Health sector development
The health systems in the Pacific Island Countries represent great diversity and different stages of development related to their past and current affiliations to the Commonwealth, France and USA.
In the three French areas and territories (French Polynesia, New Caledonia and Wallis and Futuna), the health system is based on the French system, and most funding is provided through the French government. The population has universal access to heath at all levels of health care through a social health insurance scheme. Overall, the system has adequate number of health professionals, nearly all of whom are trained in France.
Under the Compact Agreements with the three countries affiliated with the United States (Marshall Islands, the Federated States of Micronesia and Palau), the health services are supported to different degree by grants from the Federal government of the United States and have access to United States technical agencies. In the Northern Mariana Islands, which is under United States administration as part of the UN Trust Territory of the Pacific, the health system is fully funded by the United States. Health expenditure per capita is high in all these countries. These funding sources influence management and organization of health services and also the training and registration requirements for health professionals.
Countries in the Commonwealth-based group are independent states with historical development of British colonial health system. Countries mainly fund their own health services with support from the Australian Agency for International Development (AusAID) and New Zealand Agency for International Development (NZAID). Generally, health services are free at the point of care.
In Vanuatu, since its independence, there has been an amalgamation of the French and English systems. This process of reform is still evolving.
The major challenge is the provision of service to a population that is scattered over many islands. The logistical problems of ensuring reliable, uninterrupted and good quality primary health care on remote outer islands include infrequent transport links, costly communication and high operational cost. In some countries development efforts may bypass poor or most disadvantaged regions, and services (when they are available) are of low quality, especially for the poor. Logistics is contributing to the disparity in service delivery. For instance Kiribati consists of 33 coral atolls including three island groups, which span over a distance of approximately 5000 kms.
The inadequate coverage of secondary and tertiary care services makes medical evacuations a common feature of the health systems in all Pacific countries. Many patients cannot be evacuated and treated for shortage of funding.
The quality of health services is difficult to assess because there is no agreement on standards or guidelines for best practices. Countries now need to expand the objectives of the health system from coverage of services to quality of care.
Role of traditional healers varies widely across the Pacific. The traditional practices need to be catalogued and reviewed as regards to harms and benefits of these practices.
The use of e-health/telemedicine, which could alleviate some of the coverage issues are limited in the PICs. Evidence from the Solomon Islands experience has demonstrated the value of tele-pathology in improving health services and reducing the need for out of country referrals.
Most PICs provide free health care to all citizens financed by government. This guarantees a relatively fair health system in many countries in terms of financial access (geographic access remains a big problem for large groups). Health care financing continues to be a major issue for many governments. The level of health spending in PICs in general is still insufficient to address the many health challenges. Many health systems are dependent on donors’ funding for public health functions and for human resource development. A few countries, including Samoa and Tonga have conducted National Health Accounts in order to establish the overall expenditure on health care, and Fiji has also indicated interest in this.
With minor exceptions, the primary health care services in the PICs have been either free of charge or heavily subsidized by the Governments. However, the percentage of out-of pocket payments, especially for drugs and specialized health services varies, and can reach up to 35 percent of total health spending (Fiji, Vanuatu).
Several Governments including Fiji are developing health insurance schemes, encouraging both commercial and community social health insurance systems. Currently the level of pre-payment schemes (health insurance) is low and those that exist are all limited to selected groups such as government employees. Social health insurance (when the entire population is covered through a pre-payment system) has implementation problems because the formal workforce and the tax base is small in most countries, and effective mechanisms for collecting health insurance fees are difficult to establish.
WHO recognizes the need of Member States to strengthen their health systems and the need of WHO to improve its own capacity to assist them in doing so. WHO has produced a draft health system strengthening (HSS) strategy entitled "Everybody's Business: Strengthening Health Systems to Improve Health Outcomes – WHO's Framework for Action", Six key building blocks of health systems are identified:
- service delivery;
- medical products and technologies;
- health workforce;
- financing; and
- leadership and governance (stewardship).
The framework calls for WHO to emphasize achieving (and measuring) results in health systems strengthening. The global WHO HSS Framework provides a strategic vision for WHO and is being currently translated into concrete actions that can be taken by the Pacific Island Countries.