Health Report 2000 -Solomon Islands | Solomon Islands | Maternal Death

MINISTRY OF HEALTH SOLOMON ISLANDS

Solomon Islands Government

NATIONAL ANNUAL HEALTH REPORT 2000

Review of Work of Ministry of Health, Solomon Islands 2000

October 2001 © Lester Ross, George Malefoasi, Dennie Iniakwala, Peter Wale & Abraham Namokari Ministry of Health P.O.Box 349 Honiara Solomon Islands

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TABLE OF CONTENTS

SECTION 1: GENERAL INFORMATION ................................................................ 4
1.1. INTRODUCTION: .................................................................................................................................... 5 1.2. THE PERMANENT SECRETARY’REMARKS: ......................................................................................... 5 S

SECTION 2: ENVIRONMENTAL SITUATION ................................. 8
2.1. BACKGROUND: ..................................................................................................................................... 8 2.2. THE POLITICAL SYSTEM: ...................................................................................................................... 9 2.3. THE ECONOMY: .................................................................................................................................. 10 2.4. FACTORS AFFECTING SERVICE DELIVERY:......................................................................................... 10
2.4.1. External Factors:...................................................................................................................................... 10 2.4.2. Impact of the Ethnic Conflict on the Health Services Delivery- April 1999-October 2000:.................... 12

2.5. INTERNAL FACTORS: .......................................................................................................................... 15
2.5.1. Management & Planning of Health Services:.............................................................................................. 15 2.5.2. Human Resource Management and Development:..................................................................................... 16 2.5.3. Health Legislation:..................................................................................................................................... 16 2.5.4. Health Financing & Budgeting and Resource Allocation Factors: ............................................................... 16 Table (7) Total government budget and the allocations from 1988 to 2000:.................................... 17 Table (8) Distribution of the Recurrent Health Budget 1991-19 (B $00 ............................. 17 99 S D ’0) 2.5.5. Structural Reform: ..................................................................................................................................... 18 2.5.6. Important Elements in Reform: ................................................................................................................. 19

SECTION 3: TECHNICAL MATTERS-COMBATING COMMUNICABLE DISEASES ............................................................................... 20
3.1. OVERVIEW: ........................................................................................................................... 20 3.2: ROLL BACK MALARIA ........................................................................................... 20
3.2.1. THE VECTOR BORNE DISEASE CONTROL PROGRAMME- THE MALARIA CONTROL PROGRAMME – N OVERVIEW ............................................................................................................. 20 A

3.2.1.1. MALARIA SITUATION IN HONIARA, 1991 TO 2000........................... 20 3.2.1.2. MALARIA SITUATION IN THE PROVINCES, 1991 - 2000 .................. 21
1) PROVINCES WITH DECLINING OR STABLE TRANSMISSION ....................................................................... 22 2) PROVINCES WITH SIGNS OF INCREASING TRANSMISSION ........................................................................ 23 C) PROVINCES WITH INSUFFICIENT INFORMATION ..................................................................................... 24 3.2.2. BRIEF REPORT OF MALARIA IN SOLOMON ISLANDS (2000) AND THE IMPACT OF THE ETHNIC CRISIS: ..................................................................................................................................... 25

3.3. STOP TUBERCULOSIS ................................................................................................. 27
Graph Showing New Case Notification for Leprosy 2000............................................................... 30 Table ( ) Provincial Leprosy CaseLoads and prevalence: ................................................................ 30 Graph ( ) Leprosy Prevalence 1997-2000......................................................................................... 31

3.4. STI/ HIV/AIDS: ................................................................................................................... 31
3.4.1. STI/HIV/AIDS PROGRAM:.............................................................................................................. 32

3.5. VACCINE PREVENTABLE DISEASES: ..................................................... 34
3.5.1. NATIONAL DISEASE SURVEILLANCE: .............................................................................................. 34
Graph (1) showing incidence of vaccine preventable Illnesses in SI 1997-99 ................................. 34 Graph (2) showing incidence of vaccine preventable illnesses by provinces in 1997-99:................ 35

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2.6. THE HEALTHY ISLANDS, HEALTH CITY, INITIATIVES: .. 36
2.6.1. General view: ......................................................................................................................................... 36 3.6.2. Health and Environment....................................................................................................................... 38 3.6.2.1. General protection of the environment............................................................................................. 38 3.6.2.2. Air (pollution)................................................................................................................................... 38 3.6.2.3. Water quality .................................................................................................................................... 38 3.6.2.4. Solid waste disposal ......................................................................................................................... 39 Water supply and sanitation Indicators................................................................................................. 39 3.6.2.5. Food safety ....................................................................................................................................... 39 3.62.6. Housing ............................................................................................................................................. 41 3.6.2.7. Work place........................................................................................................................................ 41

3.7. INFANT AND YOUNG CHILD NUTRITION: ......................................... 41 3.8. REPRODUCTIVE HEALTH AND FAMILY PLANNING .......... 42
3.8.1. Maternal Mortality:............................................................................................................................. 43 Table (1) showing Maternal Mortality Rate/ 100,000 births ............................................................ 43 3.8.2. Strengthening nursing and midwifery: ........................................................................................................ 43 3.8.3. Family Planning:................................................................................................................................. 45 Table (2) Family Planning Coverage (%) total users at end of December/wcba x 100):.................. 45 Graph (3) showing FP coverage by end of December 1997,1998, 1999 & 2000: ............................ 46 Table (3) % Supervised deliveries: .................................................................................................. 46 Table (4) Antenatal Coverage: First antenatal attendance (% first visit / expected births).............. 46 Graph (4) showing antenatal coverage (1st visit/ expected births 1997-2000:.................................. 47 Table (5) Total Fertility Rates 1986,1996,1998: .............................................................................. 47 Table () FERTILITY RATES BY PROVINCES FROM 1997 TO 2000 (births/ 1000 popWCBA. 47

3.9. NON-COMMUNICABLE DISEASES (INCLUDING MENTAL HEALTH): .......................................................................................................................................... 50

3.9.1. PREVENTION AND CONTROL OF NON-COMMUNICABLE DISEASES: .......................................................................................................................................... 50 3.9.2. MENTAL HEALTH SERVICES ......................................................................... 52
3.9.2.1. Activities:................................................................................................................................................ 52 3.9.2.2. Findings (Outputs):................................................................................................................................. 53 Table (6): Total Cases Admitted to .................................................................................................. 53 N t nl scir U i Kl ui op a(n )N19, 9, 19. aoaPyh tc n , i ’fH silol I 97 98 99 i ai t u t y 1 & ..................................... 53 3.9.2.3. Analysis: ................................................................................................................................................. 53 3.9.2.5. Major Issues/ problems & recommendations: ........................................................................................ 54

3.9.3. INITIATIVE TOWARDS TOBACCO CONTROL: .............................. 54
3.9.3.1. Tobacco Free Initiative ........................................................................................................................... 54

3.10. STRENGTHENING HEALTH SYSTEMS IN SOLOMON ISLANDS: ............................................................................................................................................ 55
3.10.1. Proposed Health Reform: ........................................................................................................................ 55 3.10.4. Essential drugs and medicines policies:..................................................................................................... 59 3.10.5. Traditional Medicine: ............................................................................................................................... 61

3.11 TECHNICAL COOPERATION AMONG DEVELOPING COUNTRIES: ................................................................................................................................... 61
Table ( 10)Matrix of Current Donor Activity Impacting Directly on the Solomon Islands Health Sector: .............................................................................................................................................. 62

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Emergency Support given by the World Health Organization (WHO) to the Ministry of Health and Medical Services, Solomon Islands Government .............................................................................................................. 69

3. 12. ERADICATION OF POLIOMYELITIS: ....................................................... 71 3.13. HEALTH PROMOTION:........................................................................................... 72 3.14. EMERGENCY AND HUMANITARIAN ACTION: .............................. 74 4.0. CONCLUSION:..................................................................................................................... 74
ANNEX 1------------------------------.......................................................................... 76

SECTION 1: GENERAL INFORMATION

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1.1. Introduction:

12 T eP r n n S ceaysR mak : .. h ema e t e rtr’ e rs

Aim: It is a great opportunity and honor for me to present the National Health Report 2000. The intention of this report is to inform every one including the public, of the challenges, external threats, difficulties the health care system in Solomon Islands had gone through in the past 12 months of 2000 achievements. This report also stresses the key issues as experienced and observed in 2000. Key Issues: The political and socio-economical factors had a significant pressure and threat on the health system. These external factors accentuate the existing structural weaknesses of the public health sector. The impact of the devastating effects of the above external factors was seen in areas of funding of health services delivery and essential medical supplies to the people of the country. The twenty-months ethnic tension, which saw its height on June 5th 2000 was the prime factor for the all the adverse impact on health services delivery both at the National Referral Hospital and all through out the provinces. [Political and Socio-economical issues] Health managers at the national, provincial and institutional levels were under tremendous pressure to ensure that health care services are maintained during the difficult times. It was a time when serious thoughts were made between personal safety and service for the people and between professional ethics and personal safety. Staff management was d fu, hnt r w sei a f r o s e . an into tecm i et f ii l w e h e a l t t e fr a t H d’ t o fr h o mt n o fc t e gi e a m fy t m many health workers it could have been an anarchy in health in 2000.

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[staff management issues]

Health funding was practically not there. Like other many public services, provincial health grants were not paid on time or paid at all in a few service areas. Lack of payment of provincial wages led to low staff morale and even closure to a few clinics. Debts with the two main overseas buying agents for medicine led to cessation to supply medical orders from us. There was obvious lack of commitment to maintain the purchasing power for essential medicines despite an approval by Cabinet (Paper by the Minister of Health) to debt service the overseas buying agents concern. [Health Funding issues]

The health reform initiatives by the Solomon Islands Government through the Ministry of Health in its pan for 1999-20031 came under pressure in 2000. The issues were related to getting a coalition and understanding with key stakeholders such as the Department of Finance and Public Services Division. Nonetheless, there were some success in creation of a new Chief Executive Officers Post at the National Referral Hospital, and other key positions vital for the structural reform at the Planning and Accounting Division. However, the implementation of the structural reform was interrupted by the difficult imposed by the surrounding milieu, which was such that was not conducive for any reform to be smoothly implemented. [Health Institutional Strengthening implementation issues-change management]

There were obvious and practical issues and problems related actual services delivery and impact of the surrounding milieu to the health status of the people. There were obvious interruption of both curative (health institutional) and (community based) health protection and prevention programs. Malaria was reported be on the rise again in some provinces, particularly on Guadalcanal. Maternal Mortality rate shows an increase again on Guadalcanal, which is directly affected by the ethnic tension. Prevention programs such as antennal and
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MOH (2000). National Health Policies and Development Plans 1999-2003.

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family planning coverage showed significant reduction. Demand for health services on Malaita increased as a result of exodus of some 20,000 Malaitans from Guadalcanal Islands. The Pharmacy Services Division reported an increase of 20% drug usage on Malaita a lone. [Disruption of health services issues as a result of the conflict] Recent (2000) health statistics and data showed some decline in most service delivery coverage including family planning, antenatal care, and immunization. The recent Census 1999 revealed a very high infant mortality rate of 66/ 1,000 live births (higher than the WHO target of 50/1,000 live birth. [Health Status Issues]

Achievements:: The year 2000 was difficult year to achieve any health objectives stipulated in the targets of the National Health Policies and Plans 1999-2003. There was not much development but more or less crisis management. However, there were some moments of achievements. The most important achievement is the maintenance of essential health care services all through out the country during the twelve months old conflict. Despite its erratic ness and difficulties clinics and hospitals were open. Essential medicine somehow passed through the battle frontline to the people in desperate need. [Continuous health care services delivery despite the tension] The Solomon Islands Health Sector Development Project approved and signed late 1999, started its implementation begging of 2000. Despite its interruption in the mid year, some activities continued there after. The priority issues to be addressed include; 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. [Inception of the Solomon Islands Health Sector Development Project/ World Bank Loan]

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The Solomon Islands reached the Polio-free status in 2000. Solomon Islands joined other member states to signed and announced during a WHO Regional session in Kyoto, Japan a polio-free status in the Western Pacific Region. Nonetheless, Solomon Islands is committed to continue its national polio and flaccid paralysis surveillance. There is no place for compliancy. [Solomon Islands Polio-Free]

SECTION 2: ENVIRONMENTAL SITUATION

2.1. Background: Solomon Islands is a nation of island villages scattered over 800,000 square kilometers of sea. It is a home to people of many races, cultures, languages and customs. The predominant race is Melanesians (93.3%) followed by Polynesians (4%), Micronesians (1.5%) and others 1.2%. The nation has a landmass of 28,369 square kilometers. It consists of six major island groups with thousands of

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small islands, which are divided, into nine provinces plus Honiara the capital, which is a separate municipal authority. Some 25% of land are considered arable. Climate and geography impose constraints on development; the population is dispersed throughout the islands and equitable access to services, resources and income has proved difficult to achieve. As part of the Pacific rim of fire and being inside the cyclone belt, Solomon Islands is susceptible to natural disasters; mainly earthquakes, landslides, cyclones and flooding, resulting in the destruction of homes, food crops and sometimes lives. This, plus the scattered nature of the islands with their small isolated villages imposes significant cnti s n h cut ’dvl m n ad rv i o s v e fr o e ad hde. osa to t on y ee p etn poio fe i so w m n n cir rn e rs o sn rc l n Indicator Total Population Population growth Rate Total Fertility Rate Crude Death Rate Crude Birth Rate Infant mortality Rate Life Expectancy Population density Average household-hold size 1970(a) 160,998 3.4 7.4 10 45 67 54 1986(a) 285,176 3.5% 6.1 10 42 38 60 1999 (b) 409,042* 2.8* 4.8** 7 38 38 65 13 6.3

(a) From government census report (1976, 1986) ministry of finance, statistic office (b) Estimate from World Bank reports (world bank 1994 Health Priorities and Options in Pacific Member Countries. (*) National Population Census 1999 (**) UNFPA Source

The population is largely young, dependent and rural. Some 48% are under 15 years old. 18% is under five years old. With such a young population it can be expected that there will be a high population growth rate for many years to come, irrespective of reproductive co e w i l dt f e cir , e gbr i t a’ f i s Fml p ni hi s h h e o e r hde bi on n o y a l . a i l n g c, c a w l n n d s mi e y a n acceptance is currently estimated at about 12% of women of childbearing age. More than 80% of the people still live in rural areas, although urbanization, especially in the capital Honiara, is growing at 7% a year. Melanesians from 94% of the population, Polynesians 4%, Micronesians 1% and Chinese and Europeans 1%. The majority of Solomon Islanders are Christians (90%). Although Christianity has had a profound influence, traditional social structures and customs remain important. Kinship, traced partrilinearly amongst some peoples but most commonly matrilinearly, remains the basis of Solomon Islands culture. About 87 distinct languages are spoken throughout the country. Pidgin is the lingua France and English is the official language. Dissemination of information can be a challenge in the Solomon Islands. 2.2. The Political System:

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The Solomon Island, which gained independence from Great Britain on the 7th July 1978, is a sovereign democratic state and has a linicameral legislature, The National Parliament with 50 elected members. It is administratively divided into nine (9) Provinces and a municipal authority, with their own political and administrative establishment, resembling the Federal system of government. The Parliament members are elected on political party basis or as independents, on a four yearly term. The Solomon Islands as a member of the Commonwealth, the British Monarch, as Head of State, is represented locally by a Governor-General, who is recommended to the Queen by the National Parliament. The governmental and political institutions of Solomon Islands are firmly established in theory and practice on principles and systems of governance, with an exemplary record on human rights constant with the high ideals of the United Nations Charter. Political stability, civil order, harmonious ethic religious relations and peaceful social environment were the characteristics of the Solomon Islands, both in relations to regional and neighbors. There is a strong move towards Federal and Statehood system of government. The government is currently looking into this idea. Sooner or later it may come as a parliament bill. The Ministry is carefully monitoring this move as it may have significant impact in management and service delivery. 2.3. The Economy: Since independence in 1978 Solomon Islands has struggled to develop its economy, to build infrastructure and to provide services to its 409,042 (1999 Census) people who live in 65,014 households in widely dispersed villages. 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 ethnic tension on Guadalcanal has had significant adverse effect on the eoo yo t cut. sar u, o m n Iad’ ur tptr o eoo i cnm f h onr A e y e l Sl o sns cr n ae f cnmc st o l e tn development, which was dominated by large-scale logging, mining, fisheries and agricultural projects financed by foreign capital fell dramatically. The devastation of the economy gives rise to risk to the health of the people especially to lives of women and children. T eG vrm n’ r eu clco fl yhl cm a dt 19. rv c l h oe et e ne oetn e b a, o pr o 98 Poi i n s v li l f e na health and wages grants are not paid for several months. Recently there is a regular untimely py et f ul s vn ’a rs n w gsT e ia ov u f ac ln eoo i am n o pbc e at sae ad ae hr s n bi si ni ad cnmc i r s li . e o n a crisis, which threatens the health service delivery of the country. The Solomon Islands Government through the Ministry of Health is currently supported by the Australian Government though the AusAID Trust Fund, which helps the ministry to maintain basic health care services delivery to the people.

2.4. Factors Affecting Service Delivery: 2.4.1. External Factors: The external factors affecting health services delivery in the country are related to its geography, socioeconomic status, demographic and environmental, political and

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infrastructure characteristics. We have recognized that the socioeconomic and demographic trends as major factors affecting health services in the country. Whilst the environmental, political and infrastructure factors generally affect the health service delivery to a lesser extend. Solomon Islands is growing at a declining rate, 3.5% in 1986 (2.8% in 1999) with a total fertility rate of 6.1 in 1986 to 4.8 in 1999, crude birth rate of 42 per 1,000 poppulation 2 in 1986 to 38/1000 pop. In 1999, and crude death rate of 10 per 1,000 in 1986 to 7/1,000 in 1999. Despite some improvements it is still very high by international standard. The diversity of the composition of the Solomon Islands population implied the diversity and complexity of health needs by different socio-cultural background. Therefore interpretation of health need may be different, that calls for selective and strategic planning to allow for the demand-supply theory to determine of resources distribution. The public health sector in the country is labor intensive having very minimal or no modern technology that fosters efficiency and increase productivity of health institutions. Nonetheless, there are opportunities yet to be exploited by the Solomon Islands public health sector. For this reasons, the Solomon Island health sector is adventuring into practical, feasible, simple and cost-effective ways of mobilizing local resource inorder to permeate the ‘na et bre ’ n caegso t hahs trbt f m teet nl n f dm n l a is ad hlne n h el e o, oh r h x ra ad u a rr l e t c ,o e internal influences mentioned above, to allow the dominant public health sector to reach out to the vulnerable people which are the women and children of the nation, effectively. The m j i o nt n ppli ( ot 0 a rr d ee , e i s n i n mg t n a ry f ao’ ou tn a u 8%)r ua w lr ds t i i at iao ot i s ao b e l ls p e g f c ri from rural areas into the capital. The health implication of these demographic trends is that the demand for health service by the age group of less than 1 to 4 years old and female of childbearing age is high and expected to increase in the next five to ten years. It has alerted SIG to focus on health services towards this category of age group. The SIG is also faced with challenges of maintaining primary health care services at t cm ui l e wt t l idr or sag vt b uw n d‘hi t s n h o m ny e l i h i t e uc , gr a d y n at e n e i ’ e t vs h e m e s e a e e t c no currently experienced by the country. Coupled with the increasing demand for higher level of secondary and tertiary health care services at the capital and other urban areas. The ethnic tension on Guadalcanal Islands has significantly affected health services delivery. There was migration within Guadalcanal to other provinces. Demand of health services rose in many provinces. Follow up immunization of children were not received. TB patients on second phase of treatment were delayed. Health clinic facilities and equipments in some clinics were either stolen or damaged. Malaria control programs on Guadalcanal were badly affected. In response the Ministry of Health drew up rehabilitation programs. However, it is encouraging to note here that despite the difficulties on the Island, primary health care was maintained all through the height of the conflict. Clinics were kept opened as much as possible. Drugs and necessary supplies were sent in, from the center to the peripheral clinics under very difficult circumstances with the help from some local

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people and the International Red Cross. Communications links through 2-way radio were kept opened with clinics. 2.4.2. Impact of the Ethnic Conflict on the Health Services Delivery- April 1999-October 2000: The major impact of the conflict on the Health Service Delivery System, is the inability of the system to deal with such situation as it has never been planned for or even experienced in the past. The majority of the activities planned are reactive to the situation as well as through other organization such as the Red Cross and the National Disaster Council. However, the impact of the conflict on the health service delivery can be outlined as follows: During Height of the Conflict:  During the height of the tension, concentration of displaced population in care centers, public buildings or other settlements has been a challenge to the system. This challenge has been alleviated with the help of the Red Cross society. The risk of acute respiratory infections, diarrhea and dysentery, measles and other epidemics is high in such cases, however, such risks were averted due to formation of a mobile team by the Health Division of the Honiara City Council, who regularly visit these care centers.  Armed attacks, during the height of the tension, in addition to targeting the civilian population, damaged key infrastructures such as homes, roads, water supply, communication and even health facilities. These infrastructures are crucial for effective health delivery on Guadalcanal.  Due to insecurity and military operations on Guadalcanal access are restricted to large areas of territory and constrain the delivery of health services, as well as general response and recovery operations. Supplies of drugs and essential medical supplies were virtually ceased in restricted areas. Communications to health facilities were also proven difficult.  Armed men entered the National Referral Hospital and fatally shot two militants in July 2000, while recovering in the hospital. This causes fears among the staff as well as the general public. Hospital staff refuses to attend to duties and the surgical ward was closed and services were confined to emergency cases only. Hospital admission was drastically reduced with a bed capacity rate that dropped from above 80% in January 2000 to approximately 36% in July 2000. Outpatient attendants dropped from approximately 100 patients per day to about 30 patient per day in July/August 2000. There is lack of public confidence in the safety of the hospital.  More patients were attending provincial hospital. Gizo hospital in the Western Poi eadKlui opa i Ma i Poi er ot a ot tp rv c n i’ hsiln lt rv c e r d l s a r l n uf t aa n p e m ie increase in-patients attending the hospital, especially women and children. Expatriate doctors were evacuated from these provincial hospitals, thus exacerbating the shortages of doctors and increasing the workload on the remaining few.

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As the Conflict Prolonged:  As the conflict continues, major commercial activities such as the Oil Palm industry, the Gold Mining Industries, and Fishing ceased operations. Martin J concluded (Martin J 2000) that the economic effects include declining production, employment, revenues and investment and destruction of productive investment. This general economic crisis forced cuts in the budgets to the social services including health. Procurement of essential drugs and medical supplies becomes a major concern; especially when there are current debts of about SBD $5 million is yet to be settled.  Financing of health activities in the provinces such as cold chain maintenance, fuel for transportation, community outreach programs are being severely affected. Most provinces have received their health services grants since June 2000, this has prompted the Directors of Health in the provinces to reduce or cease certain health activities.  The inability to pay for wages of provincial health staff has prompted the Provincial Health Authorities to allow their officers to go unpaid leave. While those working in hospital and clinics are retained, the primary health care workers in the communities are severely reduced. Public health programs such as water supply and sanitation are suspended.  Epidemiologically, it is difficult to assess the disease pattern as case reporting are not well maintained. There is a need to for full assessment of morbidity and mortality situation as soon as feasible. As the Conflict Subsided and Peace is Negotiated:  It is anticipated, that when the conflict subsides and eventually resolved through the peace process, a major impact will be that the health needs will increase and the health sector will face new demands for curative care as well as major backlog of preventive measures, which could not be implemented during the tension or conflict.  Movement of population will increase greatly, while previously cut-off areas will become accessible. The health sector will be required to re-establish coverage, since equitable access to services will play a major role in stabilizing the community and contributing to the peace process. Expansion of certain facilities in these areas will call extra resources both in terms of finance and human resources. Re-building and Charting the Way Forward: It becomes evident that several key areas can be identified as crucial to rebuilding health services delivery in Solomon Islands as part of confidence building for peace and concurrently delivers health. The following are the priority areas were identified by the Ministry of Health:

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Immediate level one priorities 1. The ongoing procurement of medical supplies must be maintained. Due to the financial difficulties, it is becoming difficult to finance the debts with buying agents in Australia and New Zealand. A number of essential drugs were being procured through funds provided by New Zealand and Australian Governments through the ICRC. This assistance however, was sufficient to meet the drug requirement for one year. The problem still remain that funds for drug orders for 2001 needs to be secured, however, the debts had not been settled prior to processing of the 2001 drug orders. The approximate total funds required for debt servicing and procurement of new drug orders would be SBD 12 million. 2. In strengthening and supplementing the management capacity of the Ministry of Health to cope with current situation, there was the need for interim Technical Assistance and Advisors. While the current management are pressured and committed on crisis management, the Ministry needs to have additional experts that focus on management issues that will aide in advancing the health services delivery institutional capacity. More specifically, the interim Technical advisors will be focusing on (a) Budget / Financing; (b) Human Resource Planning and Development, and (c) Information Technology. 3. The out-reach services to the provinces must be re-established. Funding and re-sourcing of the provincial health services are often provided and coordinated form the National Government through provision of financial grants, extended national services and facilities. There is a need to finance these activities at the provincial level. 4. As the resources available for health services are limited and getting scarcer, it is important financial management system be strengthened. This should be focussed on providing on simple but effective accounting software including computer hardware. A Technical Assistance be provided specifically for this purpose and training of accounting staff in financial management at both national and provincial levels. The proposed bulk payment of health funds to the ministry will certainly needs improved facilities including human resources. 5. Rebuilding the confidence of health workers is crucial and counseling of those affected by emotional and psychological trauma as direct result of the crisis is important. Funding for such activities is required. 6. Finally, level one priority for immediate action is the re-establishment of hahs v e o G aa aa A ti s ae enp ne frh gvrm n’10 el e i s n udl nl cvi hv be l nd o te oe et 0t rc c . it e a n s day program, which focuses mostly on restoration of health services on Guadalcanal, including Honiara. This focus area may require rebuilding of heath facilities for Guadalcanal Province and renovation work on health infrastructures. Medium level one priorities: 1. As population movement increases demand on health services in the provinces, there is a need upgrade and /or expand health facilities in the provinces. The

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activities in this area will be concentrated on the two main provincial hospitals at Gizo adKlui h wl l i o e rv i o hahs f acm oao adhah n i’ . i iao n l poio f el tf co m dt n n el u fT s l s v v sn t a, i t facilities. 2. The immunization program has proven to be very cost efficient measures to combat major childhood illnesses. Maintenance of the cold chain is very important, therefore it is crucial that supply of fuel for refrigerator is maintained. Currently WHO and NZODA has been assisting in this regard, however, a long-term support is required. 3. Due to changes as resulted from reform and the current conflict, all senior managers and other key stake holders with in the health sector be well informed. A National Health Conference can be an avenue for such discussion and collaboration. It is important that a funding should be made available for hosting a National Health Conference. 4. As population moved to other provinces and the reduced number of patients attending and referred to the National Referral Hospital, there is a need for redistribution of medical staff to the provinces. In connection with this redistribution, certain infrastructures such as housing, clinical facilities and equipment are also provided. 5. Water supply and sanitation has proven to be a very effective approach for improved general health status of an individual and communities. A lot of health problems associated with lack of water supplies and poor sanitation has been resolved through provision of adequate clean water and sanitation facilities. There is a need to extend the current RWSS/Sanitation program of the Ministry. 6. Finally among the medium term level priorities, there is a need to review the infrastructure development (Hospitals and Clinics). Building of hospitals and clinics are to be prioritized as population catchment in certain rural areas changes during the ethnic unrest.

2.5. Internal Factors:

2.5.1. Management & Planning of Health Services:
Internally, within the health sector, the demand for health care in the country have been traditionally influenced by what could be regarded as 'medical need' as the basis for public policy and planning, and resource allocation. However, it has been shown and highlighted that basing resources allocation decisions solely on medical needs is likely to cause misallocation of resources. It may result in underutilization or overutilization of r or s A wdl polm dt tne’si eedn o pi . hr oe ii e uc . s i y rc ie h ‘ d i n pnet f re T e fr ts s e e a a e d c e , essential to plan according to the 'demand', which would at least ensure against the wasting of resources, and accurately measure the likely demand for health care services in the next five to ten years. However, to enable an equitable health resource distribution, a

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comprehensive health management information system is essential. An area we lacked at the moment. T esr ud gmlui 20 i val w s‘ism ngm n’ a e t n h ur ni i n 00 n ib a cs aae et r hr h o n i e et y ri t a innovative strategic and development planning for the health sector. It was a time when attention was to maintain services at its basic minimal level both in Honiara and the provinces. Coupled with lack of funds it was very difficult situation for the health managers to manage and implement all planned activities.

2.5.2. Human Resource Management and Development:
Human resource management and development faced difficult times in 2000. Firstly, staff training at the overseas and local institutions was interrupted because of the ethnic tension. Opportunities for training scholarships were curtailed. The choric shortage of manpower (especially doctors) was accentuated, when expatriate doctors and a few foreign volunteer health workers fled the country during the height of the ethnic crisis. A few local doctors also fled because of threat to their family. Management of staff in the health sector could not be handled efficiently, when pr nl rvne w r ra dt s fpr nladf i’ s e ads ui. vn e oa geacs e e t o tf e oa ( a ls a t n e ry E e s i e le a s n m y) fy c t worse is the lack practicality in assurances from the Police authorities to maintain law and order at the health institutions (such as the National Referral Hospital) during the ethnic tension. It was a period where by management could not prescribe or impose directives on s fbta engttadnopr e tf i o e et d tf u r hr eoie n i roa s fsn l m n i ecisions related to the level a t a c t a’ v v n of services to be maintained at these times of difficulties and insecurity because of the ethnic t s n S m c hdbe gi df m t s fsno e et n cm i etT ii e i . o uh a en a e r h tf i l m n ad o mt n. h s no n o e a’ v v m s evident in the fact that despite the effects of the tension, the National Referral Hospital and clinics around Guadalcanal Province continue to maintain basic health services to the public. With this regard the nurses and doctors and many other health workers should be commended for their courage and commitment to provide much needed health care to the people of the country. It was a period when management of staff was at its highest attention.

2.5.3. Health Legislation:
The Government through the Ministry of Health is planning to review and update the existing health legislation in line with the needs of today and the future. As eluded in the several meetings all the existing health legislations and other related legislations are out of date. Some health legislations need updated and improvements. The priority areas are the Health Services Act 1979 (& Health Services (Hospital Regulations) 1980), the Pharmacy and Poisons Act 1941, Pharmacy Practitioners Act 1997, and the Mental Treatment Act 1970. The Health Services Act 1979 needs changing to focus and promote and support the health reform policies and strategies, the Ministry is undertaking.

2.5.4. 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

17

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 (7) Total government budget and the allocations from 1988 to 2000: Total Govt. Rec. Health Rec. Budget SBD$M Budget SBD$M 1988 101.2 12.7 1989 125.2 14.8 1990 146.6 18.3 1991 162.8 20.5 1992 208.8 24.3 1993 231 26.9 1997 412.5 48.8 1998 532.5 54.3 1999 441.0 56.7 2000 396.7 64.6 Source: Account Section, MOH (2000. Years Share to Health (%) 12.5 11.8 12.5 12.6 11.6 11.6 11.8 14.4 16.3 16.0 Health Revenues SBD$M 0.1 0.2 0.2 0.2 0.2 0.2 Per capitaSBD$ Nominal 42.5 47.9 57.4 62.4 71.7 76.8 135

Real 27.5 27.2 29.9 28.1 28.9 28.4

Table (8) Distribution of the Recurrent Health Budget 1991-19 (B $ 0) 99 S D ’ 0 0 Sections Total Central Total Province Total National %Provincial %Central % National 1991 11901.1 6632 185331.1 35.8 64.2 100.0 1992 15907.8 6994.4 22307.2 28.7 71.3 100 1993 16758.9 8180 24939.3 32.8 67.2 100 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 18963.6 31290.5 37.73 62.26 100 1998 21209.2 34070.1 38.36 61.63 100 1999 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 rhrt n‘ tu bs ’ ugt gi ape. h bde sut ei di nby the a e h o pt a d bden s pld T e ugt t c r s r e t a u e i i r u v D pr et f i ne oj te m r t npoin opr n y o b sedr le eam n o F ac’ b cvs oe h rv i pot i fr i pne i t n s ei a dg ut g sk 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 3. The implications of the current budget setting and allocation are an issue to be addressed in the Health Strengthening Institutional Project. D si t G vrm nscm i et ohaha r l t a 1. ( e t h oe et o mt n t el s ee e s 6 % second pe e n ’ m t fc d 0 highest to Education), 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

3

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

18

proportion of the recurrent health budget to community and public health programs, provincial health services, environmental services, and health education and promotion. Untimely payment of health grants was a problem. Many provinces did not receive their provincial health grants and wages for about two to six months. This caused suspension of many health care services including outreach services to most villages living more than three kilometers from the nearest clinics and most remote areas. This is evident from the coverage figures of public health programs (see Family Planning and Antenatal coverage). Some health workers including the direct employed nurse aides were temporarily laid off resulting in closure of Nurse Aide Post4.

2.5.5. Structural Reform:
The Solomon Islands Government since mid 1997, headed out with a policy direction of Public Sector Reform & Re-structural program, which principally driven by economic objectives. The Solomon Islands Public Service Policy and Structural Reform Program (PSRP)is shaped by the perception that; the public service was inefficiency; and over-staffed, to the extent that salaries were absorbing most public expenditure, leaving little for actual operations or capital investment and maintenance. Salaries were so low that staff had little incentive to work. Pay differentials had been so eroded by populist policies that the formal remuneration of senior staff in particular was derisory, making some form of corruption inevitable. And order and work discipline had deteriorated, such that the government could no longer look on public service as a reliable instrument for implementing policies. The Government in its Policy and Structural Reform has set the direction towards increasing proportion of the recurrent health budget to the rural community and public health programs, provincial health services, environmental services, and health education and promotion. In responding to this policy redirection and adjustment the health sector is reviewing its organizational and staffing structure to refocus its effort towards supporting the National Health Policies and Development Plan 1999-2003, which literally aimed at getting a effective and efficient public health sector as well as improving the national health outcome. The development so far is that the health sector is in the process of formulating a m j ‘ st i aS eg ei ’ rj toe ete m ng t cags nigdt a rI tuo l t nt n g po c t f cvl aae h hne ev ae o o n it n r h n e f iy e s improve the delivery of health services. At this stage, with the support from the developing partners such as the Australian Government through AusAID, and to lesser extend from the World Bank, intense work is done in identifying priority health issues and priority program areas. Project goals, objectives, strategies, activities and schedules are under way and near f aztno t ds n T efcsi i tea a o r i i pbchahs t ’ i lao f h eg. h ou s n h r s f e e n ul el e o s ni i e i e vw g i t cr organizational structure and functions, before incorporating changes of improvement to policy development, management and supervision, planning, monitoring and evaluation of the health services.
4

Report from Makira Province

19

Whs l l t d wt r om ipr i s xr s i t oe lgvrm n’ iti e o o i e r m e te epe e n h vrl oe et l t t h f av sd e a n s Policy and Structural Reform program, the sector strongly reckoned that vigorous effort is needed in gettinge iec’ m j cscn r o te ul hahs tri prcl ‘fi yi a r ot et s fh pbc el e o, a i a fc n n o e i t c n tu r the National Referral Hospital at the capital, which absorbs a significant portion of the annual health budget. By doing this it will enable redistribution of resources to other priority areas, which was undermined in the previous health budgeting process. The strength of the SIG reform program is the political commitment, which drives the economic reform. In relation to the health sector, the commitment from executive level of management staff is there, and which is slowly filtrating down into the middle management level and to a lesser extend down to the operational level. The obvious challenge is getting the majority of the operational staff to be part of the change and not to be left with fear and threat. One of the reasons for the acceptance at the management level is the notion to improve the management and supervision, planning, monitoring and evaluation of the services delivered to the customers. However, the weaknesses of the reform program is the lack of coordination and linkages between reform by central agencies such as Department of Finance and D pr et f ul Sr csdsi a eiec o aet nl fne ‘ st i a eam n o P bc e i , e t n x t e f x ray udd I tuo l t i ve pe sn e l n it n Strengthening Unit, which assist the Government to implement the reform program. Nonetheless, there are opportunities that would ensure an effective restructuring of the health sector for the benefit of service delivery to the people of the country. Firstly, the increasing commitment from external development partners has fostered confidence on the local counter part officers. Secondly, there is already an effective primary health care network, which is the road to the people at the community level. Thirdly, the restructuring is mainly done in a big way within the health sector, whilst outside the sector, appropriate behavioral changes to healthy life style is promoted through the health promotion. The threats to the restructuring program so far is very much related to the fear that the central agencies (who hold the power of authority and delegations) may wrongly perceive the restructuring of the health sector as threat itself, to them. It is essential that the health sector having established the effective and efficient organizational structure and process should have a significant degree of accountability and responsibility in human resource management and development, financial management, budgeting and resource allocation.

2.5.6. Important Elements in Reform:
Firstly, whatever done must be modified to suit the local context. Secondly, the customers who are the end users and recipients of the services must be valued in all the strategies and programs put in placed for the reform. It is about changing cultures, knowledge, attitudes and current practice of health staff as well as the people of the country. Customer focus in programs aimed at changing personal behavior is proven to be vr e eteT iibcue ul ibs j gdo te utm r pr pi .t l e f cv. h s eas qat s e u e n h cs e ’ e etn Iao y f i s i y td o s c o s allows gettingdw a t cm ui l e t i e i t adudradtepols o n t h o m n y e lo n sg e n ne t h ep ’ e t v v ta sn e problems. It provides a structure of solving problems and improving services. Secondly, all stakeholders must be involved. The process involves teamwork and break down barriers both external and within the service delivery.

20

It is obvious that theses basic fundamentals are often being over looked. At the end of the day what matters is the service delivery to the people.

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SECTION 3: TECHNICAL MATTERS-Combating Communicable Diseases
3.1. Overview:
Despite the financial constraints the government is facing, the Ministry of Health continues to maintain basic health services, with what is available and can be done. Most communicable public health programs continue to operate. The two years of 1999-2000 ethnic tension were the most difficult year for the Ministry. Nonetheless, basic services and emergency were also taken cared of.

3.2: Roll Back Malaria
3.2.1. The Vector Borne Disease Control Programme- THE MALARIA CONTROL PROGRAMME –An Overview 3.2.1.1. MALARIA SITUATION IN HONIARA, 1991 TO 2000 In 1992 and 1993, Honiara was the place with the highest incidence of malaria in Solomon Islands. Because of the constant movement of people in and out of the town, many of the infections were probably acquired elsewhere and brought into town, to act as a source of new infections for residents.

21

Solomon Islands Annual Malaria Incidence
500 400 300 200 100 0
Cases/1000/Year

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

Honiara was also the place with the most dramatic fall in incidence of malaria in the last ten years. Apart from the normal prevention activities of nets and some spraying, Honiara benefited from an intensified campaign supported by WHO which involved weekly house to house surveillance for fever cases and visitors to Honiara, who were screened by blood slide and treated if necessary. Complete coverage of the town became progressively more difficult in late 1999 and early 2000 because of increasing 'no-go' areas, and surveillance stopped completely in June 2000. The effects of interruption of activities can be seen in Figure 2. It must be noted however that a some of the increase in incidence can be accounted for by the adjustment of the Honiara population downwards (from 71,628 in 1999 to 49,107 in 2000) after the 1999 census. 3.2.1.2. MALARIA SITUATION IN THE PROVINCES, 1991 - 2000 All the provinces in Solomon Islands except Rennell/Bellona have malaria transmission. Based on incidence in 2000, the eight malaria-endemic provinces can be divided into three categories: 1) 2) those where incidence has continued to decline or remained relatively stable (Choiseul, Makira Ulawa, Malaita) those which show signs of increasing transmission (Central, Isabel, Western, Temotu)

22

3)

those where there is insufficient data to make a judgement on the situation (Guadalcanal).

1) Provinces with declining or stable transmission
Choiseul Province has benefited from past support from UNDP/WHO, as well as from the recent (1999) deployment of a very able and active Provincial Supervisor to the province. It will be receiving support from a Rotary International Project which was due to start in 2000 but has been delayed for a year due to the unrest. Makira-Ulawa Province has also had a very competent Supervisor and some support from the World Bank in 2000.
Fig 3a CHOISEUL : Annual Incidence/1000
600 500
Cases/1000/Year

Fig 3b MAKIRA ULAWA:Annual Incidence/1000
600 500
Cases/1000/Year

400 300 200 100 0

400 300 200 100 0

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

Fig 3c MALAITA: Annual Incidence/1000
600 500
Cases/1000/Year

400 300 200 100 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

Malaita Province is where the majority of AusAID support has been given through the SPC Regional Vector-Borne Disease Project. Despite the large influx of people back to the province during 1999 and 2000, incidence has been held relatively stable though an increase was recorded since the beginning of the crisis in 1998.

23

2) Provinces with signs of increasing transmission

Fig 4a CENTRAL: Annual Incidence/1000
600 500
Cases/1000/Year

400 300 200 100 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

Fig 4c TEMOTU: Annual Incidence/1000
600 500
Cases/1000/Year

Fig 4d WESTERN: Annual Incidence/1000
600 500
Cases/1000/Year

400 300 200 100 0

400 300 200 100 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

Of these four provinces, Western and Central are the most worrying. In fact Western province data from last year is only from the 10 months Jan - October; the last two months of the year have still not yet been received. Western Province had an influx of people from Honiara in the second half of 2000, but most of the problems in the province appear to result from a breakdown in staff morale, management and planning in the province. Central Province has suffered disruption under the ethnic tension and has no means of donor support planned in the near future. Isabel has had a very successful programme in recent years, with a large community participation and health communication component. It has not benefited from any direct donor support to the province, but has a very active and competent supervisor who has run the program for many years. Temotu is similarly at risk for epidemics and in addition suffers from a high proportion (~20%) of cases showing chloroquine resistance. As in Isabel, there is no past history or immediate prospect of specific donor support to the province.

24

c) Provinces with insufficient information Guadalcanal is the province which has shown the slowest progress in reducing incidence in recent years, although gains have been nevertheless substantial. A first glance at the graph
Fig 5 GUADALCANAL: Annual Incidence/1000
600 500
Cases/1000/Year

400 300 200 100 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

above would suggest that incidence continued to decline in year 2000, but in fact several of the clinics in the province were closed for more than half of the year and sent in no reports. Therefore the incidence figure for 2000 is greatly underestimated. REMEDIAL MEASURES IMPLEMENTED: - WHO with other donor partners
implemented several measures to curb the increase in the number of cases. Diagnostic services were restored in several clinics with the provision of rapid diagnostic test kits; A new divisional office with adequate staff was set up to carry out control measures among the internally displaced people. o Staff were reassigned to the affected areas so that people of the same ethnic group carried out the programme in their provinces; o Indoor residual spaying of houses was carried out in accessible areas and over 50,000 people were protected by this measure along with the provision of insecticide treated nets. o Several workshops were organized for nursing staff to guide them on the management of severe cases. o Free nets were distributed to pregnant women and mothers with infants through the international Red Cross. o Efforts are being made to enhance the level of confidence amongst the community by familiarizing visit by the staff; o The community contribution for the nets were lowered to make it more affordable; o The revolving fund for nets was judiciously used by the programme to overcome the lack of operational funds; o Epidemiological case monitoring officers were deployed in all the affected areas to keep track of increases in the number of reported cases and severe cases; o The surveillance programme in the capital is also being restored in a phased manner.

Some of these measures have contributed to the lowering of incidence rate in 1999 but the increase in violence and large-scale movements of people disrupted control operations and led to the increase in cases in 2000. A special programme for the restoration of all activities will be launched

25

shortly and would depend on the commitments by various partners. The economic crisis faced by the Govt. and lack of law and order is the only impediment for future success.

3.2.2. BRIEF REPORT OF MALARIA IN SOLOMON ISLANDS (2000) AND THE IMPACT OF THE ETHNIC CRISIS:

THE CRISIS:- The two-year ethnic conflict between two indigenous island groups in Solomon Islands has caused serious economic, social and political disruptions in the country. The ethnic conflict erupted in 1998. In subsequent months armed militants from Guadalcanal province drove out over 35,000 people, mostly from the island of Malaita, from their settlements on Guadalcanal and around the capital Honiara. The conflict resulted in loss of over one hundred lives. The retaliation by the Malaitan militants began on 5 ue 00 hn hy a i ot c i op ’aad h P Jn 20 w e te cre u a il u d t n te rime Minister was forced out rd vc et of office. Frequent clashes between the two groups continued and several villages on Guadalcanal were destroyed. The new government brought the rival factions to the negotiating table and it culminated in the signing of the Townsville Peace Agreement on 15 October 2000. The transition to restoration of normalcy continues to be plagued by various factors. The economic impact of the current crisis is devastating and the annual revenue for the country has decreased from USD 79 million to 38 million this year (2001). All major health programmes are affected all over the country.

26

IMPACT ON MALARIA CONTROL:- There has been a steady reduction in cases of malaria since 1992 and a workable and sustainable program for malaria control was established (fig 1). An intensified malaria control program in the capital Honiara launched by WHO in 1995 has reduced the incidence by 82%. Deaths due to malaria have also

Fig. 1 Solomon Islands: Annual Incidence/1000
500 400
Cases/1000/Year

300 200 100 0

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001
P.falciparum P.vivax Total

declined by 50% percent since 1995, a new strategic of malaria prevention and control was introduced in Solomon Islands. Impregnated mosquito nets were introduced combined with focal spraying, strengthened diagnostic services (microscopists), larval control and health communication. The success of this new strategy is indicated in Figure 1, which shows the general decline in annual incidence per 1000 population during the years 1992 to 1999. The decline began to plateau out in recent years, and a definite upturn in the curve can be seen in year 2000. This is mostly contributed by an increase in Plasmodium falciparum starting in 1998. This may be partly due to an increase in chloroquine resistance in this species. Plasmodium vivax malaria is the relapsing form, and new cases can thus occur in the absence of active transmission. For this reason, P.vivax often becomes the predominant species of malaria at low levels of transmission, but this has not happened in Solomon Islands except in Isabel province. Despite all these successes the program has suffered a major set back in 1999-2001. Diagnostic facilities have temporarily closed in several parts of Honiara and Guadalcanal. Low staff morale, lack of funds and delay in the implementation of control measures are the main factors hampering the program. Malaria mortality has also increased in these affected provinces. Preliminary data from the Paediatric ward of the national referral hospital in Honiara clearly shows an increase in the percentage of malaria admissions from 10.7% in 1998, 15.7% in 1999 and 22.5% in 2000. All the transport vehicles and canoes were stolen in this crisis. Communities in several villages were frightened to cooperate with the malaria

27

staff in retreatment of nets. Stable malaria endemicity is maintained over a wide range of transmission intensities in Solomon Islands. The Internally displaced people with higher parasitimia (> 20% prevalence rate) were displaced to regions with moderate transmission intensities (prevalence rate <8%). This has resulted in increase in the number of cerebral malaria cases within the population.

3.3. Stop Tuberculosis
Solomon Islands Context: The National TB program has been successful in introducing the DOTS. To date there is 100% coverage. The DOTS strategy has significantly contribution to the increase to the cure rate. However, there are local issues such as transport that hinders the community part of the sputum collections. The proposed strategy to the above problem is to use the existing malaria microscopists at DOTS centers, to be able to read sputum for AFB. There was a drop in the cure rate to 78.4% compared to 83.3. %. Nonetheless, there is a strong believe that this is an underestimated because all patients are yet to be checked. Theses problem was caused by the ethnic tension when many patients were migrating from one place to another. Some have not settled permanently since their movement.

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. . In 1999, the Cure rate for the National Tuberculosis Control Program has also increased from 30% in 1996 to 83.3% in 1998. 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.

28

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).

Policy Status: 4.8.0. Policy on Tuberculosis: 4.8.1. Policy Goal: New TB Case Notification Rate 19986 - 2000  To reduce transmission, 180 morbidity and 160 mortality due to 140 Tuberculosis 4.8.2. Objectives: 120  To improve 100 cure rate 80  To reduce 60 mortality rate 4.8.3. Indicators: 40  Cure Rate 20  Mortality Rate 0 86 87 88 89 90 91 92 93 94 95 96 97 98  Treatment 102.1 115.1 121.6 154.1 116.5 91 107.2 103.5 69.9 94.4 79.7 77.1 63.6 All Cases 35.3 39.8 44.8 46.6 36.8 26.7 38.8 43.8 31.1 29.5 28.4 25.6 39.9 Smear ( +) Completion Rate 4.8.4. Strategies:  Improve case holding and treatment  Improve contact tracing  Implementation and extension of short course chemotherapy (SCC)  Implementation of Direct Observation Therapy Strategy (DOTS)  Health education and promotion-community awareness 4.8.5. Action Steps:  Intensified disease surveillance-intensified contact tracing in hospitals and rural facilities by health workers whilst index case still on treatment. TargetsForD TSIm entation O plem  Use of chronic cough registry  To ensure that 100%of detected newsm positive cases  ear  The standardization of the treatment regimes, areenrolledunderD TS; O  To ensure a treatm successive rate of at least 85%for  ent SCC in the country.
NCDR 1 per 100,000

sm ear-positivepulm onarycasesinD TS; O  Todetect70%ofestim  atednewsm positivecases. ear– (PacificStrategicPlantoStopTB2,000)W O H)

29

 Modification of TB forms for disease notification  Computerization of TB registry at the center and province/ entry of all data for monitoring and

evaluation purposes in the central data bank/ standardize evaluation epidemiological and operational indicators for reporting and planing.  Conduct refresher courses, workshops, conferences for TB & Leprosy coordinators  Skilled training for staff in program management for middle level managers, program administration for national TB & Leprosy managers, laboratory staff TB specialists, and communication skills for IEC officers  Training for officers in new TB protocol  Annual supervisory visits to provincial TB coordinators  Capacity building of TB & Leprosy staff  Automation of TB/ Leprosy unit at the center  Continue public health education through media and community talks 4.8.6. Implementing Division/ Department: Division: TB/ Leprosy Unit of DCC/ MHMS  Responsible Officer: National TB/Leprosy coordinator, MHMS in collaboration with Provincial Health Directors and Provincial TB coordinators ----------------------------------------------------------------------------------------------------------------------------------------Leprosy: Solomon Islands is embarking on the Special Action Program to Eliminate Leprosy (SAPEL) recommended by the WHO and funded by Pacific Leprosy Foundation (PLF), N wZ a n. hriati t n hth t n fr oo ‘ l-free) could also be e el dT e snc ao tater d o pl (oo a e ip i e i pi achieved in leprosy (leprosy-free) in the near future. It is now six years since Solomon Islands maintain its status within the WHO target of prevalence rate <1 case/ 10,000. In 2000 the prevalence rate for SI is 0.2 cases/ 10,000. It was 0.17/ 10,000 in 1999. The screening process is confined to high prevalence areas to detect new cases, and have them treated immediately. 4.9.0. Policy on Leprosy: 4.9.1. Policy Goal:  To eradicate Leprosy in the country 4.9.2. Objectives:  To reduce the prevalence rate of leprosy from 0.6/10,000 pop in 1998 to less than 0.3/10,000 pop by 2003. 4.9.3. Indicators:  Prevalence Rate of Leprosy 4.9.4. Strategies:  To strengthen and improve case finding, contact tracing and case holding  Improve current recording and reporting system 4.9.5. Action Steps:  Staff training by workshops on management and treatment of leprosy

30

 Community awareness campaigns
4.9.6. Implementing Division/ Department:  Division: TB/ Leprosy Unit of DCC/ MHMS  Responsible Officer: National TB/Leprosy coordinator, MHMS in collaboration with Provincial Health Directors and Provincial TB coordinators
Graph Showing New Case Notification for Leprosy 2000
Leprosy Cases for Year 2000 ( 28/12/00)
30

25

20

Number

15

10

5

0
New Leprosy Cases

86 16

87 18

88 17

89 14

90 19

91 20

92 16

93 8

94 10

95 9

96 24

97 21

98 14

99 12

0 6

Table ( ) Provincial Leprosy CaseLoads and prevalence:

Province Gaudalcanal Malaita Temotu HTC CHP Rennell and Bellona Central Islands Province Isabel Western Makira/Ulawa Total

Patients on Registry By end of Year 2000 3 1 1 3 0 0 0 0 0 0 8

Status Active Active Active Active 0 0 0 0 0 0 Active

P/R 10,000 Pop 0.4 0.1 0.4 0.6 0 0 0 0 0 0 0.2

31 Graph ( ) Leprosy Prevalence 1997-2000
Leprosy Prevalence from 1987 - 2000 12

10

8
PR 1 per 10,000 pop

6

4

2

0 Leprosy Prevalence

87 9

88 10

89 9

90 4

91 3

92 3

93 2

94 1.1

95 0.63

96 0.67

97 0.99

98 0.45

99 0.17

0 0.2

3.4. STI/ HIV/AIDS:
Solomon Islands Context: Despite recording one HIV case in Solomon Islands, the risk and potential for the problem to flare exists because of the socio-cultural behavior of the higher school age and teenage population, which was evident in a local study. The highest recorded cases of STI were in 1996-1998.

32

3.4.1. STI/HIV/AIDS Program: A Situational Analysis was completed in 19995. This analysis will form the basis of a STI/HIV/AIDS Strategic Plan to expand responses for prevention of STI and HIV transmission in a multi-sect oral manner. Some of the issues revealed were related to lack of knowledge HIV transmission and related safety issues, counseling skills and training, within the majority of health workers. STI was indicated as major causes of morbidity for adults and young people and increasing in urban and rural urbanizing centers. Poor documentation in the Health System was highlighted. Barriers to the use of STI services in the health system were related to the stigma associated and the symptomatic nature of the illnesses and attitude of health staff. Determinants and remedies for HIV epidemic are present, such as high rate of STI, migration and lack of condom use etc. Behavioral determinants are also present, which is related to sexual behaviors in relation to homosexuality, heterosexuality in relation extramaritual and premarital sex and commercial sex worker. There are also demographic, economic and social determinants revealed as unemployment and opportunities link to sexual risk taking behaviors.
 

A Strategic Planning Core Committee (SPCC) was formed to coordinate and implemented activities. 14 stakeholders involved from Govt., NGOs and community based organizations. 5 priority areas were identified as areas needing strengthening: Reducing the vulnerability of specific groups and promoting safer sexual behaviors. Preventing and control of sexually transmitted infection. Blood supply Promoting multi-sectoral responses Care and support for people infected and effected by HIV/AIDS.

1. 2. 3. 4. 5.

From January to June 2000, the fourth phase of the Strategic Plan Formulation Process took off. It involved a consultation process driven by SPC and involving key stakeholders such as Government Miunistries, NGOs and Churches. The fifith pahse is the documentation of the First National Multi-sectoral Strategic Plan to prevent transmission of HIV Infection and consequently reduce the socio-economic burden of the potential impact of the infection on the country. The key strategies related to; [1] reducting the vulnerability of specific groups amd promoting safe sexual behaviors in ceratin taget groups such as the sex wokers, married men and women; seafarers; youth; health workers; and TBA. [2] prevention and control of STI in certain target groups.

5

H.R.Buchanan, K.Konare, A. Namokari (1999). A Situational Analysis of STI and HIV in Solomon Iad:C ac C ac N o a. s ns“ hne hne a I MOH, November. l ”

33

3.4.2. Current Status of HIV/ AIDS:Only one (1) case was reported in 1994 (but a foreigner from PNG). There have been steady increases between 1992 and 1998. The most prevalent syndromes are discharges and genital ulcers with PID and infertility amongst young girls. Penile & vaginal discharges -1992 (398) 1995(1182), 1997(1801) 1998(2134). Genital Ulcers- 1992(44) 1995(282), 1997(396), 1998(381). Source: HIS (underestimation). Penicillin Gonorrhea resistant has declined dramatically. 1989(54),1992(41), 1996(32), 1998(15). A contributing factor to the decline is the new treatment protocol with syndrome approach. Standard blister packs (or STD packs) readily available in all clinics. After introduction of the syndrome treatment, there was 50% reduction of gonorrhea penicillin resistance. Nonetheless, compliance & KAP of nurses still poor. STI case management is still poor. Condoms restricted only to family planning. Shortage of condom supply scared nurse to give them away. Inadequate stock at provincial clinics. Counseling skills very deficient among nurses.

   

 

HIV Testing:

Since 1990-1998 (a period of 9 years) total of 14,055 HIV testing was done (i.e. 1,562 tests per year. 90 0 762 91 0 1,904 92 0 1,674 93 0 1,748 94 1 1,764 95 0 1,574 96 0 1,639 97 0 1,583 98 0 1,407

HIV + No.Tests

Testing policy: only suspected cases including cases with STI, relapses of TB, blood donors, and clinically suspected cases by physician. Blood donors main group for HIV screening. While rural hospitals have been equipped to screened blood prior to transfusion protocols are not always followed at Gizo, Makira and Lata.

Policy Status: 4.10.Policy on Sexually Transmitted Disease: 4.10.1. Policy Goal:  To reduce the incidence rate of STD, and prevent HIV/ AIDS infection in the country. 4.10.2. Objectives:  To reduce the morbidity rate of STD from 1,464 cases in 1995 by 50% by 2003. To prevent HIV/ AIDS infection.

34

4.10.3. Indicators:  Morbidity Rate  HIV infection Rate 4.10.4. Strategies:  Improve data collection system  Implement the standard diagnosis and treatment guideline nation wide  Improve surveillance and screening for STDs/HIV  Intensify public information and education on STDs/HIV/Aids 4.10.5. Action steps:  Review of Treatment Guiidelines for STD  Development of National Policy on HIV/AIDs 4.10.6. Implementing Division/ Department:  Division: Disease Control Center, MHMS Responsible Officer: National STD/HIV Coordinator ---------------------------------------------------------------------------------------------------------

3.5. Vaccine preventable diseases:
3.5.1. National Disease Surveillance: Guadalcanal recorded 29 cases of whooping cough in 1998 and 4 cases in the previous year 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. In 2000, total number of 28 cases of whooping cough was recorded under the HIS. Majority of 23 cases were from Makira, two cases from Malaita and one each from Guadalcanal, Western Province and Isabel Provinces. Theses cases were not confirmed by medical officers.

Graph (1) showing incidence of vaccine preventable Illnesses in SI 1997-99
Graph showing incidence of vaccine preventable diseases in SI, 1997-99
0.07 0.06 0.05
Incidence rates

Source: HIS, MOH

Neonatal tetanus 0.04 0.03 0.02 0.01 0 1997 1998 1999 Tetanus Whooping cough Suspected Polio Measles

35

Graph (2) showing incidence of vaccine preventable illnesses by provinces in 1997-99:

Graph showing incidence of vaccine-preventable diseases by provinces
0.4 0.35
Incidence rates

0.3 0.25 0.2 0.15 0.1 0.05 0
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

Neonatal tetanus Tetanus Whooping cough Suspected Polio Measles

Choiseul Western 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 the over estimation of the % Immunization Coverage Rate (Cases) population. This has been verified through an 1995 1996 1997 1998 1999 2000 Immunization Coverage Survey
BCG Hep B3 DPT3 Polio3 Measles TT2 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 49.5 51.5 57.9 57.9 54.7 in Malaita (%) 1999 99.1 99.1 86.7 84.6 58.8

immunization coverage survey in Malaita province in 1999. The overall immunization coverage has remained over 80% compared to the reported coverage. However, 2000 was a difficult time in maintaining the health services because of the tension.

BCG Hep B3 DPT3 Polio3 Measles

5.2.8.3. Immunization drop Outs:

36

The drop out rates of coverage has indicated two issues, viz, firstly, the compliance from mothers, and secondly, consistency and effectivity of the health programs to sustain and maintain services. Ideally, the level of coverage of first doses should be around the same to the third dose. However, according to the HIS data, there is practical implication that first BCG doses may not be recorded (this is proven by EPI veirification Studies in Gizo 2000), or otherwise. The discrepancy of the recording of EPI data needs to be reviewed and strengthened.
1997 2.75 3.23 -1.4 2.12 1998 7.69 3.21 -12 2.2 1999 0.9 3.72 -7.16 3.73 2000 -10.5 8.7 -9.3 7.7

BCG-Measles DPT1-DPT3 HepB1-HepB3 Polio1-Polio3

2.6. The Healthy Islands, Health City, Initiatives:
2.6.1. General view: 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. 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 “ au Iad e ri” 1995. This was reaffirmed in “hR ro a gee” 1997. Y nc sn Dc ao in al l tn a Te a t gA rmn in an e t In adopting this approach, Solomon Islands use the Malaria Control Program as the entry point. 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:

37

   

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 r r eti s fl ot g usn oiai l i t cucead G ’ e e n teo a yu r p iH n r n u n h hr sn N Os p s av l h o a, cd g e h . 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 ae o 1 ad 9 ero . i te m n P lythe NYP cuts across various sectors. gs f 4 n 2 ya l L eh Wo e’ oc, sd k s i 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 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 H n r Ct C uc, ot G op adohr G ’ B Ma 2000, several trees were oia i oni Y u rus n t N Os y y a y l h 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,

38

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.

3.6.2. Health and Environment
3.6.2.1. 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. 3.6.2.2. 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. 3.6.2.3. 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.

39

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. 3.6.2.4. 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. Water supply and sanitation 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

3.6.2.5. 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 Pure Food Act, which aimed at fostering food safety, is a platform to incorporate multi-sectoral integration involving wider scope of stakeholders to strengthen the national food safety programs. The Environmental Health Division has participated in the Codex Alimentarius Commission through the South Pacific Commission. It is also important for economic productivity to promote and establish international standards with respect to food safety. 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. As stipulated under the National Health Policies and Development Plans 1999-2003, the strengthening of the Public Health Laboratory

6

Ministry of Health (2001). Report from Environmental Health and Rural Water Supply and Sanitation Program, Unpublished Paper.

40

is key component to monitor and reduce prevalence of food borne illnesses and their impact on the communities, coupled with awareness campaigns. 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. Policy Status: 5.1. Policy Goal:  To further strengthen Environmental Health Services in particular promotion of clean water, proper wastes disposal (sanitation), food hygiene, inspections and quarantine, and occupational heath and safety at work and at home. 5.2.Objectives:  To increase environmental public health activities in food hygiene, inspections and quarantine, and occupational health and safety at work in the next five years. 5.3. Indicators:  No. of EHD Activities  No. Water supply & Sanitation projects constructed  Water Supply coverage  Sanitation coverage  No. of Public Health Activities implemented 5.4. Strategies:  Review of existing legislation and regulations.  Establishment of a Public Health Laboratory.  Establishment of refuses dumping sites and incinerators.  Inspection of food processing outlets, places of work, settlements and villages.  Establishment of quarantine and vector control units. 5.5. Action Steps:  Legislative review: Review Environment Health Act 1987. Repeal of 1987 Act to re-install 1970 Act with modifications: To allow expansion of the role of the division and govt.  Food hygiene and Safe water  Safe drinking water and proper sanitation facilities are basic necessities to better health. Commitment is made to further strengthen and expand the activities of the Rural Water Supply and Sanitation Program to achieve national coverage by year 2000. The sanitation component will be given grater emphasis to increase the level of coverage by the same target year.  National Rural Water Supply and Sanitation Program

41

 Community awareness and training in maintenance of systems.  Health promotion and personal hygiene on and sanitation.  Implement the construction of systems as in the 1997 - 2001 project.  Food safety and Hygiene:  O etnl t p visf ePrFoAt96. pao i h ri not “u o c 9” rias e os e o h e d 1  Training and awareness on the requirements of the Pure Food Act 1996.  Establish effective collaboration with other sectors

5.6. Implementing Division/ Department: Division: Environmental Health Division/ Rural Water Supply and Sanitation Responsible Officer: Director EHD/RWSS in collaboration with Provincial Health Directors. 3.62.6. 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. 3.6.2.7. 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. 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. ----------------------------------------------------------------------------------------------------------------

3.7. Infant and Young Child Nutrition:
Solomon Islands Context:

42

Policy Status: The National Nutrition Survey of 1989/90 revealed that malnutrition is a problem of children and women, with 23% of children being underweight, 7% women underweight and 39% overweight (obese). Vitamin A deficiency is evident to be increasing and related to Malnutrition in children. 4.5.2. Policy Goal:  To further strengthen the National Nutritional Program, and increase collaboration with other public and private sectors, church and Non-Government Organizations. 4.5.3. Objectives:  To reduce the proportion of children under weight from 23% in 1989/90 to less than 10% by 2003.  To reduce the proportion of women underweight from 7% underweight to less than 5% by 2003.  To reduce the proportion of women overweight from 39% in 1989/90 to less than 10% by 2003. 4.5.4. Indicators:  Proportion of children reported under weight %  Proportion of women reported underweight %  Proportion of women reported overweight % 4.5.5. Strategies:  Strengthening and improvement of primary health care activities at community level; -community awareness especially among, women, mothers and children Re-enforcement of prevention of diseases and disability in infants and young children by: - Provision and increase access to safe water and adequate sanitation.  Provide appropriate weaning and nutrition practices and adequate diet  To promote healthy lifestyles programs such as healthy diets, smoking-free environment and exercise 4.5.6. Action Steps:  Endorsement of the National Food and Nutrition Policy 1992 by the cabinet in 1994  Continue to implement Baby-Friendly Hospital Initiative  Development of guidelines for nutritional Surveillance in 1991  Development of Plan of Action for Food and Nutrition  Development of National Breast-Feeding Policy in 1995  Establish Growth Monitoring System  Establish and extend Family Health Card to provinces 4.5.7. Implementing Division/ Department:  Division: Nutrition Unit of Reproductive Health Division, MHMS,HQ, and Provincial Health Services  Responsible Officers: Nutritionists and Provincial Health Directors.

3.8. Reproductive Health and Family Planning
T eMisy plyo r rdcv ad f i p ni i t po oead h n t ’ oc n e oute n a l l n g s o rm t n irs i p i my a n 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.

43

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. 3.8.1. 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 (1) 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

Graph showing maternal deaths 1997-1999 by provinces
8 7
No. of maternal deaths

7

Choiseul Western Isabel

6 5 4 3 4 3 4 4 3

Central Islands Guadalcanal Malaita

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.

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.
Makira Ulawa

3.8.2. Strengthening nursing and midwifery: The Ministry of Health, Solomon Islands has acted on the issue of nursing and midwifery very actively through the Solomon Islands Health Sector Development Project (SIHSDP). The SIHSDP funds the midwifery-t in por ,hog asf L a f m rn g rg m truh ‘ t on r ai a o’ o the World Bank. The objective of this project is to assist the Government (Ministry of Health) to improve the health service of Solomon Islands people through better maternal care and family planning and more effective prevention and control of malaria and improving the

44

capacity of MOH to plan and manage provincial health programs and mobilize community awareness and participation. The objective of the maternal component of the project is to decrease the maternal complications and deaths during pregnancy and at birth. Training of more nurses in quality maternal care is an integral strategy to achieve the objectives. This pilot project is a lead up to the construction of a Midwifery School at the National Referral Hospital, Honiara, which is planned to start second half of this year. The school will enable the Ministry of Health to train more nurses into the specialist area of midwifery. The plan is to train about 10-15 nurses from National Referral Hospital and the provinces in midwifery each year. The Need for Midwifery Training: The Ministry of Health has reasonable working estimates of the current and future need for the midwives and obstetrics doctors with obstetrics competence. A practical and coherent plan is in placed to meet this need through training. This midwifery training is very focused and objective driven with sound academic background. This pilot initiative will further strengthen and enhance midwifery training in country. However, there will be difficulties and external factors that would threaten and weaken the program. Therefore risk management plans and strategies will be developed as the program continues. According to the calculations based on the 1997 population figures, the Ministry will require to train 93 nurses in midwifery that means an intake of 19-20 per annum. This is to meet the quantification needs of 1 midwife per 500 births plus 1 midwife per 3000 women of reproductive age (Which was about 96,000 15-49 WBA in 1997) plus extra 27 midwives in management and supervisory duties, minus the attrition rate of 10% per annum. This is how the figure of 93 comes about. However, the Midwifery School can only take 10-15 midwives. But the estimated graduating classes will be between 10-12 per annum. Therefore by end of 20, h hit po csi sa, e oeoah v 6 md i sw i iaot 4 05w i sh rj t l pnw hp t ci e 9 i v , h h s bu 7% c e e’ f e e we c of our requirements. It therefore implies that we should find ways to reduce the attrition rate, increase number of intakes or continues to train additional 5 nurses in PNG. The above calculations will be review in view of the 1999 population census. Maternal Health Status: The Government is putting more emphasis in improving the health status of mothers during pregnancy, at birth and after birth. In Solomon Islands this is a very critical period for the live of the mother and the baby. In so far, our standings by world standards are very low, although we have been showing significant improvement. Our information system showed that the major causes of infant mortality are complications of childbirth. However, there are major improvements during the past 2 decades, dropping from 70/1,000 per live births in 1976 to 28/1,000 live births, in 1999. Infant mortality rate in Solomon Islands is acceptably below The Global Strategy for Health for ALL by year 2000 guiding target of IMR 50 per 1,000 live births. Pneumonia, malaria, diarrhea and meningitis are other causes of infant death. Solomon Islands have relatively higher maternal deaths by international standards and in the region. In 1999 it is estimated by the MOH that 154 women out of 100,000 births die of pregnancy related causes. Again there is marked improvement in reduction of the

45

maternal mortality rate from 549/ 100,000 live births in 1986 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 statement 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. It is because most causes of maternal mortality are preventable. When we look at the resource needs and the demand for maternal care services, there is a real challenge ahead of us. The challenge is to reduce the gap between demand for maternal care services and supply of services. This is evident in the draft Health Status Review Report 1997-1999 by the Ministry of Health, which revealed that hospital utilization in maternal care services in the provinces have increased at different rates. That is the number of admissions in maternal care/ 1,000 populations has increased. Similarly the trend of the bed occupancy in maternal care also increased in the provinces between the periods 1997 to 1999. That means number of beds occupied at particular time is increasing. Maternal care also has the highest bed occupancy rate in nearly all hospitals compared to other services. Progress of Preparation of the Pilot project on Midwifery training program: Preparation work took about 12 months, since June 2000. The effect of the ethnic tension has caused delay in the starting of the midwifery-training program. Project staff left. One of our key midwifery tutors also left. However, It is because of the commitment and hard work of the staff of the Project Implementation Coordination Unit, the Project Coordinator and her staff, the midwifery tutor, and staff from the Reproductive Health Division of the Ministry of Health that enable us to start the program. 3.8.3. 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 18.67 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 and remained the same in 2000, but coverage in many vary significantly. There is a decline in coverage in Choiseul, Western, Isabel, and CIP, whilst Malaita, Temotu, RenBellona and Honiara showed an increase. Guadalcanal showed zero coverage. This is related to under-reporting as well as a direct impact of the ethnic tension on the province.
Table (2) Family Planning Coverage (%) total users at end of December/wcba x 100):

Solomon Islands By Provinces: Choiseul Western Isabel Central Islands
7

1997 8.5 1997 6.9 11.2 7.9 6

1998 8.6 1998 5.0 8.2 13.2 15.7

1999 6.5 1999 7.8 9.1 11.4 17.9

2000 6.5 2000 4.5 3.4 5.7 15.1

1997 Estimate by Reproductive Health Division, MOH

46

Guadalcanal Malaita Makira Ulawa Temotu RenBell Honiara

7.1 10.2 7.9 14.2 3.3 5.6

5.8 11.3 6.9 12.3 5.3 5.6

5.4 3.9 6 13.5 2.5 2.7

00 13.2 6.1 14.5 2.7 3.0

Source: HIS, clinic monthly reports
Graph (3) showing FP coverage by end of December 1997,1998, 1999 & 2000:

% ist Antenatal visit/expected births

Graph Showing Family Planning Coverage by end of December 19972000
20 15 10 5 0
Solomon Central Malaita Temotu Western Honiara
1999 2000 66.7 2000 56.1 69.7 63.2 70.7 34 104.2

1997 1998 1999 2000

Table (3) % Supervised deliveries:

1995 85
Sources: **RHD/MOH, 1997

1997 86**

1998 -

Table (4) Antenatal Coverage: First antenatal attendance (% first visit / expected births)

Solomon Islands By Provinces: Choiseul Western Isabel Central Islands Guadalcanal Malaita

1997 68.9 1997 59.4 79.8 54.6 55.1 66.0 70.6

1998 71.9 1998 61.7 75.3 60.4 73.6 72.4 72.8

1999 65.9 1999 65.2 74.5 68.8 68.9 52.1 73.6

47

Makira Ulawa Temotu RenBell Honiara

54.6 53.8 46.5 78.0

71.7 48.4 38.5 80.5

56.2 60.2 31.1 68.8

70.4 51.6 56.4 55.2

The year 2000 showed some minimal increase in the coverage but still below 1997 and 1998 figures. There was mixed findings by provinces. Malaita showed more than two fold increase in first antenatal attendance as compared to the previous year 1999. Other provinces like Makira, Rennell Bellona, CIP, and MUP also showed some increase from the previous year, whilst Guadalcanal, Choiseul, Western, Isabel, Temotu and Honiara declined in 2000.
Graph (4) showing antenatal coverage (1st visit/ expected births 1997-2000:

Graph showing antenatl coverage (first visit) 1997-2000
% first visit/ expected births
120 100 80 60 40 20 0
Is ab el ra lI sl an ds G ua da lc an al M al ai M ta ak ira U la w a Te m ot u R en Be ll an ds se ul ho i es te rn

1997 1998 1999 2000

Is l

on

C

W

So lo

Table (5) Total Fertility Rates 1986,1996,1998:

C

en t

m

Years

1986 (Census)

1996 5.8

1999 4.8

Total 6.1 Fertility Rate Source: UNFPA of maternal mortality rate.

Total Fertality Rate declined from 6.1 in 1986 to 4.8 in 1999. Majority of six provinces (Choiseul, Western, CIP, Malaia, Makira, and Temotu) have reached 100 births in 1,000 WCBA population mark during the period 1997-99. Isabel and Guadalcanal recorded levels below 100/1,000 WCBA pop. However, Guadalcanal is also known to have higher level

Table () FERTILITY RATES BY PROVINCES FROM 1997 TO 2000 (births/ 1000 popWCBA Province Year Births Fertility rate (births/1000pop WCBA) Choiseul 1997 449 97.3 1998 555 116.8 1999 509 104.0

48

Western

Isabel

Central Islands

Guadalcanal

Malaita

Makira Ulawa

Temotu

Honiara

Rennell Bellona

Solomon Islands

2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000 1997 1998 1999 2000

463 1,575 1,591 1,329 1,376 417 377 308 382 397 486 584 630 773 932 1048 838 2,600 2,660 2,917 4,640 682 839 591 778 438 403 480 503 10 6 2 6 19 16 10 23 7360 7,865 7,778 9,017

90 120.8 118.5 96.0 90 93.14 81.6 64.5 70 89.3 106.1 124.0 130 47.3 54.7 59.0 40.0 115.7 115.7 123.9 190 103.6 123.1 83.7 100 107.7 96.5 111.7 110 0.7 0.4 0.12 0.3 39.5 32.3 19.6 43.8 81.3 83.7 79.7 88.8

*Total births / total pop of WCBA 15-44 x 1000 Source: Health Information System, Annual Health Reports 1997,1998,1999,2000, Statistics Unit, MOH. The number of total births in 1,000 Women of Child Bearing Age in Solomon Islands generally increased from 79.7 in 1999 to 88.8 in 2000. Whilst there is a increasing trend in the past year, accuracy of reporting and lack of accurate population census may distort the picture. All provinces except Choiseul and Western showed an upward trend. In evaluating the national and provincial reproductive health services and program the following approach could be used:

49

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. T e rg ms u ucu b v w d yh flwn i i s h por ’ot tol e i e b teoo i n c : a p d e l g de  Clear policy directions and strategies at all levels  Number of nurses trained in family planning  Number of nurses trained in midwifery  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. T e rg msn c a d u o ea v w d s h por ’ati t ot m sr i e a a ip e c ee ;  Behavioural changes – Total Fertility rates and contraceptive prevalence  Demographic changes-TFR, Infant Mortality and Maternal Mortality rates. There were favorable and unfavorable 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:

50

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 ‘ht a t ipc o t vl etko f i p ni w d i te i g? n o w a w s h m at fh i g a n a l l n g e i n h vl e O e f e e l a l my a n d l a 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 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. T e G vrm nscm i ett r rdcv hah i l rl te .T e h oe et o mt n o e oute el s i ay hr h n ’ m p i t t l e e National Population Policy was drafted with little integration in implementation as expected. Involvement of relevant sectors is yet to be seen.

3.9. Non-communicable Diseases (including mental health):

3.9.1. Prevention and control of non-communicable diseases:
Solomon Islands Context: The Comprehensive Review of Health Services Report, May 1996 has revealed an alarming increase in Non-communicable disease such as diabetes, hypertension, and cancer. It was noted that about 10% of admissions are related to diabetes. In response to the health need, the Ministry has established under the Disease Control and Prevention Unit a program called NCD section to evaluate the status of NCD, develop national strategies on surveillance, treatment, monitoring and prevention of the pol . h ot t fh por it dvl m n o a C neR g t ,n Dae s rb m T e u u o te rg m sh ee p et f ‘ acr eir ad i t e p a e o sy be

51

cnrlplyf m w r A ‘i ec‘et i e alhd a teN t nlR f r ot oc r e ok o i a . Da t C n r s s bse t h aoa e r l bi e t i i ea Hospital for acute care, education and prevention of the illness.

Policy Status: 4.7.0. .Diabetes: 4.7.1. Policy Goal:  To alleviate the impact (morbidity) and severity (disability) of diabetes in the target population. 4.7.2. Objectives:  To improve information (IEC production) in diabetes in the next five years.  To improve clinical management and treatment of diabetes in the next five years.  To prevent disability due to diabetes through community awareness. 4.7.3. Indicators:  IEC production on diabetes.  Clinical Management and Treatment Protocol fully documented and implemented  Improved collaboration links with the community.  No. of diabetic cases per year  No. of diabetic foot ulcers reported 4.7.4. Strategies:  Increase public awareness,  Earlier diagnosis and treatment,  Improved quality of care,  Improved infrastructure and organization of care. 4.7.5. Action Steps:  Prevention through: Public Awareness using the media, church groups, and other non-government organizations and community health talks from the unit. Healthy life-style promotion Development of health promotion and education materials  Improvement of Quality of Care through: Improve data collection system. Training of staff at the hospital and rural clinic levels. Development of clinical guidelines and education and clinical care kits. Training workshops of health workers within the country. Establish gestation diabetes program for pregnant mothers. Provision of adequate equipment and supplies for diagnosis and monitoring patients. Participation in regional and international conferences and organizations for the control of diabetes.  Infrastructure and organizational development:

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Upgrading of facilities at the National Referral Hospital and establishment of diabetes center. procurement of necessary equipment for provincial hospitals and the National Referral Hospital strengthen role of primary health care centers improve health information system for surveillance purposes  Development of an overall diabetes policy  Formation of a National Diabetics Society 4.7.6. Implementing Division:  Division: Disease Control Unit of MHMS, HQ, Medical Department, NRH and Provincial Health Services.  Responsible Officers: Officer in charge Diabetes Control Program of DCU in collaboration with Head of Medical Department, NRH and Provincial Health Directors. Outputs (Findings): It is for the first time, that there is actual registration of diabetic cases8 . There is an increasing number of diabetics since 1990 as recorded by the Diabetic Center. It is understood that there is more than what is recorded. The cases recorded in 1999 and 2000 have increased from 71 cases in 1996 to 109 and 100, respectively. The actual magnitude of the problem needs to be accurately measured but it is apparent that impact of the problem on the health of the people is increasing. The Ministry needs to strengthen its capacity to address the issue and problems related to increasing burden due to non-communicable diseases.

3.9.2. Mental Health Services
It is the Ministry mission to increase accessibility to basic mental health services t og t pia hahcr apoc.ts las cne t t aet rh a h uh h r r el a prah I ia y a ocr h ptn ’i t r r e m y t e w n a i s gs e retained and recognized by the community. The National Psychir U i a Klui a i n t i’ tc t uf Hospital, and the Honiara psychiatric unit are the only two service providers. However, irregular provincial tours do occur. 3.9.2.1. Activities: 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
8

Diabetic Center, Disease Prevention and Control Unit Annual Report 2000

53

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. 3.9.2.2. Findings (Outputs):
Table (6): Total Cases Admitted to Nation l sci r U i Kl’fHopt aP yha i nt i ui si l tc , u a (only) IN 1997,1998,& 1999. . Table B: Total Cases seen and Treated by the National Psychiatric

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

Unit, Honiara, MHMS,HQ, in 1997,1998 & 1999 1997 354 79 41 117 162 75 1998 1999 598 830 130 87

Total Cases Seen New M F Total new Old M F

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

3.9.2.3. Analysis: The access to mental health services is fairly limited in terms of mental health workers to rural population. 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 at the National Pyh tc H sil Klui H sil s ir c ai opa t i’ u f opa t

Total Admin & seen New M F Total new Old M

1997 1998 1999 663 715 915 158 79 237 276

222

117

54

increased from 663 in 1997 to 915 in 19999, with an average of 764 per year. 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. In 200010, total number of cases admitted at the National Psychiatric Unit, Kiluufi Hospital was 84. 3.9.2.5. Major Issues/ problems & recommendations: T em i iu i teMisy cpbi t ss i bt i tuoayad h a sesh n s n t ’ aaiy o utn o n it nl n irs l t a h st i l 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 poe , h hs aldeoak foe m n’cm i eto h s v e rcs w i ipry u t l o gvr et o mt n t t e i s s c t c n s m e rc . 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.

3.9.3. Initiative towards Tobacco control:
Solomon Islands Context (Intervention):
3.9.3.1. Tobacco Free Initiative Solomon Islands fully supports the Tobacco Free Initiatives. The Solomon Islands Government has approved a draft Tobacco Product Control Legislation in 1999. The Bill is now with the Legal Draftsman at the Attorney General Chambers. It is hoped that the bill will be tabled in the sitting of the Parliament 2002, after the elections in December 2001. Solomon Islands government has received support from WHO in terms of Technical Assistance in formulating the bill. The technical support received from WHO is very much appreciated. Solomon Islands, however, needs to build its capacity in assessing the magnitude of the Tobacco related health problems. In this light, Solomon Islands would like participate in the Global Youth Tobacco Survey.
9 10

MOH (2000). National Pyshiatric Reports 1997, 1998, 1999, National Psychiatric Unit. MOH (2000). National Pyshiatric Reports 2000, National Psychiatric Unit

55

However, there real practical challenges including politics, economic, and sociocultural issues. With the current downturn of economy leading increasing unemployment and poor financial status of many families, people ventured into selling of cigarettes and tobacco stick as their quick source of gaining some money. Coupled with no restrictions and cheap price it is the easiest way to get into business. Sporting organizations are engaging tobacco companies in the advertisement, and direct financial support. In is a problem which is appears to get out of hand in the country. At this very moment political will is the critical success factor for any break through with this sociocultural problem.

3.10. Strengthening Health Systems in Solomon Islands:
3.10.1. Proposed Health Reform: Solomon Islands Context: The Solomon Islands Public Service Policy and Structural Reform program is shaped by the perception that; the public service was inefficiency; and over-staffed, to the extent that salaries were absorbing most public expenditure, leaving little for actual operations or capital investment and maintenance. Salaries were so low that staff had little incentive to work. Pay differentials had been so eroded by populist policies that the formal remuneration of senior staff in particular was derisory, making some form of corruption inevitable. And order and work discipline had deteriorated, such that the government could no longer look on public service as a reliable instrument for implementing policies. The Government in its Policy and Structural Reform has set the direction towards increasing proportion of the recurrent health budget to the rural community and public health programs, provincial health services, environmental services, and health education and promotion. In responding to this policy redirection and adjustment the health sector is reviewing its organizational and staffing structure to refocus its effort towards supporting the National Health Policies and Development Plan 1999-2003, which literally aimed at getting a effective and efficient public health sector as well as improving the national health outcome. The development so far is that the health sector is in the process of formulating a m j ‘ st i aS eg ei ’ rj toe ete m ng t cags nigdt a rI tuo l t nt n g po c t f cvl aae h hne ev ae o o n it n r h n e f iy e s improve the delivery of health services. At this stage, with the support from the developing partners such as the Australian Government through AusAID, and to lesser extend from the World Bank, intense work is done in identifying priority health issues and priority program areas. Project goals, objectives, strategies, activities and schedules are under way and near f aztno t ds n T efcsi i tea a o r i i pbchahs t ’ i lao f h eg. h ou s n h r s f e e n ul el e o s ni i e i e vw g i t cr organizational structure and functions, before incorporating changes of improvement to policy development, management and supervision, planning, monitoring and evaluation of the health services.
I. Health Reform Goals:

56 To improve the health of the Solomon Islands population by strengthening the management and operational capacity of the Solomon Islands public health sector through the health reform process. III. Proposed Reform Strategy: The reform process envisaged in the next ten years is into two forms, 1} Structural Reform and 2) Process Reform. They are interdependent. It is planned that structural reform should set the framework and structural basis for the process and systems to fall in. Nonetheless, there may be areas that both overlap and may happen at the same time. Part 1: Structural Reform 1.1; Action Steps: Several actions steps were carried out as preliminary steps towards the reform recommendations: Solomon Islands Launched its Policy and Structural Reform Program: The Solomon Islands Government (SIG) launched its Policy and Structural Reform Program (PSRP) in 1997. Public sector reform is an element of the PSRP with an emphasis on improving productivity and efficiency of service delivery. Health Sector Reform initiative (under Restructuring of the Ministry of Health): In response to the PSRP agenda, the Ministry of Health is embarking upon a Structural and process reform. The former concerns with reorganization of the Ministry of Health and its functions whilst the latter deals with reviewing and changing the process of operations of the ministry. While the ministry is clear about the directions it wants to take, there are environmental and internal structural and systems issues, which must be addressed to ensure successful implementation of the health reform. A Cabinet Paper to start the process was prepared by the Ministry of Health, submitted and approved in 1998. Request for partnership in the health reform process though developing partner (donor) support and assistance: T eMisyo H ahsb ie a ‘el Ist i a S eg ei Po c Pooa dr gag n h n t f el umtd n H ah ntuo l t nt n g rj t rps’ ui ir t t t it n r h n e l n rd a donor meeting with the SIG in 1998. This institutional strengthening project should drive the structural as well as the process reform. The launching of the Nati0nal Health Policies and Development Plans 1999-2003: The National Health Policies and Development Plans was drawn up and launched in late 2000. The plan rnocsh gvrm ns o mt eto el r om T e e pi i ply r sr e fr t oe et cm i n t hah e r . h ky r ry oc a aa : i e e n ’ m t f ot i e e Solomon Islands Key Health Policies (National Health Policies & Development Plans 1999-2003) Improvement of management and supervision of services Recommendations countries to Commonwealth

1

2 3 4 5 6

Access and Improvement of Care & Quality of services Human Resource Development For Health Morbidity & Mortality Reduction Environmental Health Health Promotion & Education

Quality, Assurance, Monitoring & Evaluation (QAME); Strategic planning, policy analysis and agenda setting in health; Health Information as a management tool, Sustainable financing of health care systems, Health Research in health sector reform; Costs of drugs; QAME, Enhancing service delivery through the reform process; traditional systems of health; HRD in health sector Health sector reforms and the improvement of health status and quality of life, Health Promotion, obesity; physical activity, sport

57

and health 7 8 Reproductive Health, Family Planning & Population Developing Partnership in Health Development. Partnership for health

It is clear from the above table that the policy direction of the Solomon Islands Government covers all the areas of recommendation by the 12th C m ow ahH ahMis r Met g5 November 1998 in St o m n el el n t s en -19 t t ie ’ i Philip: Barbados, which the Solomon Islands Government could not attend because of financial difficulties. A neighboring commonwealth country (Australia) stepped in to assist the Solomon Islands Health Sc re r u drh b n e o ‘ a hIstt n l t n teig rj t et rf m n e te a nr fHel ntui aSr ghnn Po c . o o t i o e e’ The Australian Government showed interest and commitment in assisting and supporting health reform and other related health developments. Ultimately the interest eventuates in an AusAID donor Review Mission in Jl19 ae hv gr a t SGs i r e r aed. th Sl o Iad/A saa i Lvl u 99 f r ai e r o I ’wd r om gnaA t o m n sns ut l Hg ee y t n gd e f e o l ri h Consultations held in Brisbane on 19-20 August 1999, the SIG supported the recommendation of the AusAID Health Sector Donor Review Mission (July 1999) that Australia should support a major institutional project in the Ministry of Health. The review tem also recommended provision of interim technical assistance to help keep pace with a wider public sector reform agenda, and to help health workers to get the grip of what to come ahead with the reform agenda echoed in one or two ministerial conferences and meetings. With the assistance and coordination of the interim TAs, a consultant to help drive the process of developing a draft MOH Institutional Strengthening Project (guide). A Project Design Document was drafted in April 2000. The MOH owns this process and the document, and agreed that it reflects the health sectors needs. By end of May 2001, the project is at the stage of preparation for implementation. Annex 1 to the Institutional Strengthening Project Program: The desired Outputs and Outcomes: 6) Institutionalization of the Public Sector Structural and Policy Reform: The formation of the Ministry of Economic and Structural Reform. The Solomon Islands Government early this year (2001) institutionalized the public sector structural and policy reform by forming a new Ministry called the Ministry of Economic and Structural Reform. Their role is still not clear at the moment but assumed to coordinate, spearhead economic and structural reform, and assists and coordinates reforms in other sectors such as the health reform. Part 2: Systems and Process Reforms: 2.1: Action Steps: In this particular process much of activities now are focused to awareness of the proposed health reform process, and some smaller changes in financing systems and the establishment with in the public health sector. Presentation on the topic of Health Refr d r gaNa o a Sno Hel O f esC neec i om ui n t n l eir a h fcr o f ne n i t i ’ r 1998. The awareness campaign begun at the national senior health officers in October 1998. There was a lengthy discussion on the topic. There was a repetition of the subject of health restructuring in the following two national senior health conferences in 2000 and 2001. 2) Performance Agreement signed with the Permanent Secretaries and Undersecretaries of the 20 Ministries in 2000. In an attempt to improve efficiency and productivity, and accountability at the ministerial level, the Solomon Islands with the external assistance of a ADB consultant, developed a frame work that Permanent Secretaries signed a performance agreement with the Ministers of respective Ministries on the Outputs assigned in the work plans to achieve the desired outcomes. 3) Restructuring of the 2000 staffing establishment of the Ministry of Health: Creation of Chief Executive Post at the National Referral Hospital:

58 A forward step towards the restructuring program (which is Level Restructuring) was the review and restructuring of the 2000-staffing establishment in the Ministry of Health. The key emphasis of the restructuring was to put in place key positions for strengthening the Policy, Planning and Evaluation Unit, the finance management capabilities of the MOH, the accounting section both at the center and the provinces. The National Referral Hospital in Honiara the referral and specialist hospital now has a Chief Executive Officer who is on contract, which entails out put requirements. Let alone the administrative problems encountered, it is a staring point for the program. 3.0: The Effect of the Ethnic Tension on the Health Reform Program: The recent twenty months old ethnic tension (1999-2000) had severely affected the reform program. Nearly all programs and activities was interrupted and therefore suspended. The financial crisis, which resulted from the ethnic tension, had badly affected the program. However, the conflict caused many policy makers with in the private and public sector the need to be responsive and manage changes. It was agreed that the existing structure of the public service is static and not responsive to changes in all aspects of finance and Human resource management and all other related areas. 3.1: Continuation of the Health Reform Program: The Ministry of Health, Solomon Islands is committed to continue with the implementation of the health reform program in Solomon Islands. It is hope that the newly elected government after December 2001 elections will remain committed to the proposed reform program. 4.0: Conclusion: There are strategic plans envisaged by the Ministry of Health in addressing issues highlighted by Dr. Omi (RD/WHO_WPRO) in his report (The Work of WGHO in Western Pacific Region. These issues are related to health information and evidence-based policy, health research, and human resource management. The approach the Solomon Islands Government through the Ministry of Health is in two folds firstly to ensure that the structure of the public health sector (structural reform) is conducive for the new systems and process. Secondly introduce the new concepts, processes and systems (process or systems reform). Nonetheless, more effort and commitment from all stakeholders is needed and crucial for the success implementation of the health reform program. It has been experienced that external factors such as conflicts and economical problems have posed threats to the implementation of the reform programs.

Policy Status: 7.1. Policy Directions on Health Sector Reform: More resources will be shifted towards preventive and promotive health services with concomitant rationalization of curative services through imperative cost recovery mechanisms and getting major hospital services to function as a large unit at a minimal production cost. 7.2. Policy Goals:  To establish a flatter structural organization of the Ministry of Health and Medical Services;  To provide for clarity of lines of reporting and accountability;  To ensure separation of policy development and management from operational delivery where appropriate;  To ensure that Management of key stake holders are effective and to re-define the roles and powers of Health Statutory Bodies;  T p vert fuo t “ smr oh l s ori gar c n h ct e”fet ervices; od ee o s e uo s ah  T fuoaaot Misy oai tn i gas uga ipc oo sn rsf e nt’ r n aowhrtt dtyma; c e h i s g z i t ee b er r t  To provide for budget efficiency and effectiveness. 7.3. Policy Objectives:  Restructuring of the Ministry of Health and Medical services  Review job description  Cost shifting from urban based health services to rural based services

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 Cost efficient operation of the major hospital  Improvement of the planning capacity of the Ministry of Health 7.4. Indicators:  New organizational structure of the Ministry  New posts identified  Improved planning office facilities  Reduction of costs in urban based health services 7.5. Strategies:  Seek Technical Assistance to review and development appropriate organization structure of the Ministry  Review job description of officers  Deploy staff appropriately  Development appropriate staff establishment with appropriate costs  Review appropriate health services legislation and regulations 7.6. Action Steps:  Develop new organizational structure with appropriate staff development  Seek provision for funds for deployment of staff in new posts  Deploy staff accordingly 7.7. Implementing Division / Department:  Executing Office of the Ministry of Health  Responsible Officers: Secretary to Ministry with Undersecretaries

3.10.4. Essential drugs and medicines policies:
The year 2000 was a very difficult time for the procurement of distribution of much needed essential drug in the country. As a result of the financial crisis the Government was not able to clear its debt with the two major buying agents. The debts were at an amount to apoia l S D Mio btentetoby gaet H d’int enfr h prx ty B 5 l n e e h w ui gns an t o be o t m e l i w n . t e A saa ad e Z a n G vrm n’H m naa Adw w u nt e b t gt ut ln n N w el d oe et u airn i e ol o b al o e ri a n s ti , d e medicines and other essential pharmaceutical supplies for our people, in a time of need, especially during the ethnic tension.

Activities/ Inputs: T eMisy e ot of az t fs da o t N t nl rgP lyw s h n t ’ f r t i le h it r t f h aoa D u oc a irs f ni e r f e i i hindered by the 1999-2000 ethnic-tension. However, work has started through a WHO consultant who had visited and spent three weeks assisting the Ministry to review the situation and make recommendations to finalize the National Drug Policy. Even before an official national drug policy document, the pharmacy services have already confined to the Standard Treatment Guideline and Essential Drug List for the clinical protocol as well as administrative and procurement of drugs for the country.

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According to a review done by Pharmacy Services Department11, the key issues are related re-establishing links with the buying agents by repaying the debts, making fund available for medicines. Whilst, the National Medical Store has been successful in maintaining services up to the present, a number of areas can be further improved and developed. Areas such as the current stock management system, which currently without a back up system. The current system is limited in function and not user-friendly. The system does not allow the user to do cost allocation and produce order requirements easily. A more reliable and user-friendly system with back up capacity is in need at the National Medical Store. Procurement done regularly but without guideline and standards to follow. Practice is based on precedence and what was done previously. Assessment of the current procurement system and establishment of system for procurement is a need needing attention in the near future (health institutional strengthening project). The overall structure of the Pharmacy Services Division needs to be reviewed and changed. Currently the office of the Director of Pharmacy is based at the National Referral Hospital Pharmacy Department as supposed to its national functions and responsibilities. Thus, there is difficulty in focusing on overall management and planning of the pharmacy services, and day-to-day problems of the NRH are given priority over national responsibilities. The shortage of qualified pharmacists (and pharmacy manager) has limited t pa ay cpcy t m ng ad sprs te pa ay s v e e etely. h hr c’ aai o aae n ue i h hr c e i s f cv e m s t ve m rc f i Nonetheless, the Director(s) and the staff should be commended for the significant impact the pharmacy service to be able to proved access to essential medicine to the people of the country. The other important function of the pharmacy services department as per the legislation is the registration of medicine and regulatory affairs. This is an area, which is apparently weak. The Pharmacy Services Department in liaison with the MOH is seriously looking at strengthening of the regulatory affairs of the Ministry through the Pharmacy Services. It does have implications on the current pharmacy legislations. Policy Status: 2.7.1. Access to Essential Drugs: 2.7.2. Policy Goals:  To achieve adequate supply of essential drugs and medical sundries  To achieve training and support of qualified personal  To have control of dealings in medicinal products through legislative and regulatory mean 2.7.3. Objectives:  To ensure that essential drugs are always available in 90-100% of rural clinics in a year for within the plan period. In particular reliable and adequate supply to rural health care facilities. 2.7.4. Performance Indicators:  Availability of essential drugs at the rural clinics  No. of trained pharmacy officers  Legislature reviewed
11

Anna Chao (2001). Review of Report on Status of Pharmacy Service Division February 2001 by Mr RF Skinner, Unpublished Paper, MOH.

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2.7.5. Strategies:  Development of the National Drug Policy  Organization infrastructure to provide for regular schedules demand-driven supply of essential medical supplies to rural healthcare facilities, from the responsible provincial distribution center.  Provision of adequate staffing establishment and deployment to distribution centers to ensure prompt and efficient processing of orders and prompt and effective dispatch/delivery  Maintenance and development of means of communication with customers (health care facility personnel) through radio, telephone, documentation and personal direct and indirect (through other health personnel) contact, at rural health care center or at province center. Reviewing comments and complaints from customers, and identifying shortcomings and needs.  Maintaining and developing regular means of information provision and dissemination (Bulletins, memoranda, continuing education data etc)  Development of information on usage of supplies through management of distribution and usage information. Identification of wastage, dead stock, etc. and recovery, recycling; determination of usage patterns for national, provincial groups and for individual health care providers.  Maintenance of Essential Drugs List and other national standards for medical products, treatment protocols and monitoring of compliance  Management and review of the procurement activities with attention to efficiencies in costs, quality and supplier performance.  Strengthen the establishment

3.10.5. Traditional Medicine:
There is no formal policy on traditional medicine, which is practiced widely in all the communities in numerous forms. There is mixed feeling about some forms of traditional medicine, as there were cases of death and severe complications. The issues raised are related to lack of detail information on the plant or herb used, its pharmacokinetics (if any), and when and what to use for. However, a research by a senior government officer was done in 1993, which revealed that there are more than forty medicinal plants present in Solomon Islands. The study also found that these medicinal family plants are also found in China and Philippines. All these medicinal plants are in their crude form and need refinement and improvement through a manufacturing process. The practicality to further go into formalizing traditional medicine is difficult because of lack of commitment, expertise and research facilities and other support. However, the issue of registration of traditional medicine can be incorporated in the National Drug Policy as a way to start, whilst the issue of developing a formal policy can follow. Other opportunities include expanding the Solomon Islands Medical Training and Research Institution (SIMTRI) role to traditional medicine. A close collaboration will be built with other stakeholders such as the Ministry of Forestry.

3.11 Technical Cooperation among developing countries:
WHO according to the Director- General (2000) is putting effort in overseeing the technical corporation among developing countries (TCDC). For our shake it is important to

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explore further about the TCDC. There have been changes imposed on many public health sector organizations within the South Pacific Islands Nations. It is occurring in Samoa, Vanuatu, Papua New Guinea, and most recently in Fiji, and Solomon Islands starting fairly recently. Changes in the health sectors are driven by external developing partners on the basis of the local baseline indications that public sector is inefficient and ineffective. Whilst, there is genuineness of the need to change the structure and the behavior of people from traditional restrictive ness to ways that foster efficiency and effectiveness within the public health sector, it is more important that social values as basis for policy formulation and planning. In relation to the Solomon Islands context, the model or approach for technical cooperation should be like what is currently exercised in the Malaria Control Program. There i sogt hi l up r i t m o ‘ r aetm li t hi l dirads a s t n e n a spotn e s fp m nn a r e n a av e n m l r c c r e ’ aa c c s l operational grant. The conceptual underpinning of the approach is that there is guidance to other external developing partners who is also interested to participate. Solomon Islands Context: We are clear in our policy that developing partnership for health development is crucial. We also see the importance of donor coordination, and would like to improve on the current administrative support, which is on adhoc basis to start. The table below briefly shows areas of support and assistance by donor agencies or developing partners.
Table ( 10)Matrix of Current Donor Activity 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) COMPLEMENTA RY COMPONENTS OR ACTIVITIES WITH SOLOMON ISLANDS INSTITUTIONAL STRENGTHENI NG PROJECT Progress (2000-March 2001)

World Bank (Soft Loan)

Solomon Islands Makira and Guadalcan al Provinces

Solomon Islands Heath Sector Development Project (SIHSDP) ($4.5 – 5.9m loan) for 5 year period

The project commenced in February 2000 The priority issues to be addressed include  Maternal care and family planning including the development of midwifery training  Malaria prevention and control  Provincial

The SIHSDP is located in the MOH building with Policy,Planning and Evaluation Divison.

The project is more than a year old. However, there was limited activities done in 2000 because of the ethnic tension. Up till now Oct. 2001 there were already four (4-6 monthly SemiAnnual Reporting done. Most activities in 2000 were related to establishment of a full PCIU facilities and staffing, planning of worksplans and budget, and procurement. Otther

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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 AusAID Solomon Islands Ministry of Finance Institutional Strengthening Financial accounting systems in Ministry and other line agencies The SIG is intending to introduce financial delegations to “t t il e” sa g e l re c v 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

training and service delivery programs was badly disturbed by the ethnic tension. Some of critical point of overlap with this the SIHSDP exists in the activities associated with (1) Health Management Information Systems, (2) Services delivery components such as Malaria and Reproductive Health programs (including EPI), and (3) Rehabilitation of clinics (Civil Works).

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requirements AusAID Solomon Islands, Scholarships Program $0.6 M This program supports training of clinical health staff including  Diploma of Nursing at SICHE  Critical Care Nursing at Qld Uni  Dental Surgery at FSM  Medicine/Surg ery at FSM  Post Grad Obs/Gyn at PNG Close liaison needed, especially in relation to the health workforce planning and HR development policies and programs, to be facilitated by the proposed new project. 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. The project was terminated in 200o earlier than planned.

AusAID and cofunded by NZODA

Solomon Islands

Rural Water Supply and Sanitation $10.3m

AusAID (CASP)

Solomon Islands

Malaria Control, Health education and Education supplies

Provision of Potable Water supply and sanitation facilities for rural communities This project will be drawing to close in 2001. Annual provision of bed nets, anti malarial pharmaceuticals, larvicide and fogging chemicals

AusAID

Regional program

Hepatitis B Project

Hepatitis B immunisation

This vector Borne disease control program interlinks with the MHMS policy development processes and the effective operational planning and implementation within the Provincial Health services. Hepatitis B immunisation

The project was suspended in 2002

65

AusAID

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

($2.0m)

(1997-2000)

Vector-Borne Diseases Control Project ($10)

AusAID (Regional)

Pacific Action for Health ($3.4mil)

AusAID (Regional)

Regional program including the Solomon Islands Regional Program including Solomon Islands

Pacific Islands AIDS and STD Prevention Programme)

AusAID (Regional)

Integrated Community Health Project Kia/Kotova and Maringe areas councils in Isabel Province

AusAID (Regional)

Regional Programm e including Solomon Islands Regional Programm e including Solomon Islands

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

Assists with programmed medical and environmental health services and introduction of vector control mechanisms. The project is designed to provide preventive and health promotional support at community, national and regional levels. Supports and TA to national programs in relation to STD and AIDFS education, prevention, treatment and care. Funding provide through World Vision. Objective was to improve quality of life for about 8000 villagers through the development of an integrated community health programme. Project will cease in 2000 Project implemented by Family Planning Australia 19942000 Project to be extended to facilitate inclusion of family planning training into formal curriculum for nurses and teachers To be implemented

Malaria and other vectorborne diseases

N Ds C ’ particularly those linked with tobacco and alcohol

STD and HIV/AIDS

Situational Analysis Report on STI/HIV completed.

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

AusAID (Regional)

Strengthening family planning organisation finances training and administration. Strengthening family planning organisation finances training and administration. This has policy development

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by Family Planning Australia 19992004

AusAID (Regional)

Regional Program including Solomon Islands

Tertiary Health Care Provision Project

AusAID

AUSAID & NZODA

Communit y Peace & Restoration Fund Emergency Funding

Humanitarian AidHealth Projects Procurement of Medical Supplies

Volunteer medical teams offering specialist services and local capacity building through on-the-job training in Plastic and reconstructive surgery, neurology, eye care and paediatric surgery See Annex (1)

implications and rural health service management proposals which are relevant Phase 2 end of December 2002.

Phase 3 yet to be finalized.

Humanitarian Aid

Executed by Red Cross International

NZODA

Honiara and other urban areas Solomon Islands

Family Health Project ($0.3 Mil pa)

Reproductive health and family planning including program development and IEC production Scheme operates through National Training Unit in Ministry of Education and is targeted at nurse training.

NZODA

Solomon Islands

Training Scholarships

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 in support of the operational management initiatives of this project and the workforce planning strategies which will be developed. Specialist treatment in New Zealand. Need to maintain

18 months supply of medical supplies was procured through the aid, when the country was not able to pay up its debts with international buying agents. Project terminated end 2000.

Suspended in 2000 as a consequence of the ethnic tension.

NZODA

Solomon Islands

Medical Treatment Scheme (NZD65,000/

To assist with treatment of patients for which specialist treatment

Suspended in 2000 as a consequence of the ethnic tension.

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yr) JICA Solomon Islands Rural Health Facilities Rehabilitation Project $15 m

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

liaison. Project Design and 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. It is understood this project will function in cooperation with the NZODA to minimise duplication and will involve churches. Part of a larger Public Sector Reform Project operating from the Institutional Strengthening Unit of the Pie n t ’ r Mis r m ies Department t supported by ADB Linkages exist with a number of SHP components. Suspended in 2000 as a consequence of the ethnic tension.

ADB

Solomon Islands Village areas

Population and Family Planning

Reproductive Health including development of IEC materials

ADB changed its stand and opted for NGOs. Program never being finalized.

ADB

Solomon Islands

Public Sector Executive development Program

Management education programme for Senior Public Servants.

Diploma in Public Services Management Course with Masset University continued despite the tension. Out of the 20 that started about half dropped out leaving 8 regular attendants. Last Module due 2930.10.01.

WHO

Solomon Islands

WHO ongoing Role

Frameworks and technical assistance for projects to promote: Healthy Islands, Health Promoting Schools, New Horizons in Health Funding of fellowships

WHO

Solomon Islands

Human Resources

Potential for candidates to be

Highly successful. There was 100%

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Country Program

Development

identified for training in support of the operational management initiatives of this project and the workforce planning strategies which will be developed. Malaria control

implementation rate. All approved fellowships were taken. Final draft of the 2002-3 done in liaision with the Ministry of Health

WHO

Solomon Islands Solomon Islands

WHO

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

Included in the 20023 Budget

Funding of workshops, training and fellowships for Health Inspectors. Health education and promotion including development of IEC materials. Provides fellowships, limited supplies and materials and WHO office running costs. Provision of contraceptive material for family planning training. Scholarships for midwifery/paediatr ic nurse training. No authoritative document available. Population awareness activities in Family Planning and Maternal and Child Health No authoritative documentation available Pilot one year project to target unemployment, substance abuse and sexual health.

WHO

Solomon Islands

Primary Health Care

UNFPA

Solomon Islands

Reproductive Health

UNFPA

Solomon Islands

Dispossessed Youth Project ($44k)

UNFPA European Union

Solomon Islands Solomon Islands Health

IEC Project (80k) National Census

No authoritative document available Demographic and health data collection and Census conducted during Census successfully completed in 1999.

69

Republic of China

planning Unit and National Census Office Solomon Island National referral hospital

analysis.

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

To implement Phase III of the Hospital refurbishment and upgrading.

Save the Children Fund

Solomon Islands country Program mainly funded by AusAID

Child Protection Project

Incorporates child protection, community based rehabilitation and a youth outreach programme and family support centre.

November 1999 with preliminary reports anticipated in mid 2000 Mainly Renovation on the old ward buildings. Project coordinated and monitored by the National Referral Hospital Development Project Committee (Formed by Ministry of Health & Ministry Works with representatives from ROC and individual contractors. SCF normally operates with a government or NGO partner and provides funding and project management and administrative support

Data analysis completed, and reported. Phase 3 continued despite the tension. By end of December 2000 there 50% completion rate. Follow up was done in April 2001 to enable continuing funding commitment from ROC.

Emergency Support given by the World Health Organization (WHO) to the Ministry of Health and Medical Services, Solomon Islands Government
The ministry of Health has approached WHO on several occasions for emergency support during the two years of this crisis. All the support given is summarized in the Table below. The main areas of support are:1) Reestablishment of malaria control–On Guadalcanal the main emphasis was to establish diagnostic facilities and distribution of treated mosquito nets. Free nets were distributed to all pregnant women and mothers with infants through the clinics. The International Red Cross helped the programme to distribute the nets to the clinics. On Malaita new office and staff houses were built to accommodate additional staff and create a new operational team to cater for the displaced people especially in north Malaita. 74% of the population was provided with nets and the distribution is continuing. The Solomon Islands Medical Training and Research center was also repaired.

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In June 2001 further support was provided to the malaria control programme for the procurement of nets, chemicals, outboard motors, canoes, computers, microscopes and spray equipments. Funds were also provided for the surveillance activity in Honiara and training of health personnel on management of severe cases. Fuel requirements for the programme was also provided. 2) 3) 4) 5) 6) Immunization :- The cold chain for the storage of vaccines were maintained during the crisis. Funds were provided to procure fuel for the refrigerators and to transport them to the provinces Drugs:- A list of essential drugs were provided to the ministry. This will ensure the availability of drugs through out 2001 (AusAID has also provided similar support). Mental Health:- Two workshops were organized for nursing staff in the two provinces to identify and manage psychiatric problems associated with the crisis. Stress management was one of the core topics covered in this training. Prosthetic care: - Since more people were admitted to the hospital with various injuries the demand for prosthetic care has increased. Funds were provided to get essential supplies from local and overseas suppliers. X-Ray machines:- Two portable units are being procured for the provincial health services. Programme and activity Cost (USD) Malaria control:- establishment of a new regional office at 30,000 Malaita to cater for the displaced people. Malaria Control:- Provision of rapid diagnostic test kits and 35,000 mosquito nets for displaced people of Guadalcanal. Restoration of the Solomon Islands Medical Research and 50,000 Training Institute Immunization programme:- Support to maintain the EPI 6,000 cold chain Health care services:- Provision of essential drugs 91,000 Support to Mental Health programme:- to organize 2 workshops for peripheral health workers on psychiatric care and stress management. Support to rehabilitation/ orthopedic care:- Prosthetic care. Procurement of new portable X-ray machines to replaced damaged ones Maintenance of cold chain for vaccine storage for the whole of 2001 Installation of a new cold room at the national pharmacy 7,000 4,000 62,000 14,800 1,125 Status Completed Completed Completed Completed Completed Completed Completed In progresss Completed In progress In progress In progress In progress Completed

Month/ Year July 1999 July 1999 July 1999 Sept 2000 October 2000 Nov 2000 Nov 2000 Feb 2001 July 2001 September 2001 August 2001 August 2001 August 2001 May 2001

Support to the prevention and control of Tuberculosis in 21,000 North Malaita Operational funds for the malaria control programme 60,000 S&E for the malaria control programme Reagents and test kits for STI/HIV detection TOTAL USD 178,000 5,000 564,925

SBD = 2,943,260.00 (2.9 million dollars)

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All the above assistance are provided by WHO from its regional office resources and the biennium allocation of USD 1.5 million is also being fully utilised for planned activities in consultation with the Ministry of health. Policy Status:

Policy 8: Developing Partnership In Health Development 8.0. Policy Statement: Due to lack of capacity in many aspects of health development at all levels of the (Public) Health Sector, developing partnership in-country and out of the country will be further developed and strengthened. 8.1. Policy Goals:  Enhance collaboration with local NGOs and international health developing partners in particular health services delivery to rural population, health financing e.g. donor assistance, human resource development, and training and research, and tertiary health care. 8.2. Objective:  To enhance and improve collaboration and coordination between the Government and developing partners with in the planned period. 8.3. Indicators:  More collaboration links through MOU developed with local NGOs, and international developing partners.  More donor assistance available for health.  Greater participation of NGOs in providing health and related services secured. 8.4. Strategies:  Develop Memorandum Of Understandings (MOU) in Health Development with local NGOs incluing c re ad i ieao lo rans le i t G vn e’ o ybc e h cs n whnr tn d opre i i whh or ns l oeis uh, t tn ia n tr n n t e em tpi j v. c t  Increase collaboration with (appropriate) international human resource development institutions e.g. schools, colleges, universities.  Improve donor coordination 8.5. Action Steps:  Review existing MOUs with different stake holders.  Promote and establish MOU with NGOs including Churches, to assist in health prevention and promotion, and secondary health care delivery to the rural population.  Enhance efforts to secure donor assistance  Enhance efforts to secure accreditation with international universities and other human resource development sources.

3. 12. Eradication of Poliomyelitis:
Solomon Islands Context: Solomon Islands is free of Poliomyelitis. There are no new cases of poliomyelitis recorded in the past ten years. At the moment Solomon Islands is participating a survey to ascertain whether poliomyelitis is completely eradicated as apparent.

72

Polio vaccination coverage is very good in the country. Solomon Islands will continue this high level of immunization coverage. We will also put extra effort in improving our national surveillance acute flaccid paralysis.

3.13. Health Promotion:
Solomon Islands Context: The health sector is anticipating under the health reform package a paradigm shift from just Health Education to a broader Health Promotion. It is aimed to embed with in the local culture the notion of living a healthy lifestyle in the context a city, islands, communities, markets, schools, workplaces and health services. With the restructuring involvement of stakeholders such as church organizations and non-government organizations will be the emphasis. Local resources in terms of existing formal and informal structures, legislation, and systems will be mobilized in order to sustain health promotion advocacy. Pemnr w r ii por snt dvl m n o teN t nl el P ly rii y ok sn rg s i h ee p et fh ‘aoaH ah oc, l a e e o i t i which will be the platform for reform in health promotion. Policy Status: Policy 6: Health Promotion And Education 6.1. Policy Statement: The people of this country will be encouraged to improve and promote personal hygiene, live healthy lifestyles and take responsibility for their own health through appropriate and effective means of communication. Formation of linkages with the community and dissemination of health information is an important strategy ia ii t pi’ bc e n cen h o y oeis hvg e l s j v. c t 6.2. Policy goal:  To enhance behavioral changes, that promote healthy lifestyle and family health especially family planning, maternal care, malaria prevention, and population education.  To promote healthy lifestyles and make healthy choices possible for the people through a combination of education and strategies designed to create supportive environments. 6.3. Objectives:  To increase focus and reorient commitment to enhance preventive and promotion health services to the local community, especially the vulnerable people, the women and children, in the next five years.  To carry out more health education and promotion activities in the rural clinics from 37.3% in 1995 to 80% by 2003.  Increase integration of IEC into all health programs within the ministry as well as other stake holders (NGOs) in the next five years  To promote family health from within the village to encourage and support efforts of parents to make responsible decisions regarding family size and family health.

73

 To strengthen capacity of the health workers to plan, coordinate, implement and evaluate health
promotion activities/ programs in the next five years. 6.4. Indicators:  No. of health education and health promotion activities  Fully documented and implemented orientation  No. of health promotion activities implemented.  Individuals, and families aware, informed and more responsible for their own health and family' health.  Integration of IEC into all health programs and other stake holders (NGOs) involved.  Families aware, informed and more responsible for their own family health.  Human resource development which reflects new health promotion orientation  Improved planning, implementation and evaluation  Key nurses and health educators up to date on promotion on current health issues and problems. 6.5. Strategies:  Reorientation of the Health Education Division from health education to a wider scope health promotion.  Review of roles, jobdescriptions to reflect health promotion priorities.  Increase funding  Secure donor assistance  Identify appropriate IEC training courses.  Organize regular meetings  Establish guidelines for development of IEC materials  Redirect Staff training to health promotion  Organize regular health promotion workshops for local communities, church, and leaders.  Improve community out reach programs and establish village health committees  Strengthen the health education division and the production of IEC materials  Review & change training programs to reflect health promotion focus, partnership and principles of sharing resources.  Improve social research capabilities of health promotion supervisors through training.  Staff training -conduct refresher courses on health promotion 6.6. Action Steps:  Reorientation of the Health Education Division  T.A for IEC & Health Promotion  Increase funding to Health Promotion from Health Budget  Staff training  Resourcing of the division Hard ware & soft ware  Workshops 6.7. Implementing Division/ Department:  Division: Health Education Division  Responsible Officer: Director Health Education in collaboration with USHI and Program Managers.

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3.14. Emergency and humanitarian action:
Solomon Islands Context: Solomon Islands like many other neighbor countries have experienced first hand of disasters either natural or man-made. The unforgettable natural disasters were the, the Earth Quark in 1978, Cyclone Namu in 1985, and the recent twenty months old ethnic tension 1999-2000, which its effect is still experienced. In respond to these natural disasters, management was done through the National Disasters Council. The NDC is created in the Ministry of Home Affairs under legislation, and is limited only to natural disasters The Ministry of Health had been managing disasters though the NDC. Areas of significant involvement in disaster management are the Social Welfare Division, Malaria Division, Water Supply and Sanitation, Health Education and Promotion Division, the Hospitals and Clinics. However, there is no emergency management information system related to health. There is limited information on the inventory of already identified and potential hazards, the risk population, and forms of preparedness strategies. A key deficiency is proper emergency information system. Nonetheless, there is opportunity that a proper emergency management system can be established. The key success factor would be to incorporate EMIS in the current Health Information System at the Statistics Unit, Policy, Planning and Evaluation Division, Ministry of Health. It may not be necessary to create an entirely new separate network but to see if the current network could be linked to a database for EMS. The proposed EMS network or structure will be reviewed in light of the existing Health Information System (HIS). A project proposal is submitted to Manila office (WHO/WPRO) for funding to implement EMIS.

4.0. Conclusion:
The report has revealed some achievements in the health sector as well as challenges, and threats, and opportunities for the future health directions. There are general improvements in the national malaria program, polio, national tuberculosis control program, national diseases surveillance, and maternal health care. There also challenges to the Solomon Islands Government in its planned health developments such as the health reform programs, re-enforcement of the mental health services in a more active way, and prevention of non-communicable diseases. The forthcoming tobacco blhu t t oti sdg e isol e plc n’ er l d s i a i e of commitment to the health of their people. The evidence of support from foreign developing partners provide some opportunities to be exploited especially in getting appropriate technology in the filed of medicine andm ngm n t e e T erlbc m li ad‘ ah iad itte aae eto t r h ‘ l ak a r’n h l ysnsn ii s gh . o aa et l i v’ a are concepts to keep the momentum to drive health development forward. The past twentym nh e n cs cue dvs tno tecut ’eoo yada et tehah ot t i ri as ea ao fh onrs cnm n f c d h el s h c is s ti y f e t

75

services delivery. The rehabilitation and restoration of normal health services delivery will take sometime.

76

ANNEX 1-----------------------------COMMUNITY PEACE AND RESTORATION FUND: AUSAID

EXPENDITURE SUMMARY:
Wd No. Type

Brief Description

Beneficiaries

Amt. Request

Approved

Funded

Unused

Western
KeruHealth Centre Extension& Improvements Kolokolo Clinic Extension Nila Clinic Repairs VakaboClinicImprovements 20 Health 8 2 Health Health Extension and Improvement of Clin ic. Recc: byPHS Extension of health clinic. Recc PHS Repair of existing health clinic due to earthquake damage. Improvements to Maternity Ward. Recc: PHS Catchment area of 2040 people including about 500 schoolchildren Catchment area of 1741people Catchment are of 4257 people which in cludessome displaced families 5 communit ies with 1,700 people - about half are youth and children 25,000.00 31,945.00 20,000.00 25,000.00 25,000.00 31,945.00 20,000.00 25,000.00 3,911.90 22,203.26 26,126.95 14,242.30 21,088.10 9,741.74 -6,126.95 10,757.70

21 Health

Western

$101,945.00

$66,484.41

$35,460.59

Choiseul
Nukiki Clinic Pagoe Rural Health Centre Sasamunga xrayroomextension 6 Health Completio n of final 20% of new clinic. Community paid for training of Nurse Aid Construction of new Rural Health Centre. (Co-funded)EU &Fly & Build. Fullysupported extension to hopitalto house xray machin e provided by otherdonor. App: by PHS Catchment area of 2000 people. Catchment area of 10,000 Allof Choisuel 29,703.50 31,967.00 38,174.00 21,077.50 31,967.00 38,174.00 9,955.15 12,636.07 30,092.76 11,122.35 19,330.93 8,081.24

12 Health 5 Health

Choiseul

$91,218.50

$52,683.98

$38,534.52

Isabel
Nodana Clinic Toelegu Aid Post 8 2 Health Health Upgradin g/Rehabilitation of a health clinic. Appr. by PHS Upgradin g/Rehab. Aid Post clin ic. Also called Isabel Kastom Herbal Clinic. Not part of official 600 secondaryshool and 300 primary 30,000.00 school child ren. Catchment area of 3490. 700 sickpatients from outside community 28,900.00 30,000.00 23,187.50 10,380.00 1,189.26 19,620.00 21,998.24

Isabel

$53,187.50

$11,569.26

$41,618.24

Central
Koela Aid Post Rehabilitation Koilovala Aid PostRehabilitation 13 Health 5 Health Rehabilitatio n of existing Aid Post. Approved byPHS Rehabilitatio n of existing Aid post. Approved byPHS 400 communitymembers 700 communitymembers inclu ding 10 displacd families 70,000.00 70,000.00 11,512.23 15,244.50 11,362.36 1,525.10 149.87 13,719.40

Page 1

CPRF Funded Projects: Expenditure Summary Monday, October 29, 2001

77

WdNo. Type

Brief Description Rehabilitatio n ofexistingAid Post. Approved byPHS Rehabilitatio n ofexistingAid Post. Approved byPHS Rehabilitatio n ofexistingAid Post. Approved byPHS Rehabilitatio n ofexistingAid Post. Approved byPHS

Beneficiaries 500 communitymembers 1000communitymembers-in clu ding7 displacedfamilies. 500 communitymembersinclu ding 6 displacedfamilies 300 communitymembers

Amt.Request Approved 70,000.00 70,000.00 70,000.00 70,000.00 15,244.90 15,244.90 15,244.90 15,244.90

Funded 8,958.58 926.10 926.10 926.10

Unused 6,286.32 14,318.80 14,318.80 14,318.80

MaralounAidPostRehabilitation NaroguAidPostRehabilitation RavuAidPostRehabilitation TogaAidPostRehabilitation

11 Health 3 Health 1 Health 2 Health

Central

$87,736.33

$24,624.34

$63,111.99

Guadalcanal
BelahaClinic SaroClinic TasimbokoClinic VisoClinicUpgrade 20 Health 10 Health 22 Health 6 Health Constructio nof2 unit classroom&turnedinto a clinic. ApprovedbyCMO Constructio nofnewsatellite clin ic. Approved byCMO Renovation of clinic. ApprovedbyCMO Upgradeof clinic. Approved byCMO 300 people 500 people Catchmentarea of4,200people 1,500 people 18,143.40 11,921.00 20,000.00 13,000.00 18,143.40 11,921.00 20,000.00 13,000.00 13,978.45 2,176.25 11,685.65 15,967.15 235.35 20,000.00 -978.45

Guadalcanal

$63,064.40

$27,840.35

$35,224.05

Malaita
AfenakwaiClinic Completion/Furnishing AfioRural HealthCentre AnomasuClinicRebuilding GwarataAidPostUpgrading Malu'uAreaHealthCentre ManawaiClinicImprovement Mbita'amaClinicUpgrading 9 Health Health 4 Health 14 Health Health 19 Health 7 Health Furnitureneededtocompleteclinic-bedsetc plusmedicin es. PHSapproved Provision to renovate theexistingclin ic build in g. PHSapproved Provision of roofing iron toupgradepostto clinic. PHSapproved Catchmentarea of600 people Catchmentof 2000people in ward25, South Mala ita Catchmentarea of550 people 11,400.00 30,000.00 30,952.70 16,121.00 30,200.00 Catchmentarea of3,000people Catchmentarea of5,000people 15,000.00 15,000.00 11,400.00 30,000.00 30,952.70 16,121.00 30,200.00 15,000.00 15,000.00 8,389.05 55,243.45 36,497.85 12,400.00 -1,000.00 30,000.00 -24,290.75 -20,376.85 30,200.00 6,610.95 15,000.00

Provision of roofing iron toupgradeAid Post to Catchmentarea of3,822people clinic. Agreed toprovide extra fundingdueto Upgradin g ofexistin gAreaHealthCentre. PHS approved Upgradin g ofclinic. PHSapproved Rehabilitatio n ofexistingclinic.-requested equip etcetcfor$90,000. PHSapproved

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CPRFFundedProjects: ExpenditureSummary Monday,October29,2001

78

WdNo.

Type

Brief Description Furniture and improved kitchen, toile tand showerfacilitie s. PHSapproved Sola rpoweretc-needsto be ordered from Australia. PHSapproved Provisio n of mattressesforclin ic. PHS approved. Procurementofbuildin g materia ls - some equipment costsdeferred. PHSapproved

Beneficiaries Catchment area of 20,000 people in lcudin g 5,000displa cedpeople Popula tio n of 500 Catchment area of 4,000 people Catchment area of 4,000 people

Amt.Request 20,000.00 19,818.00 1,158.00 67,000.00

Approved 20,000.00 19,818.00 1,158.00 67,000.00

Funded

Unused 20,000.00

NafinuaClinic Upgrading OkwalaClinicEquipment OlomburiClinicImprovement OteRural HealthClinic Building

15 Health 29 Health 18& Health 19 11 Health

19,818.00 1,158.00 19,972.00

0.00 0.00 47,028.00

Malaita

$256,649.70

$153,478.35

$103,171.35

Makira-Ulawa
AorigiCommunityHealthAidPost Extension Heraniau'uAidPostCompletion HunutaNurseAidPost Completion ManasuguRural HealthClinic WaihagaHealthClinicAdmission Ward 15 Health 7 Health 4 Health 9 Health 18 Health Extension to caterforpatie ntsadmitted to stay Catchment area i.e.Isla nd popula tio nof overnig ht . PHSapproved 2000. Completio n of thefirstaid post -nearly fin ished 5,524 people in area of which1,476 wil it already. PHSapproved directly benefit Const. of a 3 roomNurse Aid Post -Admissio n, Office &Outpatie nt rooms. PHSapproved Constructio nofadmissio n ward alo ngside existing clinic. PHSapproved Provisio n of a perm.3 outpatientroomsto repla ce the leaf house. PHSapproved 760 people in 7 communities Catchment are of1,731 in clu dng displaced families All the ward of 1,400 people 12,400.00 16,900.00 15,652.00 16,900.00 15,652.00 21,610.75 10,507.60 12,400.00 12,405.80 6,325.50 9,253.35 8,924.03 7,930.90 4,494.20 9,326.50 12,357.40 1,583.57 4,469.10

Makira-Ulawa

$77,070.35

$44,839.58

$32,230.77

Temotu
Nea/No'oleClinic Additions 10 Health Additio nsto Clinic. PHSapproved catchement area of2500 9,054.20 9,054.20 2,740.00 6,314.20

Temotu
SummaryTotals

$9,054.20 $739,925.98

$2,740.00 $384,260.27

$6,314.20

$355,665.71

Page 3

CPRFFunded Projects: ExpenditureSummary Monday,October29,2001

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