Solomon Islands National Health Strategic Plan 2006-2010

“Our people’s health is our passion and everyone’s business”

Health Minister’s Introduction
Why there is renewed focus on people and the social health determinants affecting them in the Solomon Islands?

During the past decade the Solomon Islands people have experienced dramatic changes within themselves, their communities and their surrounding milieu and as a result some of these changes have caused serious health problems. In part, this had been due to the relative collapse of primary health care as a result of the ongoing tensions and armed conflict. The country also experiences a significant number of natural disasters and today we are witnessing the reemergence of and increasing incidence of communicable diseases such as malaria and acute respiratory illnesses. Small Pacific islands are threatened by the emerging diseases such as avian flu and as a nation we have experiencing unprecedented social violence resulting in psychosocial health problems, all of which have taken their toll on the population of the country.

In responding to these serious health issues and problems, the Ministry of Health is taking a leading role in quantifying and qualifying or verifying the magnitude and impact of the social determinants through the National Health Review 2004-5. However, this five year plan is but one step in a longer term vision of improving health outcomes. The Ministry of Health is at the frontline in the leadership and working in partnership with all key stakeholders in the coordination of efforts in responding to the problems affecting the health and wellbeing of the people of the Solomon Islands.

The ability of the Ministry of Health to ensure effective and efficient implementation of the national health strategies depends also on the capacity to collect and appropriately disseminate relevant and reliable health information. The Ministry of Health needs to balance its political authority in multilateral coordination with other ministries and Non Government Organisations involved; to coordinate with key stakeholders such as the provinces and Churches to develop appropriate plans and to prioritise resources and to establish partnerships and collaboration at national, provincial and not forgetting the international level.

There have been well documented lessons learnt from the past, and today we are increasingly gathering health information from the communities themselves, in particular from their perception of health seeking behaviour. This is supported by evidence from the routine data collection system and applied research done locally.

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After reviewing a large amount of health data and analysing the evidence, the national health strategic plan has established key health strategic directions, with identified goals and objectives, which focus on and encompass eight key strategic result areas.

These broad key strategies focus primarily on the men, women, youth and children in the Solomon Islands. They emphasise improving the quality of health and wellbeing of the people, with and through people’s active participation right at grassroots community level. Whilst the Solomon Islands Government has established a clear policy statement on improving access to quality primary health care, the national health strategic plan is providing sound, flexible and responsive public health strategies, with clear accountability to scale up accessibility and provide equity to quality health services.

However, in ensuring quality health care and services at primary and secondary level are delivered to the local population, the strategic plan emphasises improving information management and dissemination as a key task to be accomplished for decision making and planning at all levels. Information management is needed so the Ministry of Health can be enabled to identify and manage the necessary organisational change and develop appropriate accountability measures that may be needed in order to improve health outcomes.

Hon. Clay Forau Soalaoi MP Minister of Health

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Solomon Islands Government political will for better health outcomes of the country
For the first time, there is a linkage to and transformation of political intention to a more practical and evidence-based policy and health strategic planning paradigm. The Solomon Islands National Health Strategic Plan 2006-2010 provides the strategic framework for the Grand Coalition for Change, GCC policy statements. The new Solomon Islands Government policy coincided with the development of the SINHSP 2006-10. The timing is therefore appropriate in gaining political commitment and ownership and ensuring the vision and mission enshrined in the GCC Policy Statement is effectively implemented through the national health strategic plan.

On the one hand, the GCC reinforces certain values and essential aspects of key national health strategies; such as promotion of primary health, health promotion and public health strategies as an integral part of response to the increasing needs of people in view of social health determinants of common illnesses. The National Health Strategic Plan on the other hand takes on board and encompasses the key political statements of the Government and in response is identifying and developing the necessary strategies to achieve this over aim.

The Solomon Islands Government, showed commitment envisaged in their health Policy A to ensure adequate funds for increasing accessibility and equity of health care and preventive services to vulnerable and at risk environments and healthy settings are reached through the “people focused’ strategies underpinning the Solomon Islands Health Strategic Plan. The GCC key Policy Statement for Health outlines government intention to:

(a)

Ensure that the Health Sector receives adequate funding to carry out an effective and efficient health care service;

(b)

Promote primary health care in the country through the Primary Health Care Policy and establish Health Promotion Centres in all communities;

(c) (d)

Emphasise, strengthen and promote preventative health care through all appropriate avenues; Upgrade and maintain health care facilities such as hospitals, clinics and aid posts and provide the necessary equipment to enable health workers to discharge their duties more effectively;

(e)

Provide proper and adequate training and improved terms and conditions for medical and health workers;

(f)

Ensure that better networking in the provision of health care services among all stakeholders such as communities, churches and Non Government Organisations and international health organisations;

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(g)

Recognise the value and safe use of traditional medicines by scientifically verifying the potency and curative properties of such medicines;

(h) (i)

Ensure that clean water and proper sanitation is accessible to all communities; Work towards better awareness of the dynamics of population growth and its effects on development;

(j)

Encourage community participation in health promotion and delivery, and promote healthy lifestyles;

(k)

Encourage the use of mobile medical teams to reach remote communities in the country on a regular basis; in this regard, mobile medical ships and/or trucks can be used;

(l) (m) (n)

Review the overseas referral policy with a view to include several other overseas hospitals; Reactivate the Parliamentary Standing Committee on Health; Take drastic measures to prepare as well as address pandemic infectious diseases, such as Sexually Transmitted Infections, HIV/ AIDS and Avian Flu;

(o) (p) (q)

Strengthen mental health services and take measures to extend such to vulnerable groups; Encourage and support other health care providers in the country; Improve and maintain existing public health programs.

Social Welfare directions were also set by government, with the government intending to:

(a)

Provide groups such as the handicapped, single parents and other vulnerable groups with substantial assistance to help them take active part in society;

(b)

Promote the rights of children, youth and women and introduce appropriate legislation and/or policy guidelines to protect such rights;

(c)

Review the current legislation dealing with juvenile offenders with a view to using legal and cultural approaches to their rehabilitation;

(d) (e)

Continue to support charitable organisations in the country; Strengthen existing educational institutions and recuperation centres for the mentally-ill and handicapped citizens and/or establish new ones in each Province and provide them with specialised staff and counsellors;

(f)

Explore the possibility of establishing a national social security scheme, for example, a National Aged Care Scheme to financially support Solomon Islanders who are 65 or over in age

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Acknowledgement of contributors to the development of the Solomon Islands National Health Strategic Plan 2006 - 2010

The National Health Strategic Plan 2006-10 reflects a medium to longer term vision of the Solomon Islands Government in its desire to protect, empower and develop imperatives to enable a better quality of life for all of its people. This has come about as result of passion and commitment from both local staff and fellow external advisors to the Ministry of Health and through the Health Institutional Strengthening Project and their Solomon Island counterparts.

The Ministry of Health Executive gratefully acknowledges the support of all senior health officials, both at the national and provincial health centres for actively participating in the national health review of 2004 and their subsequent involvement in the planning processes of early 2006. This led to the first two key planning workshops held in late March 2006, followed closely by the national strategic planning workshop in early May. The preparatory work undertaken by all Ministry of Health staff prior in the lead up, was crucial to success of the development of the initial first draft.

On behalf of the Minister of Health, Mr Clay Forau Soalaoi, I wish to express thanks to all health participants of the National Divisions and Provinces, our Provincial health Directors, the Health Institutional Strengthening Project/ Technical Advisers, the Chief Nursing officers and other senior health staff. To all Ministry of Health staff must go very big thanks, especially those who have collected health information over the years and been dedicated towards improving health outcomes. Your support towards your national program directors and managers in the planning process has been invaluable.

A special thanks to all Non Government Organisation representatives, key health sector stakeholders and Church delegates for not only their participation in the recent planning workshops, but for their general overall support. As well, I would like to thank other

Government Ministries for their valuable input and support and assistance in developing the wider social context and for their contribution on health determinants. In particular, The Ministry of Education, The Ministry of Finance and the Ministry of Planning deserve a special mention. There were also many other people who were consulted in the lead up phase, and although not specially mentioned, their contribution is gratefully acknowledged.

A special thank you goes to the staff and technical advisors from Jane Thomason and Associates International, for their untiring commitment to foster and boost management and planning capacity within the MOH. Nearly all the assessment reports contributing to the plan

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resulted as a joint output of the Health Institutional Strengthening Project and Ministry of Health and provided the fundamental evidence underpinning the national health strategic plan. Special mention goes to Ms. Christine Evans, Health Institutional Strengthening Project National Health Review Advisor and Ms. Bakaai Iakoba our Medical Statistician, for their tremendous work on updating the Health Information System to their best and for providing the epidemiological picture on the common diseases trends.

A special-thank you also goes to Dr Alex Edmonds for his exciting qualitative study on health seeking behaviour in the Solomon Islands and to Dr David Philips for his review of Essential Public Health Functions. Their reports provided a rich background tapestry of information which has subsequently been embedded into the plan. We would like also mention the quality of mentoring from Ms. Petra Vergeer (Health Institutional Strengthening Project Australian Team Leader) Dr Cedric Alependava (Undersecretary Health Care), Ms. Chris Stuart (Health Institutional Strengthening Project Planning and Management Advisor) and Mr. Abraham Namokari (Director of Policy and Planning).

We are grateful for the continued support of our donors, AusAID, World Bank, World Health Organisation, Global Fund, United Nations Children’s Fund, Japanese International Cooperation Agency and Republic of China officials. Whenever there were planning meetings they are always ready to participate. This signifies a very strong bond with the Ministry of Health and demonstrates a commitment to assist us as colleagues, planners, critics, evaluators and supporters as the Solomon Islands faces to meet up the global challenges of achieving the Millennium Development Goals. This plan is just a beginning of a longer term vision, and we will strive to continually improve the quality of life for all Solomon Islanders.

Dr George Malefoasi Permanent Secretary

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Table of contents
1 2 Executive Summary............................................................................................................ 9 Introduction....................................................................................................................... 10 Ministry of Health Vision ......................................................................................................... 13 Ministry of Health Mission ....................................................................................................... 13 Ministry of Health Values ........................................................................................................ 14 External context ...................................................................................................................... 15 Health seeking behaviour in the Solomon Islands.................................................................. 16 Expenditure ............................................................................................................................. 18 3 Solomon Islands Strategic Health Areas 2006-2010 ..................................................... 19 Strategic Area One: Strategic Area Two: Strategic Area Three: Strategic Area Four: Strategic Area Five: Strategic Area Six: Strategic Area Seven: Strategic Area Eight: 4 5 6 7 People Focus ..................................................................................... 19 Public Health Programs ..................................................................... 21 Malaria............................................................................................ 23 Common Childhood Diseases........................................................... 25 Non-Communicable Diseases ........................................................... 27 HIV/AIDS and Sexually Transmitted Infections ................................... 28 Family planning and reproductive health ....................................... 30 Health System Strengthening........................................................... 32

Responsibility for National Health Strategic Plan Implementation ............................. 37 Appendix One: Linkages between MOH NHSP and GCC health policy...................... 38 Annex Two: Glossary of terms....................................................................................... 42 Appendix Three: References........................................................................................... 43

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Executive Summary

The development of the Solomon Islands 2006 – 2010 National Strategic Health Plan is focused on strategies to improve the health outcomes of the people of the Solomon Islands. The country and its people have undergone significant social and economic upheavals over the past few years with a result that people’s health has been negatively affected. There is also the recognition that the Solomon Islands today is no longer immune or isolated from global trends, such as HIV/AIDS, the threat of emerging diseases and climate change and there is an urgent need to address these challenges to improve the well being of every women, man, youth and child in the country. Although the plan covers a five year period, it should be regarded as a first a step in the longer term vision of the Ministry in meeting the potential health problems of the future.

The cornerstone of this health plan for the Solomon Islands has been formulated and based on evidence and research. Both quantitative and qualitative data, internal and external to the Solomon Islands, have been consulted. Using this, the Ministry of Health has been able to better analyse the social and health determinants that affect heath care and better understand the health seeking behaviour of Solomon Island people to determine priorities. Furthermore, the process of developing the plan has been one of widespread consultation and collaboration, participatory in approach and paced in a manner to ensure that all stakeholders feel they have made a valuable contribution to and are part of the process. It is a plan made by Solomon Island people, for Solomon Island people.

As a result the plan contains eight priority strategic areas. Seven of these are focused on specific health issues or health service delivery issues which are currently affecting health outcomes, or will impact on health status in the future. The Ministry of Health also recognises that in order to make a difference in health outcomes, there will be a need for organisational reform and a strengthening of systems within the Ministry and it is this area that informs the eighth core strategic area of the plan. The Ministry of Health is committed to a people focused approach in the delivery of health services, to improve health outcomes for every man, woman, youth and child in the Solomon Islands and to achieving the strategies, goals and objectives outlined in the plan. Ensuring that the vision and mission statements of the Ministry of Health are firmly embedded in the actions and attitudes of health workers will be crucial to meeting key performance indicators and for effecting positive change at an essentially preventative level. Involving other key health

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stakeholders, working towards a sector wide approach and working through partnerships will be an important aspect to the ability of the Ministry in implementing the plan. By providing a health service delivery firmly based on an agreed common set of organisational and personal values, as well as ample evidence, the Ministry of Health will expect to see health outcomes improve over the life span of the 2006 – 2010 National Strategic Health Plan.

Solomon Islands National Health Strategic Areas 2006 - 2010
Strategic area 1: People focus Strategic area 2: Public health programs Strategic area 3: Malaria Strategic area 4: Common childhood diseases Strategic area 5: Non-communicable diseases Strategic area 6: HIV/AIDS and sexually transmitted diseases Strategic area 7: Family planning and reproductive health Strategic area 8: Health System Strengthening 8.1 Accountability 8.2 Infrastructure 8.3 Information management 8.4 Organisational change

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Introduction

The Ministry of Health adopts the World Health Organisation definition of health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”1.

The key cornerstone of this health strategic plan is the pooling of evidence from various information and research sources. The Solomon Islands National Health Review is a series of independent reports and reviews which provide additional evidence for the Solomon Islands National Health Strategic Plan. These include the country’s health status assessment, the Household Income and Expenditure Survey, the Primary Health Care Clinic Survey, Facility Infrastructure Rehabilitation Plan, Mental Health Strategic Plan, Social Welfare Review, Primary Health Care Clinic Utilisation review and the Health Facilities Role Delineation.

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The national health review contains contextual evidence and information on the following aspects of the health and well being of the people, including the epidemiological trend of health burden. It is an overwhelming fact that there are health inequalities and variations on the occurrences of the common health illnesses affecting the people of the country and the social determinants. Whilst it is evident that some common communicable diseases are of low prevalence, there is obvious epidemiological transition of diseases whereby there is an increase in non-communicable disease such as diabetes and other behaviour related health problems, coupled with the threat of emerging diseases. This evidence was collated and analytically read using an issue mapping methodology2. In doing so the five key flag carrier health issues were prioritised. Supporting qualitative evidence was obtained from a study of the health seeking behaviour of Solomon Islanders using a focus group methodology. The study assisted the Ministry of Health to gain a better understanding of the people’s perception on health seeking behaviour and decision making, their reasons to access modern medicine health systems and as a result, how these decisions contributed towards health status. Health inequalities among various ethnic groups were noted, thus making these people more vulnerable and at risk to developing health problems. There is clear evidence that primary health care service demands needs to address the various vulnerable at risk groups, including gender. Evidence from reports such as the clinic utilisation helps understand primary health care systems performances

The Ministry of Health recognises that the health system, as the major supplier, funder and regulator is under great challenge to meet all health needs in the country. Furthermore there is added pressure in ensuring the needs of the people are met in good time, in both quantity and quality. The health workforce analysis also provided some understanding on health staff performances and productivity originally designated to ensure that limited human resources yield maximum benefit to the people served. All the evidence obtained, reviewed and analysed from the past and present has assisted those involved in the health strategic planning process to base today’s health decisions towards the future health and well being of all the people of the Solomon Islands.

There have been improvements in the level of planning of health activities at the national level at the Ministry of Health in the past eight years. Since 1998 there have been changes in the process, the type of and nature of planning, as well as the tools applied. For the planning period of 1999-2003, a policy development plan was utilised. The eight broad policies in this plan were concerned with developments to improve management and supervision within the Ministry of Health, including access to primary health care for rural people, human resource

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development and strengthening the capacity of disease control programs to reduce morbidity and mortality. This plan also concentrated on the promotion of safe and healthy initiatives, health education and promotion and supporting the roll out of reproductive health programs, especially in the area of family planning. Given the implications of resource limitation at that time, the development of partnership for health was regarded as a priority.

The plan identified key areas of capacity building and implementing them annually. In some ways it was incremental planning building on previous achievements. There were no clear SMART1 objectives and the monitoring and evaluation framework was limited. The level of evidence available at this stage was confined to the available epidemiological tools used in planning. The planning was very much a top-down approach with minimal consultation and negotiations, thus lacked linkage to the operational plans and budgetary process. However, it was at this same period that the ethnic armed conflict occurred and there was a subsequent diversion of goals from developmental strategies towards more of a crisis management framework.

The Health Institutional Strengthening Project was made possible following a request in 1998 for external assistance. The inception of the Health Institutional Strengthening Project, funded by AusAID has significantly impacted positively on the processes and types of tools applied in health planning.

For the period 2004-2005 there was a Ministry of Health Work Plan, where the primary focus was on the reconstruction and re-establishment of primary health care services around the country and the scaling up of secondary health care in a post-conflict environment. At this point of time, further development and progress on health planning was able to be undertaken. The concept of output-based planning was now put in practice and following the “log frame matrix” in the planning workshops with the Divisions and Provinces and national secondary care programs were able to develop their 2005 Operational Plan. Now equipped with a greater understanding of inputs required to produce the outputs, unit costing was able to be made, which was aggregated into total activity costs against cost centres for budget purposes.

From 2005 onwards, linking the operational plans to budget processes began in earnest. The process was integrative with the direct participation of all divisions and provinces. Building on the establishment of output based operational planning and budgeting, the incorporation of clear outcome objectives and indicators was incorporated and developed into the Ministry of Health 2006 operational plans. The concept of using evidence-based data to inform planning
1

Specific, measurable, appropriate, relevant and time bound

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was also applied. Health goals and strategies were revised and 29 key national strategic areas were prioritised. All divisional programs and provincial health services subsequently ensured that their activities planned for 2006 covered the areas of priority, among those revised national goals and strategies.

This national health strategic planning is a quantum leap for the Ministry of Health, building on the national health review as the situational analysis methodology allows. It is a dynamic process, a pulling together of the previous two years planning improvements. It is now more holistic, with significant emphasis on a bottom-top approach and reaching to the level of the community. This plan also attempts to understand, by trends, the magnitude and impact of social determinants affecting the health of our people. The evidence used has helped in forecasting and predicting what we might have to address in terms of health outcomes and assisted those developing this strategy to make sound decisions related to health care, not just for now, but for the future. Nonetheless, there is still room for improvement.

Ministry of Health Vision

The overarching vision for the Ministry of Health is to see a “healthy, happy and productive Solomon Islands people”. This vision will allow everyone to enjoy the highest attainable standard of health through the Ministry of Health’s efforts in health care delivery. Furthermore Ministry of Health will continually work to improve standards and services in a manner appropriate to changing needs and environmental factors.

Ministry of Health Mission

The mission statement of the Ministry of Health is to promote, protect and maintain the good health and wellbeing of every man, woman and child in the Solomon Islands. The Ministry of Health respects the fundamental right of individuals, but equally acknowledges the rights and core values of the community, as well as wider groups in the Solomon Island society, without distinction of race, gender, religion, political belief, economic or social condition, to have access to proper health and medical services. Furthermore, the Ministry of Health believes that health and wellbeing is not just solely the responsibility of the Ministry of Health, but is in fact, a responsibility of all people. The Ministry of Health pledges to provide a high quality national health system that is accessible; appropriate; responsive; and equitable, within the context of national health legislation and within the limits of resource availability. This mission statement

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will allow people to enjoy the highest attainable standard of health through the Ministry of Health’s focus on health care delivery

The 2006 – 2010 national strategic health plan places the people of the Solomon Islands as the central focus of the plan. This resolution by the Ministry of Health helps “ground” the plan into the reality of people’s lives, contexts and culture. Furthermore it will assist health care workers and service delivery providers to more appropriately respond to the health demands of men, women, youth and children in a country that is undergoing social change. This focus also recognises that the health of a population depends on many factors beyond medical care (social determinants of health) and often requires a multidisciplinary approach. With an approach that is strongly people-centred, accountability means that the MOH will be answerable to those people it seeks to serve.

The eight Millennium Development Goals – which include health, education and gender equity, form a blueprint agreed to by all the world’s countries and all the world’s leading development institutions. They have galvanised unprecedented efforts to meet the needs of the world’s poorest people and the Solomon Islands national strategic health plan 2006 – 2010 reflects the efforts of the Ministry of Health to meet the Millennium Development Goal challenges. However, there is recognition that these goals cannot be achieved overnight. Success will require sustained action across the entire decade between now and the deadline and partnerships is a key strategy by which we can meet these goals. Ministry of Health Values

The 2006 – 2010 Solomon Islands National Strategic Health Plan has as an overarching value statement which encapsulates the philosophy of the MOH “Our people’s health is our passion and everyone’s business”.

Values represent the deeply held beliefs within the organisation and are demonstrated through the day-to-day behaviours of all employees. Values should endure over the long-term and provide a constant source of strength for an organisation. It is recognised that health issues cannot be addressed only by MOH staff, but requires a concerted effort by other key stakeholders and community members. Underpinning the MOH values are organisational and social values which will guide health staff.

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Ministry of Health Organisational Values3
• • • • • • • • • • The MOH will adopt a management style based on teamwork, strong management and leadership to achieve improvement in health outcomes The MOH will have a health service that is people-centred and gender sensitive The MOH will provide a service delivery which responds to health care needs The MOH believes in equity for all, including gender The MOH will provide access to quality health care to all The MOH will ensure that service delivery is cost effective – best value for money The MOH will develop partnerships to strengthen health care initiatives and better integrate services The MOH will foster the ethic of patient confidentiality The MOH will pledge itself to the development and retention of a skilled and committed health workforce The MOH will contribute towards peace-building by ensuring good governance, by building trusting relationships and promoting community cohesion through a people-centred approach

Ministry of Health Social Values
• • • • • • MOH staff will be non-judgmental and non discriminatory to all who seek health care MOH staff will respect every man, women and child’s individual rights and culture MOH staff will be accountable for the personal professional standards of our staff and ourselves MOH staff will accept responsibility for our performance and actions while working within the health care system MOH staff shall embrace teamwork – we will work together in an honest, open and transparent way to achieve agreed goals to improve the health status of our people MOH staff will contribute towards bridging the divide between different groups in the community

External context

The National Health Strategic Plan acknowledges that there are external factors and forces which impact or may impact on health status and yet remain outside of the control of the Ministry of Health. However, it is important to identify these forces, because it “locates” the National Health Strategic Plan within a broader regional and national non medical framework.

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The population growth in the Solomon Islands is the highest in the Pacific region and estimated to be growing at 2.8%, but it is uneven, youth dominated and on the move. Access to safe water is an issue and problems of sanitation still occur. Although women are stated to be the economic backbone of the family, there are consistent levels of gender inequity. Women’s lack of participation in events that concern them, (including government processes), threatens to add fuel to the possibility of future tension4. Low-income families in urban areas and young people are emerging as the first generation of Solomon Islanders who are living in absolute poverty. The Pacific Heads of Government acknowledged that Small Island Developing States face particular difficulties in responding to HIV/AIDS and other major diseases. The threat of avian flu is a particular concern to the Solomon Islands as an influenza pandemic may occur at any time due to major changes in the virus and there would be little or no immunity against the resulting virus in the world population. With the cases in Asia, it is important that Solomon Islands and others Pacific countries assess how they are to prepare for such an outbreak. For that reason, influenza is one of the target diseases of the Pacific Health Surveillance network5. Natural Disasters affect the Solomon Islands on a regular basis. Many low lying islands are extremely vulnerable to sea level rise and are predicted be among the first to suffer the impacts of climate change. The impact may be felt for many generations because of the small island states’ low adaptive capacity, high sensitivity to external shocks and high vulnerability to natural disasters. In addition to these natural hazards, Solomon Islands is subject to increased risk from environmental hazards, as a result of logging and dumping of chemicals and garbage. Technical hazards include the location of fuel storage depots close to areas of population and transport hazards resulting from limited maintenance and overloading.

It is acknowledged that the National Health Strategic Plan has been developed in a context of social, economic and political change, taking into consideration potential future impacts in relation to conflict. Ongoing political and economic uncertainties have also ensured that communities have become more sensitive to issues of corruption and increasingly aware of the need for accountability and good governance. Health seeking behaviour in the Solomon Islands6

The Solomon Islands faces some unique challenges in the effective delivery of health service. It is recognised that utilisation of health care is on the increase, but communities make decisions in a society that still utilises home care with traditional healers and western medicine. Those

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factors affecting demand for health services are poorly understood, but the power of the health worker to affect health outcomes is increasingly acknowledged.

Kastom medicine is still widely used in some provinces, including for treatment of new and emerging diseases, as well as established diseases such as sexually transmitted diseases, but households can disagree over whether to use clinics or kastom treatment. Patterns of resort indicate that when an illness is recognised as minor, then kastom medicine is usually the first choice. Barriers to health seeking behaviour include, distance to clinic, transport accessibility, available childcare, quality of service and medicine stocks, fear of injections, drugs and surgery.

Self medication is commonly practiced, especially in relation to malaria, and when a decision has been made to seek health care away from Kastom, the first choice then is usually a clinic. There is a high level of trust in nurses, but there are many factors which weaken community confidence, including issues of confidentiality, lack of staff supervision, wantokism and lack of health information given to clients. Hospitals are valued and there is more trust in doctors, but it has been expressed that it is harder to visit relatives and the quality of health service delivery, with long waits, rudeness, poor hygiene and staff absenteeism is a barrier to people seeking treatment. Private practitioners are regarded as providing a high standard of care, but it is usually too costly for most people and is only used when other treatments have failed.

The referral system is not well understood and therefore frequently bypassed which is creating a huge burden on the National Referral Hospital and there are uneven case loads at the clinics and hospitals. Patients have been said to demand unavailable or inappropriate treatment and there is widespread interest in learning more about health issues, but health

promotion/education has suffered from poor planning and lack of a visual or dramatic component has affected attendance rates.

In terms of the “healthy village” concept there is a demonstrated interest in conducting activities and improving sanitation. Nurses state that barriers to attending clinics may be overcome if there was better perception by the community on illness severity or by improving the relationship with nurses. The health seeking behaviour report recommended that an approach that encourages community participation may be especially suitable in this country given the transportation barriers.

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Expenditure

The Solomon Islands Government budget for health allocation is 14% of total government resources, which is in line with other Pacific Countries at a similar level of development. The recent Health Expenditure Review indicated that the total public expenditure on health in 2005 was well above the Ministry of Health budget. However, non-salary costs indicate that there are sufficient resources to operate health services. As capital expenditure is low at 12% of total public expenditure, this makes allowance for expanding capital spending in the future. It is important to note that total health spending per capita in the Solomon Islands is low in comparison to other Pacific Islands countries7. There will be a need to increase expenditure at Provincial level as well as target funding for diseases of higher morbidity. The Ministry of Health also recognises the importance of escalation in recurrent costs and that there may be a need to set limits on this, while at the same time maintaining the focus on frontline clinical and public health services.

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Solomon Islands Strategic Health Areas 2006-2010
People Focus

Strategic Area One:

Goal: To promote a people-centred approach to health

Outcome Indicator: The Ministry of Health adopts a as a core value a people focus, centred on the needs and aspirations of the Solomon Island people through a people-centred approach

Objectives: 1. Activate health settings approach to empower communities to take more responsibility and participate in decision making for their health 2. Reorient staff to support a people focused approach to health through support of community participation 3. Promote Ministry of Health values 4. Increase implementation of people focus and gender mainstreaming in health care services at all levels

A healthy settings approach, with a focus in each man, woman and child in a community is acknowledged by the Ministry of Health as a the best model for delivering health care in an environment that is fraught with geographical and logistical constraints as well as wide provincial variations in disease burden. It is also an expressed objective that health service delivery will recognise, prioritise and target those communities and people who are most vulnerable. The concept of Healthy Settings8 aims at establishing more effective work relations between the health sector and other sectors to create a healthier environment by solving health and related problems closer to their source. This concept recognises that people form an integral part of the earth’s ecosystem, and therefore their health is fundamentally interlinked with the total environment. A healthy and productive life is determined by two sets of factors; those factors and risks within the control of individuals like health behaviour, and those caused by existing social, physical and economic environment surrounding the individuals.

Working in a post tension affected community is challenging for all sectors, including health. Communities may be fractured with people displaced, have their traditional resources eroded and may still be fearful. However, the health sector can play an important role in responding quickly and effectively to both the physical and psychological needs of affected communities9.

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Health programs must recognise the context and setting within which they operate so they can contribute towards building a more lasting peace. Health care services and personnel can be a means of expressing a commitment to well- being and health goals may be shared amongst different groups often giving a basis for cooperation.

It is the intention of the National Health Strategic Plan to play a part in contributing towards peace-building in the Solomon Islands through strengthening accountability at all levels. We intend to do this through improving supervision, management and displaying good leadership and governance at all levels. Just as important, however, is our aim to encourage all health workers to become positive role models, outwardly demonstrating a commitment to the communities we serve, by embedding Ministry of Health values, professional standards and responsibilities into their daily work ethic.

The Ministry of Health can support peace building by incorporating a strong organisational respect for the differing social and cultural beliefs of the Solomon Islands people. Furthermore, through adopting a strong people-centred approach, including being sensitive to issues of gender and equity, we have the capacity to build and develop trusting relationships with individuals and the communities to improve health and well being. Good health is an essential prerequisite to recovery and for rebuilding social cohesion.

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Strategic Area Two:

Public Health Programs

Goal: Public Health functions are strengthened to be responsive to community health needs Outcome Indicators: • Reduced incidence and prevalence of diseases of public health importance • The mental and social wellbeing aspects of health are increasingly addressed through the health service delivery

Objectives: 1. Increase disease prevention activities to all program areas – Oral health, Tuberculosis/leprosy, Eye health, Reproductive Health and Rural Water Supply and Sanitation 2. Target responses to high prevalence areas 3. Strengthen early case detection, appropriate treatment and management 4. Increase availability and access to safe clean water supplies and sanitation 5. A public health policy is developed, resourced and implemented 6. Strengthen social welfare, mental health and community based rehabilitation and their community focused approaches 7. Strengthen epidemic preparedness disaster and response capacity to meet requirements of International Health Regulations 8. Improve supply, distribution and availability of essential medicines at all health care levels 9. Human resource development and capacity building for implementing Public Health Functions will be developed World Health Organisation regards strengthening the performance of essential/core public health functions as central to ensuring that public health systems can respond optimally to health needs10. While public health is a core element of every government's attempts to improve and promote health, there is evidence that public health systems and services struggle to cope with current demands. Efforts to address these issues need to be considered in the context of broader health systems strengthening.

In the recent years there has been an increase in communicable diseases incidence and the threats of emerging diseases, such as avian influenza have posed serious risks to the health outcomes of the people of Solomon Islands This, coupled with a limited capacity by the health sector to respond timely and adequately in containing some of these disease threats, the

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Ministry of Health has re-orientated its structure and functions in able to match up the increasing demand to contain, prevent diseases, and sustain health care system.

Embracing a Public Health Vision will enable the Ministry of Health to deal with the changing diseases patterns in the country. The Public Health Vision focuses very much on improving and strengthening of the “National Prevention and Control Programs” embedded under the “Health Improvement Banner”. The goal is to promote national health outcomes by preventing disease through active involvement, sound and integrated task-oriented healthcare networks, expertise and proficiency, the full participation of all people in the communities, participation in international activities, and by implementing prevention and control measures against communicable and emerging non-communicable diseases.

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Strategic Area Three:

Malaria

Goal: Reduce malaria incidence and mortality Outcome Indicators: • • • Prevalence and death rates associated with malaria are reduced11 Proportion of the population in malaria risk areas using effective malaria prevention and treatment measures12 Reduction of infant and under 5 child morbidity and mortality rates caused by malaria

Objectives: 1. Increase community understanding of malaria prevention, control and the importance of early treatment including malaria in pregnancy 2. Strengthen community response to addressing malaria as well as community involvement in and support of malaria programs to create a synergy in control efforts 3. Provide timely, appropriate and effective early diagnosis and treatment at all levels 4. Increase distribution and use of bed nets and other effective environmental vector control measures 5. Early detection and response to epidemics

Malaria remains a serious health problem worldwide and Solomon Islands is one of 107 countries where malaria transmission occurs13. As well as its impact on individuals, there are many public health challenges for prevention and treatment in poorly resourced health care environments. In Solomon Islands malaria is responsible for high demand for primary health care services and in 2004 accounted for around a third of all new cases of disease reported and approximately 14% of total primary health care clinic and hospital outpatients department contacts14. More broadly the disease has a major impact on household, local and national economies through its impact on productivity.

The burden of disease is greatest in children less than 5 years and babies less than one year, with rates of malaria in these age groups much higher than those in the broader population. Malaria is the most commonly reported cause of death in the 1 to 4 year age group and an important cause of death babies15. Pregnant women are also a significant risk group, with malaria reported as occurring in 7-8% of pregnancies16.

Although the malaria rate has begun to decline in Solomon Islands, systematic declines are not yet seen across all provinces, underscoring the importance of its inclusion in the National Strategic Health Plan and ongoing focus on prevention and treatment activities. Meeting the

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challenge of decreasing malaria incidence needs increased community participation and understanding of malaria control and prevention activities. Changing and improved health outcomes also need to include timely treatment and early diagnosis.

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Strategic Area Four:

Common Childhood Diseases

Acute respiratory infections, malaria, diarrhoeal diseases, skin infections and vaccine preventable diseases

Goal: Reduce morbidity and mortality of children less than 5 years of age due to common childhood illnesses

Outcome Indicators: • • • Under 5 child mortality rate17 Infant Mortality Rate18 Incidence of common childhood illnesses in infants and children less than 5

Objectives: 1. Strengthen early diagnosis, appropriate treatment and management of childhood infections, via the Integrated Management of Childhood Illnesses program 2. Improve family knowledge of common childhood infections and the importance of prevention and seeking early care 3. Increase outreach and appropriate interventions and treatment in high incidence areas 4. Strengthen Expanded Program of Immunisation to increase immunisation coverage 5. Increase multi-sectoral collaboration to reduce common childhood diseases

In Solomon Islands, children less than 5 and babies less than 1 year bear the greatest burden of disease, with malaria, acute respiratory infections and diarrhoea important causes of morbidity (sickness) and mortality (death)19. Overall children less than 5 are 15% of the population yet experience 31% of all new cases of disease reported through the primary health care information system20. Babies are 3% of the population yet experience almost 10% of new cases of disease reported.

Rates of acute respiratory illnesses are often greater then 2000 per 1,000 population a year in babies, the equivalent of every baby having 2 respiratory infections a year. Diarrhoeal diseases, although reported less frequently than acute respiratory illnesses, also disproportionately affect the young and in this group can cause serious illness and deaths. Prevalence of skin diseases is highest in the young children and almost 1 in 5 received treatment for a skin disease in 2005. Although vaccine preventable diseases are now rarely reported, an outbreak of whooping cough in Western province in 2005, demonstrated that the expanded program of immunisation

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activities needs to be strengthened to prevent outbreaks and spread of vaccine preventable diseases.

Future approaches to decreasing childhood morbidity and mortality will include a strengthened clinical component via the Integrated Management of Childhood Illness program. Communities and families have a role in improving health outcomes for children and babies through better understanding of common childhood infections, their causes, and prevention and through seeking timely health care.

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Strategic Area Five:

Non-Communicable Diseases

Diabetes, cardiovascular disease, cancer and tobacco related diseases

Goal: Prevent, moderate and control non-communicable diseases

Outcome Indicators: • • Mortality related to non-communicable diseases reduced Incidence and prevalence of non-communicable diseases and non-communicable diseases risk factors

Objectives:

1. Promote a healthy lifestyles approach for men, women, young people and children for disease prevention 2. Strengthen the national diabetes program to include early identification and management of people with diabetes and cardio vascular diseases 3. Increase multi-sectoral collaboration to strengthen healthy lifestyle approaches 4. Investigate cost effective mechanisms in prevention, treatment and rehabilitation of non-communicable diseases.

In recent years many Pacific nations have become increasingly challenged to provide diagnostic and lifelong care for adults with chronic non-communicable diseases such as diabetes21. Solomon Islands is no exception. While complications of diabetes have led to increased demand on secondary services22, screening, early intervention and management of people at risk of disease and in early stages of disease, before the onset of complications, is not yet widespread practice. Smoking, a major cause of preventable illness and death, is estimated at 50% of the adult population23, underscoring the importance of continued health promotion aimed at reducing smoking rates. Chewing betel nut is associated with oral cancer and leukoplakia.

Strengthening early detection and management of chronic disease are important, not only to improve health outcomes of individuals, but to manage future health care costs associated with these diseases. Prevention of disease, through promotion of healthy lifestyles, is the most important long term measure for reducing prevalence of chronic non-communicable diseases.

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Strategic Area Six:

HIV/AIDS and Sexually Transmitted Infections

Goal: The Health and wellbeing of the people of the Solomon Islands will not be undermined due to the burden of HIV/AIDS Outcome Indicators: • •

Percentage (most-at-risk populations) who received HIV testing in the last 12 months and who know the results (UNGASS) HIV prevalence rate among pregnant women aged 15 – 2424 Increased rate of condom use in youth, men and women25

Objectives: 1. Implement the Ministry of Health ‘National HIV Policy and Multi-sectoral strategic plan 2005-2010 2. Reduce risk taking behaviours and vulnerability to HIV and sexually transmitted infections 3. Enhance voluntary counselling and testing for HIV as an entry point for confidential prevention and treatment services for Sexually Transmitted Diseases and AIDS (including blood safety) 4. Enhance HIV/STI surveillance, treatment and care 5. Enhance capacity building for national HIV response at both community and institutional level 6. Ensure sustainable development to enable an environment for behavioural change, destigmatisation and against discrimination impacting on health care and prevention 7. Strengthen TB/HIV/AIDS collaboration through a Direct Observation of Treatment Short Course approach

Sexually transmitted infections, as well as being an important cause of acute illness, infertility and disability, increase the risk of HIV transmission. In the Pacific Region, recent surveys of sexually transmitted diseases incidence and at risk sexual behaviours in six sentinel countries – Fiji, Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu - have demonstrated conditions ideal for spread of HIV infection26. Additional risks are widespread HIV infection in Papua New Guinea a near neighbour, with contact to Solomon Islands via its proximity to Shortland Islands in Western Province and high numbers of international shipping.

In Solomon Islands, rates of sexually transmitted disease have been increasing since 2002, particularly in Honiara, Western and Guadalcanal Provinces27.

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It is estimated by the end of 2010, the minimum number of HIV positive people in the Solomon Islands will be least 350 (REFERENCE?). With an estimated 10 undiagnosed cases for each confirmed case, as many as 1,350 may have been infected with the virus by 2010. This is a significant increase in view of the limited resources of the country for management of this (and other) diseases.

This upward trend of Sexually Transmitted Diseases, in line with findings of the report referred to above shows that much work remains in promoting the Abstinence, Be faithful, Use Condoms and HIV/STI prevention messages and reducing high risk behaviours. Poor availability of condoms and limited distribution via health facilities are also important factors influencing Sexually Transmitted Diseases rates.

The objective of strengthening tuberculosis collaboration with HIV/AIDS and the directly observed therapy approach acknowledges the international experience of many countries, particularly in Africa28, where tuberculosis is increasing in line with HIV/AIDS incidence. Tuberculosis remains an important infectious disease in Solomon Islands, the tuberculosis rate in 2005 the highest since 199529. Strengthening effective programs such as the “Internationally Recommended Strategy for TB Control” Direct Observation of Treatment Short Course and collaboration across program areas are a prudent preparation for the future as well as an important intervention in response to current cases.

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Strategic Area Seven: Family planning and reproductive health Goal: Improve reproductive health services and increase uptake of family planning methods Outcome Indicators: • • • Maternal Mortality ratio reduced Proportion of births attended by skilled personnel increased Contraceptive prevalence rate increased

Objectives: 1. Improve health worker counselling skills to discuss sexual health issues including family planning with men, women and young people 2. Improve uptake of contraceptive methods by empowering men, women and young people to exercise free choice 3. Reduce teenage pregnancy 4. Allow women choice in family planning 5. Improve safe motherhood care 6. Improve neonatal health

Globally, deaths of babies in the neonatal period, the first 4 weeks of life, are as numerous as those that occur in the next 11 months and those of children age 1 to 4 years30 and the cause of new born deaths are different from those of older babies and children. Evidence shows that improvements in neonatal health, particularly the first week of life, need increased focus on improving availability of appropriate maternal and neonatal health care. Available estimates of infant mortality31 show that in Solomon Islands between 28 and 30% of infant deaths occur in the neonatal period, with 18 to 23% of these deaths occurring in the early neonatal period, the first week of life32. Reducing this proportion and the overall number of infant deaths will need improvements in neonatal care at time of birth and in the first weeks of life at all levels of health services delivery.

Improved safe motherhood approaches are needed to influence early neonatal, neonatal and maternal outcomes. Many of these are already instituted in Solomon Islands, but challenges remain for increasing the number of births attended by skilled staff, improving health staff skills, particularly in neonatal care and improved continuity of care at all levels of health service delivery. Reducing maternal mortality needs ongoing action directed at improving staff skills and distribution of midwives across the country, systematic appraisal of all factors that contribute to maternal deaths and increased attention to these factors.

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The National Health Strategic Plan recognises the rights of everyone to have knowledge about and access to contraceptives of their choice. Improving access and knowledge requires changes in health staff skills and attitudes to contraceptive availability.

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Strategic Area Eight:

Health System Strengthening

8.1 Accountability (finance, staff and accountability) Goal: Improve management and leadership throughout the Ministry of Health to achieve health outcomes Outcome Indicator: Attitude and professional practices of health staff improve

Objectives: 1. Develop innovative staff management initiatives and systems 2. Improve staff work ethic and staff performance 3. Develop, implement and strengthen workforce planning using the WISN33 tool 4. Improve financial management 5. Strengthen monitoring and evaluation 6. Improve management and leadership at all levels From the recent qualitative study of health seeking behaviour in the Solomon Islands34, it was made very clear that one of the barriers preventing access to health care was the poor attitude of staff towards patients. It is therefore the intention of this strategic plan to strengthen accountability at all levels. We intend to do this through improving supervision, management and displaying good leadership and governance at all levels. Just as important, however, is our aim to encourage all health workers to become positive role models, outwardly demonstrating a commitment to the communities we serve, by embedding Ministry of Health values, professional standards and responsibilities into their daily work ethic.

Work ethics and staff performances need to be seriously strengthened if a patient centred approach to improve health care is to work. This can be achieved through better management and leadership practices. The Executive Management and Leadership Course in which over 60 people have taken part, should support the focus on improving accountability through encouraging participants to act as role models with integrity, supporting them to plan and take actions to deliver health services to meet the priorities and diverse needs of the communities, helping them understand their responsibilities and monitor and evaluate their own as well as staff performance.

Issues of financial accountability have also been raised as a concern in many areas throughout the county and the Ministry of Health is no exception. Improving efficiency and effectiveness of service delivery can free up more funds and resources to provide essential services at both the primary health and secondary health care levels. Investigating the staff needs (both national

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sector employees and direct wage employees) as part of workforce planning as well as ensuring appropriate financial allocation of resources will result in improved health outcomes. In making the best use of all available resources, accountability will be a significant way of making sure this happens, both at a financial and professional level. 8.2 Infrastructure Goal: Appropriate infrastructure reflective of identified needs and resources Outcome Indicator: Increased number of health infrastructure at all levels to meet minimum standards

Objectives: 1. Improved planning for health facility development 2. Develop and refurbish health facilities according to minimum standards (capital works) 3. Improve staff housing focusing to support critical health program implementation 4. Improve maintenance of all health assets including buildings and equipment 5. National Referral Hospital and provincial hospital infrastructure to be developed in accordance with minimum standards.

There is significant degradation of the primary health care infrastructure in the Solomon Islands attributable to the isolation, harsh tropical conditions and prolonged neglect and indirectly turmoil caused by the ethnic tension.

Recent evaluations of health facility infrastructure have begun to provide information about the scope and number of repair and rehabilitation needs. Eighteen area health centres are in need of some form of infrastructure upgrade, with extensive works required for 6, significant work at 7 and minor works at another 535. Review of rural health centres also identified major infrastructure needs with 6 needing replacement, 40 major repairs and 30 minor repairs36. Coordination of resources and application of minimum standards37 to future infrastructure development and repair/refurbishments will be critical to ensure that health facilities are built and repaired with climate, use and maintenance needs in mind. Additional coordination and direction will be needed to allow infrastructure needs to be prioritised. Past failure to identify how health infrastructure assets would be maintained, including equipment, and define and monitor responsibility need to be avoided in the future.

Staff housing has been identified as a major factor affecting staff postings at many clinics and identified as having an impact on staff morale38. Degradation of housing stock for staff is worse than the health facilities these are attached to. Addressing staff housing needs to ensure an

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equitable distribution of health staff to improve primary and public health service delivery will require a major, coordinated, targeted and well funded response.

In common with primary health care infrastructure, hospital infrastructure development and redevelopment need to be based on minimum standards required to support quality health care delivery and capacity to meet community needs and expectation. Development of hospital minimum standards is an area needing further development, with consideration given to future health needs and service demands to be made on provincial hospitals. The National Referral Hospital site master plan39, developed in 2004, needs to be implemented to improve health services efficiency and enhance patient quality of care.

8.3 Information management Goal: Redevelop and increase capacity and utilisation of Ministry of Health, health information systems Outcome Indicator: Increased use of evidence to support health planning and decision making
Objectives: 1. Review and redevelop an integrated health information system 2. Improve data collection, analysis and timely dissemination to all levels 3. Promote evidence based health services planning 4. Investigate legislative support (Public Health Law) 5. Communication strategy developed

With increasing emphasis by the Ministry of Health on using a strong evidence base to determine health interventions and health services planning, excellent health information management and use is crucial. To date, the value of data collection, analysis and feedback has been poorly understood by Ministry of Health workers and subsequently has not been well utilised to guide health delivery. Aside from the central primary health care health information system, the Ministry of Health also has a number of individual program data bases which do not complement each other and as a result, information is not shared.

A major problem with the primary health care health information system is based around the way it was originally developed. While there is much underreporting of data, especially of deaths, of significant concern as is the plain omission of important health information. When data has been collected, it is often found to be incomplete which compromises the validity of the information. Poorly understood case definitions also contribute to data being skewed.

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Surveillance is another area that is somewhat neglected. There is no current surveillance system in place and in light of the threat of an avian flu, early warning and response protocols need to be developed.

In addition, there is currently no central reporting or analysis of data from the provincial hospitals. In addition, the National Referral Hospital health information system is not able to provide some of the required health statistics. The development of appropriate hospital based information systems is therefore necessary to allow the Ministry of Health to have an insight into the complete health status of the people of the Solomon Islands and to plan and decide on health service delivery within hospitals. Furthermore, this will identify in which areas more focus on prevention will prevent patients from having to receive secondary care sometimes with negative consequences to patient’s life like e.g. diabetes patients who have lost a limb due to delayed treatment.

It is acknowledged that some health legislation is outdated. The Health Legislation Review of 200340 provided an overview of Health Law in the Solomon Islands and it was generally noted there was a poor understanding of the Law and of regulatory, supervisory and operational instruments given by current legislation. However, prior to considering any legal reform in light of environmental matters, it was recommended that the general powers contained in Section IV of the Health Services Act be explored, with a comprehensive review of the Environmental Act. Any subsequent polices developed for Environmental Health should be adapted to the SI context, rather than a one size fits all with legislation simple and flexible.

In terms of communication, it is generally recognised by Ministry of Health personnel that communication within the Ministry and between the Ministry and the health services requires significant improvement41. In the past communication problems have were partly due to a lack of basic functioning communication infrastructure, such as telephones, email and faxes, but this has to a large extent been overcome. However, technical improvements are still compounded by a culture of information hoarding within the organisation. There is a need to make better use of communication systems by all Ministry of Health staff, especially in terms of the radio network.

8.4 Organisational change
Goal: Create an enabling environment in Ministry of Health to adopt a people-centred approach to public health approach Outcome Indicator: Health service delivery focuses on a people-centred approach

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Objectives: 1. Health Service delivery moves towards a Sector Wide Approach 2. Health services realigned to support an integrated approach to health care at all levels to address community needs 3. Adopt key findings of the review of Essential Public Health Functions 4. Mainstream health promotion across health services delivery areas and program areas 5. Integrate social welfare, community based rehabilitation and mental health activities

There is a demonstrated need, from the evidence, that health service delivery needs to become more user friendly and respond to the demand side of community need. Strengthening linkages at all levels of the health system with coordination mechanisms that result in integrated, user friendly, patient focused services will be an organisational priority over the coming five years.

In order to achieve this, the Ministry of Health will focus on improving communication and further clarifying roles and responsibilities between national divisions and provincial programs and national divisions and provincial health services overall. In addition, there is a demand to further integrate services. To that end, essential public health functions enable systematic examination of the strengths and weaknesses in a public health system and strategic interventions. The Essential Public Health Review42 recommends modifying the existing organisational structure both limiting the number of segregated vertical programmes and combining areas where there is synergy of function and task. These recommendations have been adopted. A second recommendation was to review current programmes to consider if some might better fit a resource/advisory role rather than operational e.g. public health promotion. The Essential Public Health Functions for the Solomon Islands are:

Function 1 – Monitor and analyse health status Function 2 – Manage disease surveillance, prevention and control Function 3 – Develop/evaluate legislation, regulations & policies for public health Function 4 – Manage health systems to improve public health Function 5 – Protect public health through enforcement Function 6 – Develop human resources in public health Function 7 – Promote health through community participation Function 8 – Ensure the quality of Public Health services Function 9 – Research for public health Function 10 – Disaster and emergency preparedness and response

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The Ministry of Health recognises that in order to improve health outcomes, it needs to undertake some organisational change, including capacity building of the Ministry of Health Executive, a strengthening of Ministry of Health systems and procedures, an increased focus on working in partnership with other stakeholders and a realignment of current internal relationships with an emphasis on monitoring and evaluation.

In order to improve health outcomes it will be essential that the philosophy of the Ministry of Health ‘Our people’s health is our passion and everyone’s business’ becomes a reality. Increased multi-sectoral cooperation and partnership with non government and community based organisations will therefore be required. This can be further strengthened by the MOH moving towards a Sector Wide Approach. A key component of the Sector Wide Approach is to increase coordination and efficiency of development, but with the Ministry of Health taking the lead in strategy formulation and policy implementation. This approach hinges on the focus of achieving positive health outcomes and improved health status of the Solomon Islands people by the Ministry of Health. This is to be achieved in a number of ways, including partnerships with committed donors, a realignment of budget resources to health priorities and by ensuring clear accountability.

The Ministry of Health acknowledges that there have been severe constraints in financing which has been inadequate to run quality services and outreach and the Sector Wide Approach contains elements to strengthen weak and under funded programs and assist the Ministry of Health to tap into new sources of finance over the longer term. Much discussion has taken place with Ministers and senior officials within the newly elected Government who re-confirmed support for the Sector Wide Approach health sector support program.

4

Responsibility for National Health Strategic Plan Implementation

Responsibility for implementing and monitoring the National Health Strategic Plan belongs to every person providing health care in the Solomon Islands. Within the Ministry of Health, key “drivers” at executive, program and provincial level will be identified to ensure that progress is made in accordance with timelines and activities. It is anticipated that these drivers will mainly sit within the “Executive” at the Ministry of Health Headquarters. Implementation will be via annual operational plans, including donor programs and through a Sector Wide Approach mechanism. A monitoring and evaluation framework underpins the National Health Strategic Plan implementation.

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5

Appendix One: Linkages between MOH NHSP and GCC health policy

GCC Policy Statement
(a) Promote primary health care in the country through the Primary Health Care Policy and establish health promotion centres in all communities;

Affirmation of Issues
Studies/ available information confirmed: 1. 2. 3. 4. increasing demand on the PHC clinics limited health promotion activities from the clinic to the communities poor infrastructure at clinic, and hospital levels need to empower communities to improve on their health seeking and protective behaviours

Output level required for MOH
1. Appropriate Service Delivery Packages at the community levels: • • closely guided by the Role Delineation clear protocols for treatment of common illnesses and health promotion and prevention of common health problems

Link to SINSHP
PEOPLE FOCUS Recognised Gender (men, women and children) and their vulnerability due to social and environmental changes, causing risk to health problems such as diseases and its social determinants In response: the Healthy islands/ Healthy settings will be the overarching driving concept; that will ensure the following; Key Strategic Result areas: • empower communities • staff behaviour adapted • flexible, responsive programs, • peer education • quality care • integrated Management of Child hood Illness • family Health Cards Linked Outputs: Guidelines & protocol for disease prevention (including prevention and treatment.), health care as well as community care. Communication strategy is very important. Flexible responsive programs Awareness/ Early detection/ Response Health information systems information provided and dissemination community level PUBLIC HEALTH STRATEGIES: Recognised “Health is everyone’s business In response: Develop a comprehensive public health policy (health protective) Key Strategic Result Areas: Prevention advocacy: • strengthening village health committees for planning and community mapping • strengthen epidemic response • improve distribution and wide spread use IEC materials for BC of common health problems • standard and update information to be used for BC/ HP by key stakeholders • strengthen water supply and sanitation systems • Develop targeted disease prevention programs (for the key 5 disease and +) for health workers at community and also for non-health workers community aide (e.g. VHW) Quality Care advocacy start at 5 key diseases • develop appropriate response protocol for common diseases e.g. diarrhoeas, yaws (epidemic and endemic) and these include defined responsibility areas • improve availability/ distribution of essential medicine Epidemic Preparedness: • Develop a epidemic preparedness and response plan through inter-sect oral collaboration • Public health surveillance (public health/environment act) – updating list of notifiable diseases Integrated approach: Service Delivery packages, tailored but with standardised public health tools/ protocols/ guidelines

2.

Implementation of the MOH infrastructure plan for clinics, staff housing and hospitals;

(b) Emphasise, strengthen and promote preventive health care through all appropriate avenues

Health is everyone’s business- increasing need for Healthy Islands/ Healthy Settings Concept

1. 2. 3.

Empower communities- through the Health Setting Initiatives – such as the Tidy Village Module; Integration of the key health programs at the community / village levels Tailored Service Delivery Packages supporting Village Committees

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c) Ensure that the Health Sector receives adequate funding to carry out an effective and efficient health care services

1. 2.

3. 4.

use limited health funds wisely, efficiently and effectively donor coordination-putting donor funds in the right, evidence-proof health strategies and activities clear resource allocation proper budgeting process including key health programs and institutions (as cost centres), reflecting the operational activities with clear output performance indicators, outcome indicators and impact monitoring and evaluation

1. 2. 3. 4.

Health Institutional Strengthen Project -financial and accounting management Strengthening at National, Hospital and Provincial HQ, encourage donors into a Sector Wide Approach (SWAp). strengthening of the current RAF (resource allocation formula); Proper ME for –programs and finance

ACCOUNTABILITY Recognised: improve the accountability for health programs and resources Monitoring and evaluation (across all program areas) and to the people In response: Innovative staff management initiatives/ system Key Strategic Result Areas: • Link staff performance • leads to management and leadership – programs-national and provincial; community leaders; political leaders; role model • Finance (improve financial management with a supporting accounting system at national/ institutional/ provincial level • operational plans (strengthen ME and reporting of health activities against operational plans) • -workforce planning (WISN as a tool- adopt WISN- develop, implement and strengthen the workforce), why are you here • Minimum standards (??) • Link to community INFRASTRUCTURE Recognised: improve management of MOH infrastructure- including all hospitals, clinics and all other health institutions. In response: Process and minimum standards for new clinics are both important Key Strategic Result Areas: • maintenance • staff housing • revise and strengthen approval processes for new clinics • donor coordination • asset management ACCOUNTABILITY Key strategic results areas • Innovative staff management initiatives/ system; • Workforce planning (WISN as a tool- adopt WISN- develop, implement and strengthen the workforce) Public health strategies with accountability linked to community and other key stakeholders. Integrated approach: Service Delivery packages, tailored but with standardised public health tools/ protocols/ guidelines Healthy Settings and Tidy Village

(d) Upgrade and maintain health care facilities such as hospitals, clinics and aid posts, and provide the necessary equipment to enable health workers to discharge health duties more effectively

From: PHC Infrastructure review: poor infrastructure identified

Implementation of the Infrastructure Plan: taking into consideration 1. Recommendations from the clinic utilisation report 2. Health facility role delineation guide 3. Minimum standards 4. MRH hospital infrastructure review and master site plan 5. Equipment replacement as part of Asset Maintenance and Management Plan

e) Provide proper and adequate training, and improved terms and condition of services

1. 2. 3.

Work ethics and culture very low at all sectors including MOH Weakness in staff discipline Need to improve supervision

1. 2. 3. 1. 2.

(f) Ensure better networking in the provision of health care services among all stakeholders such as communities, churches, and NGOs is done;

Health everyone’s business

3. 4.

(g) Recognised value and safe use of traditional medicines by scientifically verifying the potency and curative properties of such medicines (h) Ensure that clean water and proper sanitation is accessible to all communities

Evidence shows that traditional medicine in SI has been the first point for health seeking behaviour-contact and alternative medicine for terminal illnesses

1. 2.

Five year HR training plan with evidence from the workforce plan (using the Workforce Indicators for Staff Needs database) Use performance appraisal to ensure right people go for further training Link staff performance management with the PSD award system (Terms of Conditions) and Scheme of Services. Clear MOU with key stakeholders especially on the Service Delivery at the community level Integration and Coordination by specific disease prevention and coordination e.g. Three Ones principle in HIV through SI National AIDS Council At the community level: Village Health Committee Initiatives Coordinated meetings/ workshops in Policy development (ME), program planning, and at times of disaster (emergency) and epidemic responses. Develop a Traditional Medicine Policy Safety principles and working with traditional healers (for safe practices)

PEOPLE & GENDER FOCUSED

1. 2.

Evidence that water borne diseases and diarrhoea remain a community health problem Level of access to proper water and sanitation is still below 80% rural areas

1. 2.

Ensure adequate funding for the RWSS program in line with the Healthy setting-tidy village approach to ensure ownership for sustainability purposes

Public health strategies with accountability linked to community ownership and sustainability

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(i) Work towards better awareness of the dynamics of the dynamics of population growth and its effects on development; ensure community participation in health promotion;

1. 2. 3. 4. 5. 6.

Higher growth, low FP/ contraceptive rates, very high proportion of children and youth agegroup High infant mortality High maternal mortality High teenage pregnancy Very low condom usage among women for FP and STI risk prevention

Reproductive health program strengthening 1. Policy development • safe motherhood • adolescence sexual health 2. Services delivery • Integrated management of Child Hood Illnesses • Supporting Family Health Care • FP strengthening, 3. Capacity Building logistics and improve birthing sites and referral systems; 4. HR development and training of health staff and community birth attendants for referral 5. Monitoring and evaluation framework 1. Integrate with other Government sectors such as Department of infrastructure and other sectors dealing with rural development initiatives. 2. Support and increase resources to rural development. 3. Increase PHC outreach services 4. Review and restructure health services delivery to improve accessibility to primary and public health services by rural people. Review and possible establishment of MOU with overseas hospitals

People focus initiatives with integrated Public health strategies linked to gender mainstreaming.

(j) Encourage the use of mobile teams to reach remote communities in the country on a regular basis; in this regard, mobile medical ships and/or trucks can be used (k) Review the overseas referral policy with a view to include several overseas hospitals; (l) Reactivate the Parliamentary Standing Committee on Health

1. 2.

Limited PHC outreach activities Unclear roles of the primary health care centres in light of increasing needs for public health protection and psychosocial health needs.

PUBLC HEALTH STRATEGIES

1.

1.

Increasing need for tertiary hospital care especially for NCDs such as cancer and heart valve diseases, and interplast treatable congenital defects political will lacking in key cross cutting health determinant risky behaviours such as HIV and Tobacco-related health problems.

Update all outdated health laws of the country Passing of the draft Tobacco Control Legislation Development of a health law governing and support the national response against HIV/AIDS

Public health strategies with accountability linked to politicians and other community leaders.

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(m) Government will take drastic measures to address pandemic infectious diseases, such as STI, HIV/AIDS and Avian Flu;

Evidence showing 1. Increasing STIs, high risk behaviours to HIV/AIDS 2. Potential threat of influenza outbreaks as seen in 2003 where there was a small outbreak of Influenza Type A (human strain not the bird strain)

3.

4.

For HIV and STI– strengthen and increase support for the National AIDS Council and the national response (which NGOs and Churches and other Government Sectors) Development of the National Pandemic Influenza Preparedness Plan Meeting requirements of the International Health Regulations (IHR), Strengthen the national Public Health mechanisms and regulations and laws, Strengthen the national Disaster and Epidemic Preparedness Response.

Epidemic Preparedness 1. Develop a epidemic preparedness and response plan through inter-sect oral collaboration 2. Public health surveillance (public health/environment act) – updating list of notifiable diseases Information management Recognised: one coordinating; monitoring and response body In response: Build capacity of central and provincial Health Information Key Strategic Result Areas: One system must cater for all needs – the right data and accessible as well for malaria and reproductive health) National Level: • Create a central repository of health information with responsible for all data analysis and dissemination of results: attending to needs of the 5 key districts/and others) • Improve data collection tools • Re-develop the HIS including a base of ICD and networking with SPC (PACNET) and international IHR • Connect with ICD10-Hospital Provincial level : 1. Create capacity for data collection and analysis 2. Data collection tools and training 3. Feedback dissemination 4. Communication and IT systems to provide communication 5. Legislative support (? change public health law-for - Surveillance issues – obligations to report)

(n) Government will strengthen mental health services and take measures to extend such services to vulnerable groups.

1.

2.

There is strong evidence of increasing mental health problems (both neurotic and psychotic problems). There are increasing psychosocial problems such a result of the changing environment and changing social health determinants.

Integrated Mental Health Services, and related community based services to vulnerable groups like CBR and Social Welfare

ORGANISATIONAL CHANGE FOCUS Recognised: need for intersect oral multisectoral collaboration/ intesectoral collaboration crucial to address social health determinants of diseases (non- disease) In response: • For debate realignment of health services at National and Provincial level - NCD and Communicable Diseases Key Strategic Result Areas: • Integrate services with community health services (CBR, SW etc) • Health promotion- wrapped around all the other programs, and not stand alone • Adopting the community approach • Support via the HIS (possible) • Social welfare division, CBR and Mental Health– rights looking at vulnerable groups, targeting at risk, driving advocacy role, accreditation.

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Annex Two: Glossary of terms
Over recent years, there has been increasing pressure from Governments and donors for organisations who have been funded to prove that the work being undertaken is relevant to needs, is effective and efficient (i.e. money not wasted and what is spent is improving health outcomes). To prove that programs are efficiency and effective has required a tightening of structures, strategies and resource utilisation and proof of relevance through research and evidence. This pressure has also means that there has to be a clear articulation of goals and strategies and the relevance of response activities to meet identified community needs. Finally, monitoring and evaluation is a critical component to accountability. A range of actions as part of a strategy. They should be SMART, realistic, and hindering factors need to be thought of. They need to identify the key players. Community Development work helps people in a community identify their needs and obtain resources, and collectively empower people to have more control over their lives. Community development refers to the processes, tasks, practices and vision to take collective responsibility for their own development. Effective community control requires adequate resources, including material resources, knowledge and a strong skills base. Empowerment means that activities will be developed in such a way that gives ordinary people real options for the future. Evaluation of a strategy is essential. To evaluate a plan one starts with the objectives. What did we set out to achieve? What did we achieve? What did we not achieve and why not? What impact had been made? How far did we get towards reaching the goal? An evaluation can be conducted in a number of ways and be both qualitative and quantitative. It can be about measuring numbers, quantitative or qualitative, about perceptions and stories The principle and practice of fair allocation of resources, programs and decision-making to both women and men, and includes the redressing of identified imbalances in the benefits available. This is what your program should be trying to achieve at the highest level. In many cases a goal may take a number of years to achieve. Often a goal may not be entirely achievable just through your efforts. E.g. one of the MDG is to reduce maternal mortality, but it is not just the health system that may be responsible for achieving this. The concept of Healthy Settings aims at establishing more effective work relations between the health sector and other sectors to create a healthier environment by solving health and related problems closer to their source. This concept recognises that people form an integral part of the earth’s ecosystem, and therefore their health is fundamentally interlinked with the total environment. A healthy and productive life is determined by two set of factors; those factors and risks within the control of individuals like health behaviour, and those caused by existing social, physical and economic environment surrounding the individuals. The second set of determinants are addressed in the Healthy Setting concept. The Healthy Village concept has been developed to address environmental and other related health and social issues in an integrated fashion. In view of the importance of the interrelation between economy and health, the Healthy Village concept has further evolved to include employment and income generation. Healthy Village actions try to facilitate and not duplicate and interfere with ongoing development activities. Healthy Village approaches have the following characteristics in common. They aim to promote and mobilise health and environmental measures and considerations at the village and the local levels. This is a measuring stick selected to indicate to let you know what you have done. There may be output and outcome indicators e.g. an output indicator for a series of trainings for nurses on EPI coverage may have been conducted may read as follows: 25 courses conducted and 250 people trained on the importance of EPI programs (but this does not tell you what effect or outcome of this training on the community). But an outcome indicator can. E.g. in Malaita and Western Province, EPI vaccination rates up to 95%. These are the ingredients, resources, capital, HR, etc which make up an activity. E.g. if you are doing an outreach visit, what inputs need to be described for that to happen. Fuel, accommodation, food, hire of canoe etc. Means of verification. Where are you going to find this measure? E.g. Your program has an objective verifiable indicator of measuring the number of village committees that have been established as a result of the healthy settings and people focus approach. The Means of Verification tells someone where they can find this information documented. It may be documented in a village report or in a quarterly report from a coordinator. These measures can be found by someone who does not know the program, i.e. an objective evaluator can find the information and check its veracity. This is more specific than a goal. Objectives specify what we believe we can achieve in the foreseeable future, and so allows us to set up specific processes and tasks e.g. operational plans. They may be medium or long term and often require a strategy underneath them and can change. Every organisation has a structure that determines how it works, who does what and where, how decisions are made and the nature of authority of the organisation. What has resulted from your output? E.g. if in increased number of outreach activities were conducted focusing on awareness raising on the consequences of malaria in pregnancy ,the outcome may be that an increased number of pregnant women attend ante-natal classes. What is expected to happen as a result of an input? ( see indicator above) An approach to increase the participation of people and communities in activities and programs. Participatory Planning Approach. This is an approach whereby plans are jointly developed and goals, objectives and strategies agreed between stakeholders and the community. There are many tools developed to assist in participatory planning, including focus groups, informal interviews, transect walks, mapping, Venn diagrams and gender analysis. Participatory planning will be one of the main tools used for developing a healthy setting approach with the community as they need to be actively involved in order to have control over their lives. A strategy is about HOW you or an organisation is going to achieve an aim or objective. It is an action or a series of actions. It specifies the means by which you are going to get from point A to point B. E.g. If a programs goal is to reduce HIV prevalence, then it may choose as a strategy behaviour change communication BCC. In the MOH there are pre-defined strategies identified in the role delineation. Strategies can be reviewed or changed according to impact and or evidence.

Accountability

Activity Community Development

Empowerment Evaluation

Gender equity Goal

Healthy settings

Healthy Village

Indicator

Inputs MOV

Objective

Organisational structures Outcome

Output Outreach PPA

Strategy

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Appendix Three: References

World Health Organisation Solomon Islands Leadership Course 2006 UNSW 3 Some of these values have been selected from the Health and Peace-building Filter. UNSW Health and Conflict Project. AusAID (Draft Pilot 3 Solomon Islands ) 2005 4 Strategy for Psychosocial Interventions for Solomon Islands, 2004. UNIFEM 5 PPHSN Guidelines for Influenza Preparedness and Control. Part 1 6 Making Health Care Decisions in the Solomon Islands. Dr Alex Edmonds. Draft. World Bank, 2006 7 Solomon Islands Joint Preparation and Design Mission for a Heath Sector Support Program. AusAID and World Bank, 20/6/2006. Draft not for circulation. 8 The Health and Peace-building filter. Draft Pilot 3 Solomon Islands UNSW Health and Conflict project. AusAID 2005 9 WHO Healthy Settings. Sustainable Development and Healthy Environmental Development. Updated 5/5/2006 10 Essential Public Health Functions in the Solomon Islands. Draft Report. David Phillips. May 2006 11 United Nations Millennium Development Goals 12 United Nations Millennium Development Goals 13 World Malaria Report 2005. Roll Back Malaria 14 Data sources: Solomon Islands Malaria Information System and Primary Health Care Health Information System 15 Solomon Islands Health Assessment Status Report. MOH/JTA International 2005 16 Solomon Islands Primary Health Care Health Information System data 1995-2004 17 United Nations Millennium Development Goals 18 United Nations Millennium Development Goals 19 Solomon Islands Health Assessment Status Report MOH/JTA International 2005 20 Solomon Islands Primary Health Care Health Information System data 2005 21 Solomon Islands National Health Review Report MOH/JTA International 2006 22 Evidenced by long stay patients in surgical wards particularly at the National Referral Hospital and diabetes related problems being identified as the 6th most important cause of hospital admissions at Gizo hospital
23 Malefoasi G., Wale P., Denty J., Smoking and Respiratory Diseases in Solomon Islands: 1999-2003, MOH, Honiara, 2004. (unpublished paper)

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Millennium Development Goals and UNGASS UNGASS 26 WHO. Regional Office for Western Pacific 2006. Solomon Islands component prepared by Ministry of Health Disease Control Unit 27 Solomon Islands National Health Review Report MOH/JTA International 2006 28 WHO Fact Sheets 29 WHO Fact Sheets 30 World Health Report 2005. Making Every Mother and Child Count. WHO 2005 31 Solomon Islands Health Assessment Status Report MOH/JTA International 2005 32 Solomon Islands Health Assessment Status Report MOH/JTA International 2005 33 WHO workforce indicators of staffing needs 34 Making Health Care Decisions in the Solomon Islands. Dr Alex Edmonds. Draft. World Bank, 2006 35 Solomon Islands National Health Review Report MOH/JTA International 2006 36 Correspondence: Provincial Infrastructure Advisor HISP. (Report pending - “Primary Health Care Infrastructure Review. Part two: Rural Health Clinics”) 37 Guidelines for minimum standards for health clinic infrastructure: Area Health Centres, Rural Health Centre and Nurse Aid Posts. MOH 2005 38 Discussions with provincial representatives - Second National Strategic Plan development meeting 2006 39 SI MOH/HISP Advisors Draft Site Master Plan Report. August 2004 40 The Health Legislation Review of 2003 MOH/JTAI 2003 41 Internal Communication and Strategic Plan, MOH and HISP. Draft Paper by the Phillips Group, March 2002 42 Essential Public Health Functions Report. Dr David Phillips 2006 Not for citation
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