Ministry of Health's mission, vision and objectives
The overall goal of the Ministry of Health, as stated in the National Development Plan 2004-2007, is “Continuous improvement in the provision and delivery of preventative and curative health services and equitable distribution of the benefits attained nationwide through effective and efficient allocation of scarce resources and good governance (accountability and transparency)”. The Ministry is in the process of developing its sectorwide plan for the period 2008-2011 to focus its attention and coordinate donor support to achieve this goal.
The proposed objectives are to: (1) improve health status in priority areas; (2) improve access to and utilization of curative health services that are efficient, effective, and responsive to patients and delivered to a high standard nation-wide; (3) improve the quality, sustainability and coverage of public health services through increased responsiveness, efficiency and effectiveness nation-wide; (4) improve, manage and maintain appropriate legislation, plans, policies protocols systems and structures within the Ministry of Health and Medical Services;
(5) improve the quality of health information and data in terms of accuracy, timeliness and dissemination, for better planning, decision making, allocation of resources and monitoring and evaluating performance; and (6) develop a well-performing, highly skilled and supported workforce to enhance the delivery of quality health services.
The strategic objectives set out in the National Development Plan for the period 2008-2011 guide the formulation of the Ministry of Health’s annual operational plans.
Organization of health services and delivery systems
Kiribati has a well established, publicly funded, formal health system administered by the central Ministry of Health. A parallel traditional health system exists, provided by traditional healers and offering local medicines, massage and antenatal, childbirth and postnatal care. Most people use both traditional and formal health services, but there is no coordination between the two systems.
A national referral hospital, situated in South Tawara, provides a comprehensive range of secondary curative services, while Kiritimati Island has a hospital providing basic surgical, medical and maternity services. A new hospital is under construction in North Tabiteuea to serve the Northern District of the Gilbert Islands. A small hospital providing basic medical services is also located in Betio, South Tarawa. These hospitals and one health centre in South Tarawa are the only facilities with medical doctors present. People requiring tertiary curative services are referred overseas for treatment if they fulfil the clinical criteria set out by the Ministry of Health.
Comprehensive primary health care services are offered through a network of 92 health centres and dispensaries. Health centres are headed by a medical assistant - a registered nurse who has undertaken additional training - who also supervises up to eight dispensaries staffed by nurses and nurse aids employed by the Island Council. Six principle Nursing Officers, based in Tarawa, are responsible for the support and oversight of health services in each district and for selected national programmes.
The Ministry of Health faces a number of challenges related to the quality of health service delivery, the availability of supplies and equipment and the maintenance of equipment.
Health policy, planning and regulatory framework
The Ministry of Health works within a comprehensive framework for policies, plans and legislation, the implementation and enforcement of which is variable. The Government has introduced an annual performance-based planning process that requires all line ministries to develop annual output-based operational plans known as Ministry Operational Plans or MOPs.
Public health legislation primarily falls under the Environmental Health Ordinance. The Ordinance, which is over 30 years old, primarily covers water and sanitation issues. The Ordinance and other legislation, including the Medicines Act and mental health legislation, are in need of review to meet current public health requirements.
Health care financing
Kiribati has a publicly funded, publicly provided health system. Government spending on health was US$ 9.8 million in 2006 and has remained fairly consistent over the last four years. In 2006, approximately 13% of total Government expenditure was on health. Revenue generated by the Ministry of Health were mostly generated from the sale of pharmaceuticals and medical supplies. Most Government expenditure is on curative services, pharmaceuticals and staff.
A total of AUS$ 26.9 million (US$ 23 million) in development assistance was approved for health in 2006. This includes AUS$ 12 million (US$ 10.2 million) to strengthen Outer Island health services over a period of four years. A further AUS$ 34 741 (US$ 29 738) was approved to extend hospital facilities in the main referral hospital. Public health services are mainly reliant on donor support.
Human resources for health
Kiribati has an ageing health workforce and relies on retired health staff employed on contract to fill some nursing and medical positions. The current intake of health workers for training is unlikely to meet future employment requirements. A total of 238 locally trained nurses and midwives made up 80% of the health workforce in 2004. Doctors make up the next largest group of health workers. The number of doctors increased from 20 to 30 in 2006 with the recruitment of 10 doctors from Cuba.
Basic nurse training is provided locally through a three-year, hospital-based training programme. Approximately 25 nurses are enrolled in the programme each year. Post-basic training is offered in midwifery and public health. In 2007, about 20 school-leavers were recruited for training as first-level nurses in Australia. These nurses will able to work in Australia and those who are able will be given the opportunity to undertake second-level nursing training. It is anticipated that some of these trained nurses will return to Kiribati and will be available for employment in the health sector in the future.
Locally recruited medical students are usually trained in the Fiji School of Medicine. In 2007, an additional 23 medical students were recruited to undertake medical training in Cuba. Once graduated, doctors in Kiribati receive additional training through short courses and workshops, provided mainly through regional health programmes.
There is a serious shortage of paramedical and support staff. The retirement of a pharmacist in 2006 left only one qualified pharmacist in the country. Most staff employed in laboratory and radiography services, health promotion, environmental health and health information units lack basic qualifications, relying on local in-service training and short courses overseas to learn their skills. There is no pathologist or radiologist employed in the Ministry of Health.
The Ministry of Health has a workforce training plan to guide the awarding of overseas fellowships, but there is no systematic process in place to ensure the ongoing competency of health workers, and no routine clinical supervision or support. Absenteeism and attrition is thought to impact on productivity, and staff motivation is reported to be a human resources management problem.
Partnerships
The Ministry of Health receives significant technical and financial support from development partners. WHO provides funding and technical support to: epidemic alert and response; HIV care and treatment; health promotion, including tobacco control; environmental health; essential health technologies and medicines; health information; and health system development.
UNFPA supports reproductive health activities and UNICEF supports the expanded programme on immunization, nutrition and infant feeding, and IMCI. The South Pacific Community supports the control of tuberculosis, HIV/STIs, noncommunicable diseases, disease surveillance and pandemic preparedness. Considerable support is also provided by the Australian Agency for International Development, the New Zealand Agency for International Development, and the governments of Cuba and Taiwan (China).
A large Outer Island project funded by the European Union is refurbishing Outer Island health facilities, providing in-country training courses from the Fiji School of Medicine and developing primary health care capacity in the Outer Islands.
Challenges to health system strengthening
Kiribati has a well established health system. Its faces many of the challenges faced by other Pacific island countries, but its geography, isolation and extremely small population exacerbate these challenges, which include:
- developing logistical systems that ensure adequate essential medicines and medical supplies are available and accessible at all times;
- recruiting, coordinating, rationalizing and ensuring the quality of basic health-worker training and in-service training, be it local or overseas;
- improving staff competency and performance;
- increasing utilization and the responsiveness of curative and public health services to reduce child mortality, improve maternal health, reduce the incidence of NCDs and reduce the transmission of tuberculosis, STIs and HIV;
- ensuring there is sufficient accurate, timely and relevant health information to inform planning, policy development and monitoring of health sector performance;
- ensuring that there is a responsive disease surveillance and response system in place and that reporting meets international requirements
- managing health sector resources more efficiency to impact on health status, improve planning and donor coordination and strengthen the monitoring of health plans and interventions; and
- updating legislation, regulations and policies.