Opportunities to Improve 38866 Health Sector Performance In the final decades of the 20th century, Pacific island countries achieved impressive results in lowering child mortality rates and reducing the diseases of poverty. Government and donor efforts to extend this progress continue but in some cases with dimin- ished effectiveness. At the same time, new health concerns challenge the region. Public health systems now face seemingly intrac- table problems associated with noncommunicable diseases such as diabetes and the emergence of communicable diseases such as HIV/AIDS. Funding from governments and donors has continued to flow into the health sector, but outcomes commensurate with the investment have been elusive. The sense is growing that new approaches are needed to address core health issues in the region. In a recent study, the World Bank and regional partners1 looked at human development across the Pacific region. This is a summary from that study of key issues in the health sector and some strategic approaches for addressing them.2 Where the Pacific Island Countries Stand will want to continue efforts to raise rates of birth attendance and im- prove management of high-risk pregnancies. While attended deliveries Within the region, and within individual countries by location and income represent a proxy for healthy birth practices -- and the rate in most level, wide variation in health status and rate of improvement is common. Pacific island countries is high (see table 1) -- the measure indicates For every indicator described below, one or more countries are perform- only that these births took place in health facilities, not that they were ing well. Others, however, are struggling to meet Millennium Development attended by personnel trained to manage deliveries and diagnose or Goals (MDGs)3 and address other crucial health needs. refer obstetrical complications. MDG AGenDA In ChIlD AnD MAternAl heAlth Figure 1: Under-Five Mortality Rates and Prospects Most countries in the Pacific have seen significant declines in child mor- for Achieving MDG Target in 2015 (1990­2000) tality rates in the past few decades. As recently as the 1990s, however, Vanuatu, republic of the Marshall Islands (rMI), Solomon Islands, and Fiji Kiribati had under-five mortality rates above 50 per 1,000 live births. Kiribati two of these countries, Vanuatu and rMI have made striking progress, lowering child mortality by 60 percent and 50 percent respectively in the RMI past decade (see figure 1). For Solomon Islands and Kiribati, substan- FSM tially reducing under-five mortality rates remains an urgent goal. For Palau most of the other countries in the region, with child mortality ranging Samoa between 20 and 30 per 1,000 live births, achieving further declines will Solomon I. be a challenge. 1990 Tonga 2000 2015 Another MDG target, maternal mortality ratio, is difficult to measure Vanuatu target accurately in low population settings. Discordant data make it unclear 0 10 20 30 40 50 60 70 80 90 100 whether some countries in the region are likely to meet their goals. Sources: Secretariat of the Pacific Community (SPC) MDG website and World Bank however, Solomon Islands, Kiribati, and the Federated States of Micro- background papers for Kiribati (2004), Vanuatu (2004), and rMI (2004) prepared for nesia (FSM) appear to have elevated levels of maternal mortality and Opportunities to improve social services: Human development in the Pacific Islands (2005). > > H u m a n D e v e l o p m e n t i n t h e P a c i f i c I s l a n d s Table 1. Key Health and Population Indicators (1996­2001) reproductive health and family planning services are not highly used in the region and contraceptive prevalence rates range from a high of 44 Population Contraceptive Attended percent in Fiji to a low of 10 percent in Solomon Islands (see table 1). IMR Growth Rate Prevalence Rate Deliveries Rate high rates of teenage pregnancy persist, accounting, for example, for 10 percent of births in Samoa, 17 to 20 percent of births in the rMI, and 18 Fiji 16 1.2% 44% 99% percent of births in Pohnpei in the FSM.7 Kiribati 43 1.6% 26% 85% COMMunICABle DISeASeS RMI 29 1.6% 34% 85% Malaria, tuberculosis, leprosy, diseases of childhood, and hIV/AIDS are FSM 40 1.8% 25-35% 88% each of concern in at least some Pacific island countries. Palau 17 Not Available 17% 100% Malaria is the leading cause of outpatient visits -- and probably of mortality -- in the Solomon Islands. In the 1990s, the Solomon Islands Samoa 18 0.9% 30% 80% made great strides in lowering malaria incidence, dropping the rate Solomon I. 66 3.1% 10% 36% per thousand population from 455 to 155. unfortunately, the country's recent economic crisis and ethnic tensions have been reflected in Tonga 13 0.4% 33% 95% diminished success controlling malaria.8 Vanuatu also continues to have Vanuatu 27 2.3% 28% 88% Figure 2. Total Fertility Rates (1985-2000) Sources: International Data Base of the u.S. Census Bureau (latest census data); 7 SPC MDG Database; SPC regional MDG report. 6 5 MAlnutrItIOn 4 regional information is limited but suggests that nutritional disorders, 3 including low birth weight, protein-energy malnutrition in young children, 2 and vitamin A and iron deficiencies among young children and their 2 mothers are all fairly common, particularly among poor and outer island 0 populations. For example, between 8 and 11 percent of babies born in the 1985 1987 1989 1991 1993 1995 1997 1999 Year Solomon Islands, Fiji, and the rMI have low birth weights,4 while the figure Fiji FSM Tonga Kiribati Palau for babies born to teenage mothers in rMI is as high as 30 percent.5 these babies are at high risk of infection because their immune systems Source: International Data Base of the u.S. Census Bureau. are not fully developed. Poor nutrition in early childhood increases the risk of perinatal, infant, and child morbidity and mortality, and it also affects Figure 3. Variation in Total Fertility Rates by Wealth Quintiles children's long-term physical and mental growth.6 (1982­2000) Fiji 1982 hIGh FertIlIty rAteS AnD POPulAtIOn GrOWth 1996 traditionally, large families have been valued in many Pacific island coun- FSM 1985 tries, and high fertility and growth rates, especially in the Solomon Islands, 1999 rMI, Kiribati, and Vanuatu, challenge governments' abilities to improve Tonga 1982 health outcomes while simultaneously increasing the capacity of health 1996 systems to serve rapidly growing populations (see table 1). Kiribati 1985 1999 Although fertility rates are decreasing, the rate is very gradual. In addi- Lowest 20% Palau 1985 Highest 20% tion, women in the lowest wealth quintile have significantly higher total 2000 fertility rates and their rate of total fertility decline is lower than women in 0.0 1.0 2.0 3.0 4.0 5.0 6.0 the highest wealth quintile. (See figures 2 and 3 for fertility rates in five countries where longitudinal data are available.) Source: International Data Base of the u.S. Census Bureau. PAGE O p p o r t u n i t i e s t o I m p r o v e H e a l t h S e c t o r P e r f o r m a n c e : S u m m a r y R e p o r t a prevalence of malaria, with an incidence rate per thousand population Figure 4. Incidence of HIV/AIDS (1997, 2005) that dropped from 85 in 1992 to 69 in 2002. In the rMI, Vanuatu, the FSM, and Kiribati, tuberculosis and leprosy are Fiji prevalent and are among the major causes of morbidity and mortality Kiribati (see table 2). FSM Communicable diseases of childhood still account for child deaths in the RMI 1997 Reported Cases region, despite high coverage of immunizations. Measles immunization Palau 2005 Reported Cases rates, for example, range from 73.6 percent in Fiji to 98 percent in Samoa Samoa 1997 Cases and 99 percent in Palau.9 Solomon I. per 100,000 Population Sexually transmitted diseases are a growing threat in the Pacific. the Tonga 2005 Cases per 100,000 Population reported number of hIV/AIDS cases remains low (see figure 4), but the Vanuatu lack of routine monitoring and surveillance mask the true extent of hIV 0 20 40 60 80 100 120 140 160 infection. likewise, the incidence of sexually transmitted infections (StIs) Source: Secretatriat of the Pacific Community, MDG report 2005. is rising, with the real rate probably higher than the reported rate; knowl- edge of StIs other than hIV/AIDS is extremely low among young people.10 Figure 5. Prevalence of Diabetes Mellitus, Population Ages 20-79 Prevalence of hepatitis B, which is often sexually transmitted, is high in New Zealand the FSM, Palau, and Kiribati.11 the rise in incidence of cervical cancer may Japan be directly due to the high incidence of the sexually transmitted human Australia papilloma virus (hPV).12 Vanuatu Tonga nOnCOMMunICABle DISeASeS Solomon I. Samoa Most Pacific countries now confront a "double burden" of communi- Palau cable and noncommunicable diseases. the incidence of diabetes, for FSM example, now approaches that in many industrialized countries in the RMI region, despite low and late detection13 (see figure 5). In Kiribati, the Kiribati Fiji annual number of diagnosed new cases of diabetes increased from over 100 in 1992 to about 1,100 in 2001.14 there is also evidence of 0 2 4 6 8 10 12 14 rising prevalence of type II diabetes among children and adolescents in Source: International Diabetes Federation, Diabetes Atlas 2003. the region.15 the prevalence of risk factors for many of these noncommunicable Cardiovascular and coronary heart diseases, hypertension, chronic pulmo- diseases -- obesity, poor diet, tobacco consumption, and declining physi- nary disease, cancers (especially liver, lung, bowel, oral, stomach, breast, cal activity -- are of equal concern. Smoking, for example, increases the and cervical) and end-stage renal disease are also of particular concern. risk of cardiovascular disease, several cancers, and chronic lung disease, liver disease (including cirrhosis and liver cancer as the result of high while obesity and poor diets are risk factors for cardiovascular disease, levels of hepatitis B and excessive consumption of alcohol) is among the diabetes, hypertension, and other cancers. Smoking prevalence rates of leading causes of death in Kiribati and the FSM. around 40 percent have been recorded in many Pacific countries.16 Table 2. Tuberculosis and Leprosy Prevalence in the Pacific (2003) Fiji Kiribati RMI FSM Palau Samoa Solomon I. Tonga Vanuatu Tuberculosis prevalence rate per 38 60 60 62 76 44 60 44 71 100,000 population Leprosy cases 2 21 76 89 7 11 5 0 7 Source: WPrO/WhO, Global health Atlas 2004. PAGE > > H u m a n D e v e l o p m e n t i n t h e P a c i f i c I s l a n d s Obesity -- a combined indicator of poor diet and low physical activ- Figure 6. Association of Public Spending ity -- affects more than 10 percent of the population in about half the and Health Outcomes in the Pacific (1990­2002) countries in the region.17 Increasingly, traditional diets are being replaced by imported processed foods that are high in fat and low in nutrients. 150 100 how effective Are health resources? 50 Governments are the main providers and financiers of health services in the 0 Pacific. With the exception of Fiji, the resources allocated to the health sector are comparable to those in most middle income countries -- a clear com- etaRytilaroM5rednU -50 mitment by governments to their people's well being. As indicated in table 3, -100 total government expenditures on health in the region range from 8.8 to 17.5 percent. Pacific island countries' health spending as a percent of GDP -150 is another measure of relatively abundant resources invested in the health -150 -100 -50 0 50 100 150 Per Capita Public Spending on Health sector. Compared with low and middle income countries, which average y = 0.0886x + 16.809 spending 2.8 percent of GDP on health, and east Asia and Pacific countries R2 = 0.0174 generally, which average spending 1.8 percent of GDP on health, Pacific note: Public spending and under-five mortality are given as a percent deviation from rate island countries range from 2.8 percent in Fiji to 12.5 percent in Kiribati. predicted by GDP per capita. Source: World Development Indicators. In relation to these resources for health, outcomes are not strong (see fig- ure 6). For a correlation between generous resources and high outcomes related more to how well policy makers manage existing resources and to hold, governments must target spending to the poorest and most how effective they are in engaging partners outside the sector in broad vulnerable and set up well-functioning institutional structures for service governance activities. Overall, increased effectiveness will result from delivery. Growing evidence shows that good policies and institutions are aligning resources with outcomes and building in incentives for providers crucial to ensure the productivity of public spending.18 and clients throughout the system. Improving health Outcomes exPAnDInG SerVICe CAPACItIeS Government effectiveness in addressing health issues can be examined Capacity expansion is still a priority in the areas of providing health facili- in three policy domains: service expansion, sector management, and ties in remote areas and in attracting sufficient numbers of doctors and governance. earlier improvements in health outcomes in the Pacific nurses to staff the health system. region were often related to the expansion of resources and services. Access to health facilities Most Pacific countries have extended system coverage successfully. With the notable exception of capacity issues related to medical staffing and In all countries, hospitals and health centers are located in urban areas while outer island access to services, in the future, health improvements will be dispensaries, nursing stations, and aid posts serve more remote populations. Table 3. Health Spending in the Pacific Region, Average 1997­2003* Low & East Asia Fiji Kiribati RMI FSM Palau Samoa Solomon I. Tonga Vanuatu Middle Income & Pacific Percent of Total 8.8% 14.8% 12.8% 8.8% 13.1% 17.5% 13.0% 11.1% 12.6% Not Available Not Available Government Expenditure Percent of GDP 2.8% 12.5% 11.3% 5.8% 8.2% 4.1% 5.1% 3.2% 2.9% 2.8% 1.8% * Constant 2000 uS$. note: the inclusion of fund categories for calculation of expenditures varies across countries: rMI, FSM, and Palau (Compact countries) exclude Compact capital funds. Kiribati, Solomon Islands, and Vanuatu exclude government capital expenditures and donor funds. Fiji, Samoa, and tonga exclude donor funds. Sources: Government budget documents; World Development Indicators; PrISM. PAGE O p p o r t u n i t i e s t o I m p r o v e H e a l t h S e c t o r P e r f o r m a n c e : S u m m a r y R e p o r t however, even with infrastructures designed to provide health services in recurrent health budgets -- even though hospitals provide very little ter- outer islands and rural areas, serving small, dispersed populations remains tiary-level care -- Pacific governments can improve the cost effectiveness a challenge. Additionally, countries with rapid population growth, such as the of their interventions by reallocating funds to adequately fund primary Solomon Islands, must continue to expand services to meet demand. and preventive care. When hospitals do provide tertiary care, they treat at Medical staffing and migration great expense many advanced cases of diseases that can be prevented or successfully managed. In the rMI, for example, diabetes and related Over 15 percent of Pacific island doctors and nurses have migrated to the complications constitute more than 70 percent of all hospital admissions u.S., new Zealand, Australia, the u.K., and neighboring island countries and absorb over 14 percent of the total health budget,20 yet diabetes that in the past two decades, and this trend is expected to continue.19 Factors is diagnosed early can be managed in outpatient primary care facilities.21 that push medical professionals out of Pacific island countries include low remuneration, poor working conditions and difficult environments, shortages Health provider motivation and performance of supplies and equipment, and a lack of continuing educational opportunities Poor performance by health providers is not uncommon. erratic attendance for professional and career development. Factors that pull them to migrate and limited availability of doctors and nurses can be barriers to improving include higher salaries and better opportunities to educate their children. to health outcomes. Additionally, in more remote hospitals, administrative deal with these shortages, especially of doctors, Pacific countries have re- responsibilities divert doctors from clinical duties. In outer island aid posts cruited retirees and foreign professionals through donor-supported programs. and dispensaries, a significant number of health assistants are reported Governments might also experiment with incentives, such as improved to be frequently absent from their posts and have been found to keep working conditions and higher remuneration, to retain staff in remote inadequate records.22 efforts to increase the accountability of health care areas. Other options include providing incentives to attract migrants back providers have begun in Fiji, Samoa, Vanuatu, and the Solomon Islands, home, such as the "return fund" and the "family incentive scheme" in the where senior managers are now appointed to five-year performance con- Cook Islands or the "homecoming program" for nurses in the Caribbean. tracts. Finding ways to extend such accountability to individuals throughout Doctors have begun returning to the Solomon Islands because the scheme the health systems has promise for improved performance generally. of service was updated and public salaries and benefits were adjusted in line with current market conditions. Pharmaceutical management even though large proportions of government health budgets are spent heAlth SerVICe MAnAGeMent on pharmaceuticals and medical supplies, many Pacific countries' For all countries in the Pacific region, the challenges of sectoral manage- procurement processes are not cost-effective or efficient. Quantities are ment are now eclipsing the earlier focus on service expansion. too small for bulk discounts and in some cases brand name rather than generic drugs are purchased. Inventory mismanagement at the ordering Service level utilization or shipping stage frequently results in drug shortages in health centers In all countries in the region, inpatient and outpatient hospital care are and dispensaries. In place of independent procurement practices, financial provided either free or for nominal fees. In the absence of referral systems savings and inventory efficiencies could result from a regional approach that require people to use health services at the lowest appropriate level, to procurement, for example through the Fiji Bulk Purchasing Scheme or a there are no incentives for using primary care facilities instead of hospitals pooled procurement body such as that established by the Organization of with their better-trained medical personnel. Increasingly, urban populations eastern Caribbean States.23 choose hospitals for all outpatient services. On the other hand, people who live far from hospitals underutilize inpatient GOVernAnCe OF the heAlth SySteM services that they need. In Vanuatu, for example, 98 percent of hospital in- Policy at the governance level can lift health sector performance by pro- patients come from the five predominantly urban islands on which the coun- moting broad institutional arrangements that link public health services to try's hospitals are located; 2 percent come from the remaining 63 inhabited people and institutions that are beyond the scope of sector management. islands. As an equity issue, because the hospital share of government health funding is disproportionately high, Pacific health budgets disproportionately Delegation and decentralization of public services serve urban populations, who tend to be the relatively wealthy. By delegating management and financial resources to local health provid- Allocation of resources by level of care ers, governments can better assign accountability and foster improved performance. With the dispersed population groups and geographic the allocation of public health resources to preventive and primary care is barriers common in the Pacific, such delegation is perhaps a necessity. low. With hospital costs absorbing more than 50 percent of governments' the key is to ensure that clear links exist across all levels of the system. PAGE > > H u m a n D e v e l o p m e n t i n t h e P a c i f i c I s l a n d s With extensive donor support, Fiji, Vanuatu, the Solomon Islands, tonga, In some cases data systems do not allow the integration of hospital and and Samoa have all undertaken reforms that support the delegation of dispensary data, or records are incomplete or inaccurate. these are responsibility for service delivery from central to local health departments. issues that can be addressed within the health sector. In other instances, In Fiji, considerable success has resulted from a two-stage decentraliza- countries have no household-level data to serve as a check on informa- tion -- first from the Ministry of Finance and Planning and the Public tion collected internally by health systems -- a governance issue. even Service Commission to the Permanent Secretary of health, and then from when household surveys are conducted, the data collected may include the Permanent Secretary to the directors of the three geographic divisions. income levels and direct expenditures on health care but lack information efforts to increase management capacity and performance have accom- on utilization, access, and type and level of provider. Such information is panied these moves. Morale among health personnel is reported to have key to planning for equitable distribution of health services across income improved and division directors are now able to allocate human resources groups and for evaluating different public health strategies, including the and budgets according to local needs.24 regulation of fee-charging practices in support of resource reallocation to Delegation and decentralization: increasing provider choice primary and preventive care. While modes of service delivery vary by country, most formal health ser- Financing of health services ­ managing fees vices in the region are delivered by the public sector. In Kiribati, Vanuatu, Pacific countries may be moving too slowly to use fees, subsidies, insur- and the rMI, health services are almost exclusively provided by central ance, and other mechanisms to encourage better use of health services government. Across the region, private sector involvement has been and better household management of family health. the many benefits of limited to two hospitals (one each in Samoa and Fiji) and to pharmacies this approach include more effective targeting of services to the poor, lim- and medical and dental clinics in urban areas. Most nGOs providing iting overuse of expensive services, bringing overseas referral costs under health services offer clinics and counseling focused on adolescent health, control, encouraging better self-care and prevention, and reinforcing the and traditional healers are important providers informal health services. concept of cost and responsibility in the use of health services. Churches have a limited role, except in the Solomon Islands where a hospital and other primary facilities are church supported. As noted, free or nominal fees for consultations and hospital services result in overuse of expensive services, mainly by those who are best So, while governments are responsible for health outcomes, ministries of prepared to pay more. If hospital fees were increased (with appropriate health are not the only option for service delivery. In instances when gov- exemptions for the poor) while primary-level services were free, the ad- ernment health services can make little headway, for example, in improving ditional resources could be used to strengthen health services in rural and immunization rates in the rMI and Vanuatu, public services may not be remote areas and to provide travel allowances for those who need them. the most effective delivery option. Contracting with nGOs or churches to health equity funds are another option for protecting the poor within a fee provide services to highly resistant patient groups or in remote areas has structure, with local authorities disbursing funds to poor households to en- several benefits. So long as contracts are sufficiently detailed to be able to courage better utilization of services. Vouchers can be used as incentives measure performance, governments can focus on outcomes, circumvent to increase immunizations and utilization of health services. the challenge capacity constraints, take advantage of the flexibility and autonomy of the of such subsidies is the sophistication of the measures required to identify private sector, and use competition to increase effectiveness and efficiency. qualifying families and the associated high initial costs for small countries, Formal health systems also have the opportunity to collaborate with as in the Pacific. traditional healers, whose importance in Pacific society is reflected in their Introducing risk sharing mechanisms numbers. In Samoa and tonga, for instance, an average of three traditional healers live in each village.25 they are often the first point of contact for Most countries in the region have begun to introduce risk-sharing mecha- diagnosing and treating reproductive health problems, including hIV and nisms. In Samoa, a medical savings scheme is being considered. Fiji, Vanu- StDs, and have the potential to serve as valuable partners to better moni- atu, and tonga are all considering social health insurance and/or increasing tor such diseases. user fees. the poor could participate through subsidized insurance or slid- Information sharing and monitoring: data for decision making ing-scale fees and copayments (as was done in Palau until 1998). Another option, adopted in Vietnam, mandates that per capita government funds be Pacific island countries have made progress improving health set aside to purchase insurance or cover health care costs of the poor. sector data collection but, with the exception of tonga and Samoa,26 governments can do much more to provide decision makers with suf- Managing overseas care ficiently detailed and accurate information to inform their policy making Given the limited tertiary treatment capacities in most Pacific countries, and planning. most governments subsidize overseas specialist care. these expenses PAGE O p p o r t u n i t i e s t o I m p r o v e H e a l t h S e c t o r P e r f o r m a n c e : S u m m a r y R e p o r t take a significant share of public health resources but serve only a few health education via videotape was an approach used by a diabetes patients. In Samoa, for example, overseas treatment absorbs 14 percent control program in the FSM. of the health budget to treat 0.1 percent of the population.27 While govern- ments have treatment criteria (for example, age and disease), it is unclear Strategic Options how well they are applied. At the least, it can be assumed that the wealthy benefit most from such services, given the pattern of underutilization by While health systems in the Pacific are notable for their variability and the poor of in-country hospital services. distinctiveness, almost all countries in the region face an unfinished agenda As costs of overseas treatment escalate, governments are looking for in achieving MDGs and addressing high fertility rates, continued prevalence of ways to contain them. Options include sending patients to Suva rather communicable disease and the emerging threat of hIV/AIDS, and the increas- than to new Zealand or the u.S.; using visiting medical specialists; mak- ing prevalence of noncommunicable diseases. to face these challenges, ing twinning arrangements with facilities in Australia, new Zealand, or Pacific health systems are reorienting themselves to consider strategic ap- the u.S.; and employing remote management models such as telemedi- proaches to these difficult problems, many of which are rooted in behavioral cine. Governments might also develop local specialty services -- diabe- issues where complex, multi-stakeholder arrangements are called for: tes treatment, for example -- if sufficient volume makes this viable. 1. Improve alignment of resources, both government and donor Some governments already have insurance schemes to cover overseas funds, toward achieving high-priority health outcomes. treatment, paying for it with contributions from those in formal employ- 2. Diversify sources of health care financing to include risk-sharing ment and providing government subsidies for those who cannot afford the mechanisms and individual payments. cost of insurance. Such an approach could be introduced in the context of 3. Increase delegation of accountability to those delivering services an overall reform of the financing of health care, or as a single initiative. and tap service providers outside of the government. Countries in the region could purchase insurance jointly, pooling risk and 4. use incentives to increase the quality of services and their ap- lowering premiums. Another approach, voluntary insurance for overseas propriate use. care, has been introduced in rMI, where the Social Security system subsidizes the program. Governments should not be deterred by the initial 5. Support initiatives that encourage healthy lifestyles. high cost of voluntary programs. early enrollees are typically those in poor 6. understand and link to demand, especially at the household and health ("adverse selection"), but their drain on the system moderates as community levels. enrollment rates increase across the (healthier) population. Programs that help people lead healthy lifestyles regional Collaboration Obesity, poor diets, and lack exercise are contributing to high and rapidly regional collaboration can be helpful in at least two conditions: when increasing rates of diabetes and circulatory disease in the Pacific region. issues span country borders and when collaborations result in significant excessive alcohol consumption is also a growing public health problem. economies of scale. In the Pacific, regional procurement of pharma- tobacco use is high, and risky sexual practices are a growing threat to ceuticals offers an opportunity to lower costs and improve efficiencies. health, especially among young people. likewise, collaboration on overseas referral policies and associated risk- In response to these unhealthy behaviors, health education and promotion sharing options would contribute to important shifts in patient expecta- have had little effect. the key will be to raise people's motivation and em- tions and government attention to cost management. power them to take responsibility for their own health. Increasing access Donors as well as Pacific governments are increasingly aware of the need to health insurance is one option, as are incentives such as those available to make strategic choices. three approaches to the provision of aid as- in developed countries (for example, smoking cessation programs, fitness sistance can have a regional impact: programs, and cash and in-kind benefits) that encourage healthy behavior. 1. Orient regional support to bring scale and efficiency to govern- Community partnerships in health ment reforms. the role of communities in providing health services is not new in the 2. ensure that support aligns with government-identified health Pacific. Governments could revive and extend existing partnerships, such priorities. Fertility and population control are key priorities, for as community health councils in the rMI, village health workers in the example, but receive lower levels of funding than their strategic Solomon Islands, and women's committees in Samoa. Community roles importance would suggest. in managing the primary and secondary prevention of noncommunicable 3. Coordinate and harmonize aid assistance to lower the diseases are especially promising. Involving local patients in delivering management and transaction costs to Pacific countries. PAGE > > H u m a n D e v e l o p m e n t i n t h e P a c i f i c I s l a n d s endnotes 1 World Bank member countries in the region are Fiji, Samoa, Solomon Islands, Federated 13 According to WhO (2000), 50 percent of diabetes cases have not been diagnosed in States of Micronesia, republic of the Marshall Islands, Vanuatu, tonga, Kiribati, and Palau. all countries in the region. 2 World Bank. (2006). Opportunities to improve social services: Human development in 14 Knowles, J. (2004). Health sector report: Kiribati (background paper to World the Pacific islands. Washington, DC: Author, human Development Sector unit, east Asia Bank [2005]: Opportunities to improve social services: Human development in the and Pacific region. Pacific islands). 3 Millennium Development Goals have a 2015 target established against 1990 baseline 15 SPC, & World Bank. (2003). Non-communicable diseases in Pacific island countries: performance. the likelihood of achieving the target is derived from a comparison of the Disease burden, economic cost and policy options. Anse Vata, new Caledonia: Secre- ideal trend line with the current trend line. tariat of the Pacific Community. 4 unDP. (1999). Solomon Islands: Human development report; Fiji Ministry of health. 16 Ibid. (2002). Annual report; rMI Ministry of health. (2004). Annual report. 17 Ibid. 5 Beaver C., Ohno, n., & Graham, B. (2004). health sector report: rMI (background pa- 18 rajkumar, A., & Swaroop, V. (2004). Public spending and outcomes: Does governance per to World Bank [2005]: Opportunities to improve social services: Human development matter? (Policy research Working Paper #2840). Washington, DC: World Bank. in the Pacific islands). 19 WhO. (2004). Migration of skilled health personnel in the Pacific region: A sum- 6 A comprehensive review of much of this literature is found in Behrman, J., Alderman mary report. h., & hoddinott, J. (2004). hunger and malnutrition. In B. lomborg (ed.). Global crises, 20 Beaver, C. (2003). Health care decision-making in the western Pacific region: global solutions. Cambridge, uK: Cambridge university Press. Also see Strauss, J., & Diabetes and the care continuum in the Pacific island countries. Geneva: World thomas, D. (1998). health, nutrition, and economic development. Journal of Economic health Organization. Literature, 36 (2), 766-817. 21 A simple register and recall system managed by public health workers in the remote 7 Asian Development Bank. (2003). FSM health sector report; rMI Ministry of health. islands of Australia's torre Straits reduced hospital admissions for diabetes complica- (2004). Annual report; Samoa Ministry of health. (2003). Annual report. tions by 40 percent. See Beaver, C., & Zhao, y. (2003). Investment analysis of the ab- 8 unDP. (1999). Solomon Islands human development report; World Bank mission reports. original and Torres Strait islander primary health care program in the Northern Territory: 9 SPC MDG database. Consultant report No. 2. Canberra: Commonwealth of Australia. 10 Iniakwala, D. (2004). Situational and response analysis for hIV/AIDS and StI prevention, 22 Asian Development Bank. (2003). FSM health sector report. control, care and support services in Pacific region in relation to the components of the 23 See huff-rouselle, M., & Burnet, F. (1996). Cost containment through pharmaceuti- 1997-2000 regional AIDS/StD strategic plan. Anse Vata, new Caledonia: Secretariat of the cal procurement: A Caribbean case study. International Journal of Health Planning and Pacific Community. Management, Vol. 11, 135­157. 11 WhO/WPrO. (2001, June). report: Meeting of public health officials responsible for 24 World Bank staff consultations. the prevention and control of sexually transmitted infections and hIV/AIDS in Pacific 25 Samoa Ministry of health. (2002). National health accounts, 2000-2001; tonga island countries and territories. Paper presented at the meeting of Public health Officials Ministry of health. (2002). National health accounts, 2000-2001. responsible for the Prevention and Control of Sexually transmitted Infections and 26 hIV/AIDS in Pacific Island Countries and territories. nadi, Fiji. the Solomon Islands plans to launch a comprehensive household survey with a complete health module. 12 WhO/WPrO. (2005, March). hIV/AIDs and sexually transmitted infections. Paper pre- 27 sented at the meeting of Ministers of health for the Pacific Island Countries, Apia, Samoa. Samoa Ministry of health. (2002). National health accounts 2000-2001. the Pacific human Development review was conducted by the World Bank in conjunction with the governments of the Pacific member countries. the report was prepared by a team led by rekha Menon and comprising Christopher Chamberlin, Ian Collingwood, Sue Dawson, Jean Fares, rapti Goonesekere, and naoko Ohno. the team would like to thank the governments of the Pacific and the development partners for their support and collaboration during the preparation of the study. The World Bank the development of this summary was managed by rekha Menon with editorial and design support Human Development Sector Unit provided by Wested, 730 harrison Street, San Francisco, CA 94107-1242 uSA. http://www.Wested.org. East Asia and Pacific Region 1818 H Street, NW Copyright © 2006 by the World Bank. Washington, DC 20433 USA PAGE