being reached. Weak health systems are an obstacle to achieving the maximum health benefit possible from the resources available.
There are many reasons why health systems are weak and these vary from country to country. No single diagnosis fits all situations. However, the issues include under-funding, lack of coordination, inefficient management, lack of human resources of sufficient quality and quantity, inaccessibility to appropriate technologies, and inadequate information for decision making. Frequently short-term interventions and projects are designed which essentially bypass the health system. There is a growing consensus that additional attention is needed to strengthen health systems.
The health systems in the Pacific Island Countries represent great diversity and different stages of development related to their past and current affiliations to the Commonwealth, France and USA.
In the three French areas and territories (French Polynesia, New Caledonia and Wallis and Futuna), the health system is based on the French system, and most funding is provided through the French government. The population has universal access to heath at all levels of health care through a social health insurance scheme. Overall, the system has adequate number of health professionals, nearly all of whom are trained in France.
Under the Compact Agreements with the three countries affiliated with the United States (Marshall Islands, the Federated States of Micronesia and Palau), the health services are supported to different degree by grants from the Federal government of the United States and have access to United States technical agencies. In the Northern Mariana Islands, which is under United States administration as part of the UN Trust Territory of the Pacific, the health system is fully funded by the United States. Health expenditure per capita is high in all these countries. These funding sources influence management and organization of health services and also the training and registration requirements for health professionals.
Countries in the Commonwealth-based group are independent states with historical development of British colonial health system. Countries mainly fund their own health services with support from the Australian Agency for International Development (AusAID) and New Zealand Agency for International Development (NZAID). Generally, health services are free at the point of care.
In Vanuatu, since its independence, there has been an amalgamation of the French and English systems. This process of reform is still evolving.
The major challenge is the provision of service to a population that is scattered over many islands. The logistical problems of ensuring reliable, uninterrupted and good quality primary health care on remote outer islands include infrequent transport links, costly communication and high operational cost. In some countries development efforts may bypass poor or most disadvantaged regions, and services (when they are available) are of low quality, especially for the poor. Logistics is contributing to the disparity in service delivery. For instance Kiribati consists of 33 coral atolls including three island groups, which span over a distance of approximately 5000 kms.
The inadequate coverage of secondary and tertiary care services makes medical evacuations a common feature of the health systems in all Pacific countries. Many patients cannot be evacuated and treated for shortage of funding.
The quality of health services is difficult to assess because there is no agreement on standards or guidelines for best practices. Countries now need to expand the objectives of the health system from coverage of services to quality of care.
Role of traditional healers varies widely across the Pacific. The traditional practices need to be catalogued and reviewed as regards to harms and benefits of these practices.
The use of e-health/telemedicine, which could alleviate some of the coverage issues are limited in the PICs. Evidence from the Solomon Islands experience has demonstrated the value of tele-pathology in improving health services and reducing the need for out of country referrals.
Most PICs provide free health care to all citizens financed by government. This guarantees a relatively fair health system in many countries in terms of financial access (geographic access remains a big problem for large groups). Health care financing continues to be a major issue for many governments. The level of health spending in PICs in general is still insufficient to address the many health challenges. Many health systems are dependent on donors’ funding for public health functions and for human resource development. A few countries, including Samoa and Tonga have conducted National Health Accounts in order to establish the overall expenditure on health care, and Fiji has also indicated interest in this.
With minor exceptions, the primary health care services in the PICs have been either free of charge or heavily subsidized by the Governments. However, the percentage of out-of pocket payments, especially for drugs and specialized health services varies, and can reach up to 35 percent of total health spending (Fiji, Vanuatu).
Several Governments including Fiji are developing health insurance schemes, encouraging both commercial and community social health insurance systems. Currently the level of pre-payment schemes (health insurance) is low and those that exist are all limited to selected groups such as government employees. Social health insurance (when the entire population is covered through a pre-payment system) has implementation problems because the formal workforce and the tax base is small in most countries, and effective mechanisms for collecting health insurance fees are difficult to establish.
WHO recognizes the need of Member States to strengthen their health systems and the need of WHO to improve its own capacity to assist them in doing so. WHO has produced a draft health system strengthening (HSS) strategy entitled "Everybody's Business: Strengthening Health Systems to Improve Health Outcomes – WHO's Framework for Action", Six key building blocks of health systems are identified:
- service delivery;
- medical products and technologies;
- health workforce;
- financing; and
- leadership and governance (stewardship).
The framework calls for WHO to emphasize achieving (and measuring) results in health systems strengthening. The global WHO HSS Framework provides a strategic vision for WHO and is being currently translated into concrete actions that can be taken by the Pacific Island Countries.
WHO in the Western Pacific Region aims to reduce the impact of emergency situations and disasters through inter-sectoral collaborative efforts. In particular, WHO continues to collaborate with Member States to develop and enhance regional, national and community mechanisms: to strengthen the emergency management capacity of the health sector. Collaborative activities with national governments, other agencies, regional institutions, donors and non governmental organizations ensure that limited resources are spent in a coordinated and cost effective way. WHO will continue to work with its partners to reduce mortality, morbidity, and disability related to emergencies and disasters.
The focus of WHO's work in the Pacific is to support countries in attaining health financing goals by gathering evidence for policy making. The tracking of health expenditures is the basis to do so – this is why we promote and support the introduction and sustaining of National Health Accounts (NHA) in the Pacific.
This programme is focused on improving health services through appropriate training of health staff and the development of appropriate and sustainable health care financing mechanisms. The main strategies and approaches are to identify specific health care financing issues and problems where WHO can intervene effectively; to enhance knowledge of overall health financing arrangements; social health insurance, National Health Accounts (NHA), financial planning and management; to support capacity-building activities and the development of a master plan with external partners. In the area of policy and legislation, the aim is to provide a framework or an environment that will enable the provision of high-quality public health and clinical services, and to provide mechanisms that enable action to ensure safety.
Laboratory support has been recognized to be the essential part of many technical programmes. Clinical and Public Health laboratories are indispensable in supporting, the prevention, surveillance and control of communicable diseases, including HIV/STI, blood transfusion services, non-communicable diseases, maternal and child health, environmental health, safe water supply, food safety and other technical programmes. Therefore, development and strengthening of the laboratory services, and provision of quality laboratory results by both, clinical and public health laboratories is considered as one of the priorities under the health system strengthening strategy. Most Pacific Island countries would not be able to sustain a dedicated public health laboratory (although all provide at least basic clinical diagnostic services). Under the regional Pacific Public Health Surveillance Network (PPHSN), Laboratory Network (LabNet) was established as an arm to provide rapid laboratory diagnosis and confirmation of outbreak prone diseases. The scope of LabNet grew broader from originally six selected diseases (dengue, measles, influenza, leptospirosis, cholera and typhoid), and will in future cover broader gamut of public health conditions and emergencies. The laboratories are in three tiers, level 1 (L1) laboratories ensuring the initial testing, followed by confirmation and detailed causative agents typing in level 2 and level 3 laboratories. The ‘Level 2’ public health laboratories (in Fiji Islands, French Polynesia, Guam, and New Caledonia) are further supported, when necessary, by Level 3 reference laboratories on the Pacific-rim countries. The LabNet ‘Level’ refers to functional level within the LabNet initiative, not to level of capacity or competence. The LabNet is coordinated by the Technical Working Body, comprising Institut Pasteur de Nouvelle-Calédonie (IPNC), SPC and WHO. The Region has got the advantage of having the LabNet, which is widely recognized as the m
This programme aims at strengthening the capacity of Pacific Island Countries (PICs) to ensure health workforces are responsive to population and health service needs and contribute to the enhancement of health systems performance and quality of care. The World Health Report 2006 is dedicated to the current global crisis in human resources and states as the workforce goal – to get the right workers with the right skills in the right place doing the right things. http://www.who.int/whr/2006/en/ . The loss of skilled health personnel through migration continues to be a concern in Pacific Islands and has serious implications for the health of the people of the Pacific. The need for country specific solutions as well as regional cooperation and partnerships is acknowledged in the support provided towards effective management of migration. The programme focuses on three main areas critical to human resources development: workforce planning and management; appropriate education and training needs analysis.
Essential medicines save lives, reduce suffering, and improve health but only if they are of good quality and are safe, available, affordable and properly used. Essential medicines are medicines that satisfy the health care needs of the majority of the population. However, in many countries today not all these conditions are being met.