Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696587889655.pdf (Vanuatu)
VANUATU Health Sector Strategy 2021-2030 Wan Strong Helt Sistem Blong Yumi Evriwan Table of Contents Minister’s Foreword Acknowledgements 1 | Overview 2 | Background and Situation Analysis 3 | HSS Strategic Vision, Goals and Objectives 4 | Health Report Card 5 | Implementation 2 3 4 12 17 32 36 6 | Membership of the HSS Steering Committee and Working Groups 40 Annex 1 Annex 2 | | Acronyms and Abbreviations Government Policies and Legislation relevant to the HSS Attachment | Monitoring and Evaluating the HSS Figures Figure 1: How the HSS Contributes to the NSDP Figure 2: Hierarchy of Planning Figure 3 Cascading Approach to M&E Tables Table 1: Health Report Card 42 43 10 37 38 32 Minister’s Foreword Acknowledgements The content and direction of the Health Sector Strategy (HSS) is based on the observations and ideas of the many people who contributed to its development.
For the time and consideration given by all, the HSS Steering Committee wishes to express its gratitude and appreciation to everyone involved.

Particular acknowledgement is extended to national program staﬀ , provincial health teams, including medical superintendents and remote facility staﬀ , development partners and all external stakeholders who contributed to the consultations which informed the development of the HSS.
Speciﬁ c acknowledgement is extended to the Government of Australia, the World Bank and the Asian Development Bank (through the regional vaccine project) for provision of technical advisory support to the Ministry of Health (MOH) to enable the HSS to be completed.

Firstly, the opportunity to begin the journey of transforming the health system to meet these emerging challenges and provide new directions for the next ten years and beyond.
The transition of the health system will enable us to better respond to current and emerging threats.

Secondly, to be innovative, to explore diﬀ erent approaches and new ideas to improve the health of our nation and go beyond business as usual.

It aims to rebuild public conﬁ dence in our increasingly decentralised health service.
To fulﬁ l our objectives a conducive environment must prevail in which governance, transparency and accountability are at work so that all people in Vanuatu who need health services receive them and all should have access to good quality health services.

I take this opportunity to thank all MoH hard working staﬀ and partners who have collated this document.
It is my sincere hope and prayers that to achieve all our objectives the MoH will not be alone, therefore it is important that we create the right alliances and partnerships to support us in building health sector management capacity and systems to ensure the eﬀ ective and eﬃ cient ality service delivery of quality services that are aligned directives.

with national directives.


Melve, MP Honourable Silas Bule Melve, MP Minister for Health I am very much delighted to present the Health Sector Strategy (HSS) 2021-2030 as a guiding document for the development and improvement of our country’s health sector.

Pursuing to ensure the existence of a healthy population that enjoys a high quality of physical, mental, spiritual and social well-being has been our top priority and will continue to be.
It is the HSS 2021-30 that provides strategies to determine a good quality health care for our entire population.

The HSS is a ten-year development guide providing strategic directions and approaches to meet the policy objectives of the National Sustainable Development Plan.

Our experiences over the last forty years have enabled us to put in place workable strategies so that the health sector can better deliver in the next ten years.
The global world is becoming challenging as we are caught in domestic and international issues.

Such are, protecting our small but vulnerable population against COVID-19, coping with lifestyle diseases like NCD’s and being prone to environmental threats.

It is within such an environment that our health system protects long-term investments in health system improvements and continues to provide essential health services to the people of Vanuatu.

As such, the HSS signiﬁ es two important opportunities.
2 | | 3 1 | Overview Conceptual Approach The Health Sector Strategy (HSS) aims to transform our health system to be resilient to health threats, and to accelerate progress made to date to improve health outcomes for the people of Vanuatu.

Our approach embraces opportunities for innovation and explores diﬀ erent paths to protecting and improving everyone’s health and well-being.

Continuing to protect our population from health threats, such as COVID-19, is a fundamental driver of the HSS.
This strategy will build a strong and resilient health system which is well prepared to respond to public health emergencies, whether caused by natural disasters, disease outbreaks or the impacts of climate change.

Our successful implementation of a range of legislative, policy and procedural improvements to prepare for a possible outbreak of COVID-19 and protect the population have already served to increase our overall health security and pandemic preparedness.
Health Sector Strategy Vision A healthy population that enjoys a high quality of physical, mental, spiritual and social well-being Through An eﬀ ective decentralized health system with a Primary Health care focus, developed and strengthened secondary and tertiary healthcare, and strong leadership to promote good governance practice at all levels of health services.
Being resilient also means being able to continue to deliver essential health services during times of crisis, and to protect our long-term investments in health system improvements.

In the past, health ‘shocks’ have often led to human and material resources being redirected from essential functions to emergency response.

The HSS commits to establishment of comprehensive, resourced plans for disaster and system responses that will ensure continuity of essential functions.
It also builds and expands on advances in clinical services, with expanding specialty care and greater provincial reach.

The future will bring additional burdens on the health sector.

Beyond emerging health threats, our sector will respond to rising Non-Communicable Diseases (NCDs), a growing need for mental health services, ongoing challenges associated with communicable diseases and unﬁ nished commitments for improved Family Health.
The HSS has been developed to equip the sector to rise to these challenges and ensure that all people of Vanuatu beneﬁ t from these responsive actions.

We will build on the opportunity of strengthening provincial health teams.

We will continue eﬀ orts towards decentralisation and focus on Primary Health Care (PHC) to achieve Universal Health Coverage (UHC).
We will ensure more equitable distribution of PHC services to be closer to where people live, while also developing secondary and tertiary services to support PHC teams.

Strong leadership in both corporate and clinical governance are at the centre of our approach.

worker density right, we also need to ensure our health workers and managers are supported by solid corporate services.
This includes access to the support and ongoing training they need together with data and information to support evidence- based decision making.

Fundamental to this overall approach is a strong health workforce.

Based on 2018 population and workforce data, our ratio of skilled health workers (doctors, registered nurses and mid-wives) to 10,000 population is 15.6.1 This is too low relative to the target of the Role Delineation Policy (RDP) of 38.16 skilled health workers to 10,000 population.
We need to work together to increase this ratio.

In addition to getting our health HSS Goals 1.

2.

3.

4.

5.

Ensure all people of Vanuatu who need health services receive them, including women, youth, the elderly and vulnerable groups, without undue ﬁ nancial hardship.

Rebuild the public’s conﬁ dence in our health system by reinforcing public health and clinical service delivery and ensuring equitable access to aﬀ ordable, quality health care.
Redesign our health system to be more resilient to health shocks caused by disease outbreaks, disasters and climate change while we better prevent, detect and manage communicable diseases.

Optimise real improvements in population health and well-being through promotion and active facilitation of healthy lifestyles and health-seeking behaviours.
Revitalise health sector management capacity and systems at all levels, including accountability through corporate and clinical governance and leadership with evidence-based policies and plans supported by strong monitoring and information systems.

6.

Redeﬁ ne collaborative action and expand our partnerships to meet the greater health needs of the people of Vanuatu.

4 | | 5 1 Health Information Unit Annual Report 2018 • • beliefs, socio-economic status or where they live.
This includes people with disabilities, adolescents, children, survivors of gender-based violence, women and girls in remote and rural areas and other disadvantaged and vulnerable populations.

People and communities play an essential role in the creation of health and well-being.

Empowerment and active community engagement are essential elements of PHC, encouraging communities and individuals to be responsible for their own health.
This extends to collective participation through involvement in community health promotion, policy contribution and accountability at all levels, including for management of health facilities (e.g.

through functioning health committees).

Responsibility for health requires multi-sectoral action – including partnerships with other government agencies, development partners, civil society and the private sector.
Engagement across multiple sectors, including government, Non- Government Organisations (NGOs) and civil society, is essential to addressing many of the determinants responsible for some of our largest health challenges.
Guiding Principles The development and implementation of the HSS is underpinned by a series of Guiding Principles based on the Government’s national and global human rights and development commitments: • • • • Vanuatu is committed to achieving Universal Health Coverage – ensuring all people have access to quality essential health services, when and where they need them, without suﬀ ering ﬁ nancial hardship as a result.
Essential health services range from health promotion to prevention, treatment, rehabilitation, and palliative care across the life course.

Primary Health care is the foundation for achieving UHC.

It provides for an organised, closely located and accessible structure of services to promote and support people’s health and wellbeing.
Vanuatu recognises that PHC is the most inclusive, equitable, cost-eﬀ ective and eﬃ cient approach to enhance people’s physical and mental health and social well-being and acknowledge the need for a strong primary healthcare work force.

The health system should provide a continuum of care through integrated primary, secondary and tertiary level care and essential public health functions working together.
A systematic, resourced referral system based on the National Referral Policy ensures that people can access higher levels of care as needed and receive coordinated follow up.
To achieve UHC, health services must be equitable, aﬀ ordable and inclusive; all people are to: be treated equally; have equitable access to needed health services with ﬁ nancial risk protection; and be encouraged/ supported to fully participate regardless of their age, gender, race, How the HSS Contributes to the NSDP Vanuatu 2030 – The People’s Plan or the National Sustainable Development Plan (NSDP) sets out the Government’s vision and provides a broad policy framework to guide planning over the period 2016 - 2030.
The NSDP seeks a stable and vibrant society based on traditional cultural values, which preserves a healthy environment, builds resilience and gives all citizens fair and aﬀ ordable access to high quality public services.

The National Sustainable Development Goals are presented within three main pillars: Society, Environment and Economy, which are underpinned by Culture.

The four main health policy objectives are listed under Society Goal 3 – Quality Health Care.
Other NSDP policy objectives also have relevance to the health sector.

These include Society Goal 4 (Social Inclusion) and goals under the Environment and Economy Pillars.

NATIONAL VISION 2030 NSDP Society Goal 3 Policy Objectives explained Ensure that the population of Vanuatu has equitable access to aﬀ ordable, quality health care through the fair distribution of facilities that are suitably resourced and equipped.
People should be able to access the health care that they need, reasonably close to where they live and without ﬁ nancial hardship.

This applies equally to people in urban, rural and remote areas.

Reduce the incidence of communicable and non-communicable diseases.

The main role of the health sector is to protect and improve the health of the population of Vanuatu.

While this includes providing good quality health care, it also encompasses keeping people healthy.
Reducing the incidence of disease means preventing people from getting ill by means such as immunisation, better nutrition, active disease surveillance and response and improved sanitation and hygiene.

Promote healthy lifestyle choices and health seeking behaviour to improve population health and well-being.

In recent years, the traditional lifestyle has been aﬀ ected by changes in the way people live: imported and processed food, less physical activity, more urbanisation.
The NSDP wants people to have healthier lifestyles: to eat better, to be more active, to keep a clean environment and look after the health of themselves and their families.

Strengthening regulations to reduce the impact of NCDs is a key component of this.

Build health sector management capacity and systems to ensure the eﬀ ective and eﬃ cient delivery of quality services that are aligned with national directives.

The health sector is large and complex.


If it is going to achieve the NSDP policy goals, resources will need to be used wisely.

This will require eﬀ ective managers, supported by strong systems (e.g.

timely information, skilled human resources, adequate ﬁ nance) to ensure the health system is fully and appropriately resourced.
6 | | 7 By outlining key priorities to shape the future of healthcare, this HSS is intended to guide the direction of the health sector in line with NSDP Policy Objectives and targets.

The HSS aims to deliver against health sector NSDP Policy Objectives under Society Goal 3 (Quality Health Care) as well as other broader NSDP Policy Objectives.

It replaces and builds upon the previous HSS, which concluded at the end of 2020.
Design Approach Development of this HSS commenced in early 2020 by the Policy and Planning Unit of the MOH under the Directorate of Corporate Services, Policy and Planning.

Governance: A HSS Steering Committee has provided strategic leadership and oversight to development of the HSS, including setting the strategic directions.

The Steering Committee is chaired by The Steering Committee sought to ensure that this strategy: • Is well aligned to the NSDP.
• • • • Is a concise, high-level document that can be used across the MOH to provide a broad strategic framework for the development of rolling ﬁ ve-year Corporate Plans and annual Business Plans.

Integrates all existing MOH policies and plans.

Has a strong provincial focus in line with the health service decentralisation agenda.

Has a strong focus on governance and accountability to support eﬀ ective implementation, including through robust monitoring and evaluation (M&E).
The HSS is structured with six goals, which together contribute to a health sector vision for the next 10 years.

Figure 1 shows how the HSS contributes to the NSDP.

The vision and goals will be achieved through strategic objectives which are presented in Section 3. the Director of Corporate Services, Policy and Planning.

See Section 6 for a list of members which include public health, clinical and health systems senior management, and provincial, inclusive and development partner representatives.
Initially the Steering Committee undertook an analysis of the strengths and weaknesses of the previous strategy to guide the development of this strategy.

The Steering Committee sought to use the HSS development process to build ownership and buy-in among MOH staﬀ , and partners, and promote engagement with a variety of stakeholders.

Involving our health workers has enriched the HSS with their knowledge and experience.
Working Groups: Key to establishing ownership of the HSS was the initiation of four Working Groups to lead and facilitate its development.

Reporting to the Steering Committee, the Working Groups represented the three MOH Directorates (Corporate Services, Public Health and Hospitals and Curative Services), with the fourth group focused on Inclusive Health (encompassing gender equality, disability and social inclusion).

Membership of the Working Groups can be found in Section 6.
Common guidance was developed for the Working Groups, outlining a series of activities towards delivery of two outputs2.

The ﬁ rst was a detailed Situation Analysis within their focal area, including a review of progress in delivering the previous HSS, and an appraisal of sectoral strengths, weaknesses, opportunities and threats.
The second output of each Working Group was a set of strategic objectives, broad activity areas and a results framework to deliver the strategic directions set by the Steering Committee.

This output was informed by the Situation Analysis.

The Inclusive Health Working Group also reviewed the outputs of the other Working Groups to identify opportunities for improving inclusivity.
Each Working Group determined its own process of consultation, including at national, departmental and provincial levels with input both from hospital-based and rural settings.

Synthesis and Validation: The Policy and Planning Unit synthesised the Working Groups’ outputs, consolidating areas of overlap.

The resulting strategy was reviewed by the Minister, the Director General and the Steering Committee to conﬁ rm direction, before a ﬁ nal stakeholder consultation.
2 The Situation Analysis and Strategy Development reports from each of the Working Groups are available from the MOH Policy and Planning Unit.
8 | | 9 Figure 1 Society Goal 4: Social Inclusion An inclusive society which upholds human dignity and where the rights of all Ni-Vanuatu including women, youth, the elderly and vulnerable groups are supported, protected and promoted in our legislation and institutions, Society Goal 3: Quality Health Care - A healthy population that enjoys a high quality of physical, mental, spiritual and social well-being Policy Objective SOC 3.1: Policy Objective SOC 3.2: Policy Objective SOC 3.3: Policy Objective SOC 3.4: Ensure that the population Reduce the incidence of Promote healthy lifestyle Build health sector of Vanuatu has equitable communicable and non- choices and health seeking management capacity access to aﬀ ordable, quality communicable diseases behaviour to improve and systems to ensure health care through the fair distribution of facilities that are suitable resourced and equipped.
Vision: population and well-being the eﬀ ective and eﬃ cient delivery of quality services that are aligned with national directives Environment Goal 1: Food and Nutrition Security Environment Goal 3: Climate and Disaster Resilience Economy Goal 2: Improve Infrastructure - A nation that ensures our - A strong and resilient - Sustainable and well- food and nutrition security nation in the face of climate maintained infrastructure needs are adequately met change and disaster risk and services for all, through for all people through increasing production systems and improving household production posed by natural and man inclusive and eﬀ ective made hazards.
partnerships A healthy population that enjoys a high quality of physical, mental, spiritual and social well-being - through - an eﬀ ective decentralized health system with a primary health care focus, developed and strengthened secondary and tertiary healthcare and strong leadership to promote good governance practice at all levels of health services.
Goal 1: Goal 2: Goal 3: Goal 4: Goal 5: Goal 6: Ensure all people of Rebuild the public’s Refocus our health system Optimise real Vanuatu who need health conﬁ dence in our health to be more resilient to improvements in Revitalise health sector management capacity Redeﬁ ne collaborative action and expand our services receive them, system by reinforcing health shocks caused by population health and well- and systems at all levels, partnerships to meet the including women, youth, public health and clinical disease outbreaks, disasters being through promotion the elderly and vulnerable service delivery and and climate change while and active facilitation of including accountability through corporate and greater health needs of the people of Vanuatu.
groups, without undue ensuring equitable access we better prevent, detect healthy lifestyles and health clinical governance and ﬁ nancial hardship.

to aﬀ ordable, quality health and manage communicable - seeking behaviours.

care.

diseases.

leadership with evidence - based policies and plans supported by strong monitoring and information systems.
VANUATU Health Sector Strategy 2021-2030 Wan Strong Helt Sistem Blong Yumi Evriwan Monitoring and Evaluating the HSS Attachment to: Vanuatu Health Sector Strategy (HSS), 2021-2030 Wan Strong Helt Sistem Blong Yumi Evriwan Guiding Principles • Universal Health Coverage • Continuum of care • Primary Health Care • Community Engagement • Equitable and inclusive health • Multi-sectoral action 10 | | 11 2 | Background and Situation Analysis External Context Many factors outside the health sector have the potential to impact the health of our population and the MOH’s ability to operate eﬀ ectively and achieve our strategy.
There are big challenges we need to overcome.

The global challenge of the COVID-19 pandemic means today’s world is more complex than it’s ever been and that health is higher on the agenda than ever before.

Government agencies have pulled together to implement the national Recovery Strategy 2020-2024 - Yumi Evriwan Tugeta, in response to the compound crisis caused by COVID-19 and Tropical Cyclone (TC) Harold in 2020.
The HSS will be the primary mechanism to implement this Strategy’s objective: To restore and strengthen health facilities and services.

In addition to the challenges caused by COVID-19 and other disease outbreaks, Vanuatu remains one of the countries in the world that is most vulnerable to natural disasters.

In 2021 we are still recovering from the impacts of TC Harold across the northern provinces, the volcanic eruption on Ambae and the Tanna ashfall.
Our vulnerability to natural disasters is intensiﬁ ed by the worsening eﬀ ects of climate change.

This is not only increasing the frequency of extreme weather events, such as Category 5 cyclones, but rising ocean temperatures are also inﬂ uencing aspects of marine food supply, and coastal erosion is a risk to both agricultural production and tourism development.
The National Policy on Climate Change and Disaster Risk Reduction 2016-2030 provides the framework for strengthening the resilience of communities and enhancing governance capacity.

Even though we are spending more on our nation’s health, compared to other Paciﬁ c Island Countries our health spending is low.

This places limitations on the long- term development of the health sector and slows progress towards UHC.

The COVID-19 pandemic is likely to add additional pressure on public funding for health.
The economic context has been dramatically aﬀ ected by the impact of international border closures on the tourism-reliant economy with job losses and the reduction in overseas remittances caused by COVID-19.

The combined impacts of COVID-19 and TC Harold led to economic contraction of 9.8% in 20203.

TC Harold aﬀ ected 43% of the population, damaging homes, schools, medical facilities and crops, all seriously impeding access to essential services and compromising food security for many ni- Vanuatu4.
The Government has estimated the combined economic cost of COVID-19 and TC Harold at VUV68.1 billion.

There is renewed focus on ‘bringing government to the people’ through decentralisation of public services across all provinces.

The Government’s commitment to decentralisation of service delivery is captured in the Decentralisation Policy 2017- 2027 which provides for a ‘bottom-up’ ﬂ ow of integrated development planning and budgeting.
Central to this process has been the recruitment of new Area Administrators based in Area Councils across the country.

In the health sector speciﬁ cally, decentralisation has contributed to provincial health capacity.

Provincial Health Administrators and other staﬀ have been recruited including Public Health Managers, Human Resources (HR) and Finance Oﬃ cers, as well as Medical Superintendents for provincial hospitals.
Decentralisation is supporting the placement of more doctors, nurse practitioners, midwives and nurses in the provinces.

Medical oﬃ cers are present Health of our Population While there has been good progress towards delivery of the HSS from 2017- 2020, such as greater coverage of health care services, slower progress has been seen elsewhere, due largely to limited resourcing, natural disasters and disease outbreaks, particularly COVID-19.
These include disrupted essential public health functions such as immunisation and nutrition as well as disruptions to training and advancement of doctors, nurse practitioners, midwives and nurses.

Overall, the health system continues to face signiﬁ cant challenges balancing increasing demand and shifting priorities with its pursuit of UHC.

Non-Communicable Diseases (NCDs): There has been some progress towards the promotion of healthy lifestyles to reduce the onset and impact of NCDs.
The period 2017- 2020 has seen establishment of primary eye care and oral health outreach services, and Mind Care services for improved mental health.

Tobacco use is reducing through adherence to improved legislation.

Yet NCDs remain a very real threat.

Three in more healthcare facilities.

The nursing workforce has also been increased through additional nurse training and temporary recruitment of nurses from the Solomon Islands.
Given the geographically dispersed nature of our population, with over 300,000 people living across more than 60 islands and 83% of these being rural based, it is essential that the accessibility of health facilities and services is maximised.

in four premature deaths are a direct result of an NCD5.

The burden NCDs are placing on the health system is rising and the costs will continue to grow without active commitment.
This includes investment in promoting and supporting healthier lifestyles including government imperatives through diﬀ erent policy instruments to address the growing burden of NCDs.

Communicable Diseases and Disease Outbreaks: Recent years have seen prevention and elimination of malaria, trachoma and lymphatic ﬁ lariasis, reductions in vaccine preventable diseases and the prevention and management of HIV and multi-drug resistant tuberculosis (MDR-TB).
Through strengthened disease surveillance, we are now better able to detect and respond to disease outbreaks and other public health emergencies.

Households and health facilities have improved sanitation.

Other challenges remain.

Dengue cases are reported every wet season, and the number of people with tuberculosis has not reduced over the last few years.
COVID-19 has highlighted system vulnerabilities, and 3 4 ADB, Asian Development Outlook 2021, April 2021 Government of Vanuatu, National Recovery Strategy 2020-2024 - Yumi Evriwan Tugeta 5 WHO, 2018; Non-communicable Diseases (NCD) Country Proﬁ les 2018: Vanuatu; Manila; World Health Organisation 12 | | 13 the stress that emerging infectious disease outbreaks places on government resources, our economy and population health.
The COVID-19 and TC Harold crisis has impacted our ability to maintain essential services and reinforced the importance of building our health system to sustain the impact of future pandemics and natural disasters.

Family Health: Improving maternal and child health remains a challenge.

Although nine out of ten births are assisted by a skilled birth attendant, women continue to die at high rates during childbirth; three out of every four maternal deaths are preventable6.
Most children are immunised against common diseases and coverage rates have increased since 2018.

However, breastfeeding rates remain moderate, one in ﬁ ve children under ﬁ ve years is stunted (low height for age)7, and the most recent data indicates death rates of children under ﬁ ve are high, particularly among newborns8 (amongst which 45% of deaths are associated with malnutrition).
The establishment of the Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) Program in recent years has created an opportunity for the MOH to achieve urgent gains in maternal and child health through strategic partnerships with key development agencies.
Our Health System Policies and Strategies: Recent years have seen several signiﬁ cant policies and plans released, including the new MOH staﬃ ng and resource allocation structure, the Role Delineation Policy (RDP) to guide health service delivery, the Workforce Development Plan 2019-2025, the Clinical Services Plan, the National Referral Policy, the Digital Health Strategy and a number of Public Health and Departmental plans and policies.
Together these reﬂ ect a strong focus on building up health services in the Inclusive Health: Levels of physical, sexual and gender-based violence against women and children are extremely high, and result in major public and personal health, economic and social costs.

There is poor access for young people to reproductive health information and services, despite high rates of teenage pregnancy and the threat of HIV and other Sexually Transmitted Infections (STIs).

This puts women and girls at greater risk.


People with disability are a vulnerable population which is often excluded from societal participation, and generally has poor access to health and rehabilitative care.

Despite women making up most of the health workforce, few are in decision making or leadership roles and therefore are not in a position to inﬂ uence sectoral policies that aﬀ ect them.
Gender equality (equal access for women and men to resources and opportunities) and social inclusion are critical factors in determining equal access to and use of health and other services and the provision of quality health care.

Multisectoral collaboration is important to address these with other line ministries, NGOs and civil society.

provinces.

Annex 2 lists the Government policies, plans and legislation relevant to this HSS.


Actioning these policies and plans to support the delivery of health services is challenging.

MOH staﬀ will require ongoing awareness and support to adhere to strategic priorities, and guidance to deliver and report against this HSS.

Accountability will be critical to this process.

6 7 8 Health Information Unit, 2019; Health Information Unit 2018 Annual Report; Port Vila; Ministry of Health.
Save the Children Vanuatu, 2018; First 1000 Days Project Household Survey; Port Vila.

Vanuatu Demographic and Health Survey 2013; Port Vila, Government of Vanuatu.

Health Workforce: Human resources remains our biggest challenge.

Vacant posts exist across all areas of the MOH; more health care workers are needed at all levels, especially in the provinces.

Health facilities can often be understaﬀ ed, leaving the health system reliant on the remaining staﬀ who in turn are tasked with an outsized workload.
When staﬀ are limited, exhaustion and demotivation become commonplace.

Work hours increase, particularly in the provincial setting, and there is a risk that the pressing needs of patients and communities can take precedence over staﬀ welfare.

Healthcare workers can struggle to advocate for their own needs as they care for others.

The approval of the Workforce Development Plan is a positive step that will in the long- term close staﬃ ng gaps.

In the meantime, challenges remain ﬁ lling existing vacancies.
Recruitment of new nurses, midwives and doctors is ad hoc and training opportunities are limited.

There is a ceiling on how many nurses and midwives can graduate from the Vanuatu College of Nursing Education (VCNE) as well as limited accessibility to English-based medical education.

VCNE faces challenges to achieving accreditation standards and registration, including issues with facilities and infrastructure.
Once nurses graduate from VCNE, continuing support during internship and beyond is very limited.

Medical interns face similar struggles with training and advancement.

There are currently no specialty training opportunities within Vanuatu outside of the VCNE midwifery program.

The weakness in training is aﬀ ecting both the number of healthcare providers as well as their ability to remain current with best practices.
Greater supervision, mentoring and continuing education are needed as these doctors and nurses gain the experience they will need to support decentralised care.

Public health staﬀ are also in need of mentoring, support and professional development.
Enhanced training and guidance will also beneﬁ t corporate staﬀ and cost centre managers, especially in the provinces, to ensure all in the decentralised structure are familiar with administrative systems, and processes, and have the right management and ﬁ nancial skills.

Health Information: Evidence is essential for monitoring the operation of policies and strategies, and for making decisions for planning and management of health services.

Clinicians need health information to inform patient care.
Core health indicators for measuring progress and improving the health information system have been established, including for hospital patients.

However, there is a lack of reliable data for decision making and performance measurement.

The systems and processes to collect and report progress are weak.

Research to inform evidence-based practice is limited.

This limits the ability of managers, clinicians and public health oﬃ cers to understand and address challenges.
Service Delivery: Rural and remote areas are disadvantaged in terms of their access to health care.

Ensuring PHC services are available as close as possible to where people live is both good for health, and the way that Vanuatu will achieve UHC.

A recent internal study showed that in some areas as few as one in ﬁ ve people are within one hour travelling time of a dispensary or health centre that has the capacity to serve them.

The RDP is the roadmap for UHC and is heavily focused on PHC.
It is acknowledged that the MOH is not currently in a position to deliver most of the minimum service delivery standards in the Policy especially in rural areas.

Funding is insuﬃ cient, and there are limited funds with cost centres at both the provincial level, and in tertiary hospitals.

High level of dependence on Vila Central Hospital for services is costly for both patients and health authorities in other provinces.
In addition, budget practices allow for little local control while overuse of 14 | | 15 3 | HSS Strategic Vision, Goals and Objectives the virement process threatens the funds that have been budgeted.

particularly TC Harold and the Ambae volcano eruption.

HSS Vision Infrastructure: Health services cannot be provided at the expected standard without adequate infrastructure.
This includes buildings, utilities, communication, medications, equipment, transport and Information and Communication Technology (ICT).

While there exists a number of functional and modern health facilities, many buildings are in poor condition due to lack of maintenance.

This has been further exacerbated by the recent natural disasters, The RDP lays out minimum standards for functional space and equipment for the various levels of facility from aid posts to hospitals.
Progress has been made in meeting these standards, but infrastructure and equipment remains a challenge for the delivery of clinical services across all levels.

Maintenance of infrastructure is not well resourced or coordinated, such that in many health facilities essential equipment is either absent or not working.
A healthy population that enjoys a high quality of physical, mental, spiritual and social well-being through an eﬀ ective decentralized health system with a Primary Health care focus, developed and strengthened secondary and tertiary healthcare, and strong leadership to promote good governance practice at all levels of health services.
The MOH and partners will monitor the impact of the HSS strategies via a series of key performance indicators, coupled with a robust results framework (see monitoring and evaluation section).

These indicators will form the basis of the MOH’s annual Health Report Card (see Section 4).

How they will be measured is outlined in the Monitoring and Evaluation (M&E) Plan (a separate attachment to this document).

The indicators below will be used by the MOH to track progress against the vision.
The vision has been described in Section 1 (Conceptual Approach).
Indicators to track progress against vision: • # of under ﬁ ve years of age deaths • Examples of locally driven initiatives [existing indicator from Core Indicator Framework] • # of maternal deaths [existing indicator from Core Indicator Framework] [proposed new indicator] • # of referred patients with standardised patient referral form complete [proposed new indicator] • # of neonatal deaths [existing indicator • # of outpatient visits (per 100,000) from Core Indicator Framework] • Number of deaths (disaggregated by cause) [proposed new indicator] • Proportion of open health centres and dispensaries with all of the selected subset of essential equipment [existing indicator from Core Indicator Framework] • Proportion of health facilities that have a core set of relevant essential medicines available and aﬀ ordable on a sustainable basis [SDG 3.b.3] • Percentage of fully functional Health Facilities according to Role Delineation Policy [existing indicator NSDP] • Coverage of essential health services [SDG 3.8.1] (disaggregated by facility level) [proposed new indicator] • # of specialists (doctors and nurses) compared against the standards in the Clinical Services Plan [proposed new indicator] • # of changes in the senior health management structure in the last year [proposed new indicator] • MOH Executive and Provincial Health Executive convening on a regular basis [proposed new indicator] All data will be disaggregated by sex, age, location and disability at a minimum with identity and other socio-economic attributes where relevant and feasible in keeping with Inclusive Health principles.
16 | | 17 Ensure all people of Vanuatu who need health services receive them, including women, youth, the elderly and vulnerable groups, without undue financial hardship.
Key Performance Indicator: Average number of outpatient visits to hospitals, health centres, dispensaries and aid posts per person per year (disaggregated by sex, age, location and disability at a minimum with identity and other socio-economic attributes as relevant) This goal draws upon the Government’s global and national commitments to ensuring all of its citizens, regardless of where or how they live, have the right to access suitable, quality health care.
It also reﬂ ects the HSS Guiding Principles of Universal Health Coverage and Equitable and Inclusive health services, and speciﬁ cally refers to the NSDP Policy Objectives which direct that: i) the population of Vanuatu has equitable access to aﬀ ordable, quality health care through the fair distribution of facilities that are suitably resourced and equipped, and; ii) services (particularly government services) must be accessible to all people, including people with disabilities9.
Through these policy commitments, the HSS will ensure quality health care services reach all people, including marginalised individuals and groups for whom societal attitudes and practices, or their speciﬁ c circumstances may increase their vulnerability to disease and/or limit their access to health services.
Examples of such groups include people with disability, women and girls, adolescents, survivors of gender based violence, the elderly and people identifying with diverse Sexual Orientation, Gender Identity and Expression (SOGIE).
Meeting the health needs of these individuals/groups requires resourced, targeted interventions and support systems to assist them to access the mainstream health services that are available to all, and for the provision of speciﬁ c services that meet their individual health needs.

The health sector will establish systems, services and activities that encourage participation from all.
This has implications for the delivery of hospital and clinical services including supported referral (at all levels, to meet the mainstream and speciﬁ c health needs of individuals), and of public health services (to ensure that health promotion and disease prevention measures are beneﬁ cial to vulnerable groups).
Corporate services, policy and planning will establish the evidence-base for inclusive health decision-making through: systems to collect, analyse and report inclusive health data, including an inclusive health baseline audit on services, staﬀ attitudes, referral systems; an Inclusive Health Research Strategy and annual reporting; and two-way feedback loops linking services to policy makers that includes communities, frontline health workers, services, and MOH.
9 Government of Vanuatu, 2016; Vanuatu 2030: The People’s Plan: National Sustainable Development Plan 2016-2030; Port Vila; Government of Vanuatu.

Delivering an inclusive HSS requires targeted health frameworks, programming, guidelines and budgets for inclusive health priorities (incorporating gender equality, sexual and gender-based violence and child protection, SOGIE, disability and mental health, and adolescent health).
Pre-service and in-service inclusive health training for leaders, MOH and frontline staﬀ , and communities will ensure technical capacity for inclusive health, and will be backed-up through inclusive MOH recruitment and retention strategies, and promotion of a diverse and inclusive workplace culture.
Formalising the role and strengthening capacity of the Inclusive Health Working Group, including recruiting dedicated staﬀ at national and provincial levels, is critical to delivering inclusion across the HSS, guided and resourced through an Inclusive Health component of the MOH annual Business Plan.
This will require support from other sectors and partners with established expertise to support mainstreaming of inclusive practices (both within and outside government), backed-up with necessary health sector budgetary support (see Strategic Objective 6.3 on partnerships).

Strategic Objectives: 1.1.


Ensure people with disability are recognised and supported by the health system: i) ii) public health and preventive services are accessible for, and can be accessed by people with disability provision of suitable, accessible services to meet the specialised health needs of people with disability, inclusive of rehabilitation, and prosthetic and orthotic services.
Ensure inclusive and supportive referral systems which enable vulnerable groups such as people with disability to access both general and impairment/issue speciﬁ c health services Ensure systems to collect, analyse and report inclusive health data that is disaggregated by age, gender, disability and identiﬁ ed, vulnerable groups.

Strengthen technical skill and capacity in the application of inclusive health strategies.
Provide targeted health frameworks, programming, guidelines and budgets for inclusive health priorities (inclusive of gender equality, sexual and gender-based violence and child protection, SOGIE, disability, mental health, and adolescent health).

Ensure health workplaces are inclusive through establishment of an inclusive leadership framework, inclusive recruitment and retention strategies, and promotion of a diverse and inclusive workplace culture.

1.2.

1.3.

1.4.

1.5.

1.6.


18 | | 19 Rebuild the public’s confidence in our health system by reinforcing public health and clinical service delivery and ensuring equitable access to affordable, quality health care.

and policies (such as the Workforce Development Plan and the Role Delineation Policy), and to align with approved staﬃ ng structures.
A key priority of the HSS will be the resourcing of a communications strategy which will utilise a broad variety of media for eﬀ ective, targeted communications to various groups and populations.

This will: i) ensure all MOH staﬀ are kept informed and motivated; ii) highlight positive health sector change and progress to the community; iii) establish benchmarks and dialogue through which the public can communicate their demands and expectations of the sector.
Key Performance Indicators: Strategic Objectives: Number of skilled health workers per 10,000 population (stratiﬁ ed by cadre) [existing indicator from Core Indicator Framework] % of the public who report that their experience with the health system is high quality, accessible and aﬀ ordable (disaggregated sex, age, location and disability at a minimum with identity and other socio-economic attributes as relevant) [proposed new indicator] The HSS will build upon strengths and improved performance of public health and clinical service delivery and strengthen its targeted communication to various groups and locations to facilitate the public’s awareness of, and conﬁ dence in health system developments.
The HSS will leverage impressive developments in public health (such as improved vector borne and other communicable disease control, strengthened disease surveillance processes and expanded coverage of sanitation for households and health facilities) to improve overall health promotion and disease prevention.

Strategic objectives include a focus on Family Health to improve health outcomes, especially for those most vulnerable, such as women, children and young people.
This will be achieved through innovative approaches to designing and delivering targeted, ﬂ exible and user- informed services whilst ensuring overall quality services.

Strengthened hospital and clinical services is key to raising the perceptions and performance of the health system to respond to diagnostic and treatment needs, and ensuring primary, secondary and tertiary care work together.
Commitment to increasing the quality and range of services oﬀ ered from rural hospitals, and particularly to strengthen the frequency and coverage of outreach services are important means for strengthened primary and secondary health care.

Elevating the status of the two referral hospitals will seek to strengthen tertiary care to ensure a robust referral system which harmonises diﬀ erent levels of service provision.
Promotion of Vila Central Hospital as a Training Institution for doctors, nurse practitioners, midwives, nurses and allied health, and the possibility for additional clinical research, will contribute important, country-speciﬁ c technical data to inform clinical and system planning and resource allocation.

The HSS commits to strengthening human resources development capacity and performance across public health and clinical services.
Staged scale-up of health workforce capacity through training and development for the existing and emerging workforce will be key to managing and delivering services according to plans 2.1.

2.2.

2.3.

2.4.

2.5.

2.6.

2.7.

2.8.

2.9.

Build a positive and supportive, sustainable workplace culture that promotes inclusion, honesty and integrity and enhances health care delivery, staﬀ satisfaction, motivation and work performance.
Ensure staﬀ are kept informed, positive health sector change is highlighted to the community and dialogue is encouraged through the implementation of a communications strategy.

Improve quality maternal and child health service coverage through the ﬁ lling of staﬀ vacancies in all community care facilities, and the resourcing of facility-based and outreach services.
Reduce maternal, under-ﬁ ve children, infant and neonatal mortality through the establishment and resourcing of comprehensive facility-based and integrated outreach antenatal and child health services and emergency referral systems.

Ensure a suitable acute, and longer-term health sector response to the prevention and management of sexual and gender-based violence and child protection issues, including systematic protocols and resources for receiving and supporting survivors.
Increase awareness and uptake of family planning services through targeted, evidence-informed communication approaches, accessible commodities and skilled personnel.

Improve immunisation coverage through demand creation, the ﬁ lling of staﬀ vacancies in all community care facilities, and the resourcing of facility-based and outreach services, including the supply of essential medicines and vaccinations, and cold chain management.
Improve quality, range and accessibility of targeted health messaging and services for adolescents and young people, with a particular focus on mental, sexual and reproductive health services.

Ensure a trained and supported health sector workforce through the establishment of supportive leadership mechanisms and skills, and the systematic roll-out of periodic in-service training for managers and public health personnel.

2.10.
2.10.

Strengthen training processes for doctors, nurse practitioners, midwives, nurses, and allied health workforce, including new clinical and leadership training programs and continuing education.

20 | | 21 Redesign our health system to be more resilient to health shocks caused by disease outbreaks, disasters and climate change while we better prevent, detect and manage communicable diseases.
Key Performance Indicator: % of attributes attained based on International Health Regulation Index (IHR) including health emergency preparedness [existing indicator from Core Indicator Framework] A resilient and sustainable health system is required to manage new pandemics such as COVID-19, and to prepare for health shocks, including threats to health security, while maintaining progress towards UHC.
COVID-19 has demonstrated Vanuatu’s resilience through Government agencies pulling together to prevent the spread of the disease through robust quarantine and contact tracing systems.

The MOH has also demonstrated improvement in its capacity to respond to health shocks while continuing to deliver essential services in the wake of natural disasters (such as the Ambae volcano evacuation and TC Harold) and emerging health threats (such as measles and COVID-19).

However more needs to be done.


It is acknowledged that these ‘shocks’ consume available human and material resources, often for prolonged periods, and redirect personnel and resources away from essential functions.

A stronger and more resilient health system will protect us in crisis situations through being better able to respond to the health shock while ensuring essential health functions continue.
A Health Sector Emergency Preparedness and Management Committee will be established with responsibility for development, implementation and scheduled revision of scenario-speciﬁ c emergency preparedness and response plans.

Staﬃ ng structures will be established at national and provincial levels which, over the early phase of HSS implementation, will be increasingly resourced to ﬁ ll vacancies.
Capacity will be developed to both prepare for and respond to emergencies, and to maintain levels of essential functions.

Systems for the establishment and rapid deployment of emergency response budgets (with development partner engagement) will be established, tested and periodically revised.
Sectoral resilience and continuity will beneﬁ t from the establishment of a multi- year, costed sectoral Capital Plan for investment in disaster and climate-resilient infrastructure (in accordance with the Role Delineation Policy).

Communicable Disease Control remains a key public health pillar, and the sector will continue to strengthen its long-standing investments in disease management and control.
Accordingly, we will build on our successes and lessons learned during COVID-19 pandemic preparedness, response and border control measures, and the successful elimination of malaria from Tafea, to strengthen our management of current and future communicable disease threats and emerging health shocks.
This will include renewed commitment to, and compliance with the International Health Regulations, development of a National Action Plan for Health Security, and well-resourced, cross-sectoral quarantine management.

Scaled-up national disease surveillance will remain an investment priority, with a larger, trained and well-resourced workforce.
This workforce will be supported to oversee an increased number of sentinel surveillance sites, as well as case-based surveillance for diseases targeted for elimination and enhanced public health laboratory capacity at national and sub-national levels.

Strategic Objectives: 3.1.

3.2.

3.3.

3.4.

3.5.


Utilise the HSS to establish or reinforce appropriate structures and plan for system responses to disasters and climate change which ensure continuity of essential functions (including public health, clinical and primary health care services), and protection of long-term investments in health system improvements.
Strengthen quality and coverage of disease surveillance and alert systems at all levels to ensure resourcing for preparedness and response to outbreaks.

Improve national (and regional) capacity to identify threats to, and maintain health security through strengthening oversight and adherence to the International Health Regulations (IHR).

Maintain progress towards elimination targets for malaria and selected neglected tropical diseases, through continued resourcing, surveillance and monitoring.
Strengthen detection, diagnosis and management of target communicable diseases, including HIV, STIs, TB, Neglected Tropical Diseases, Vector-Borne Diseases, viral hepatitis.

22 | | 23 Optimise real improvements in population health and well-being through promotion and active facilitation of healthy lifestyles and health-seeking behaviours.
Key Performance Indicators: Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic Strategic Objectives: respiratory disease [SDG 3.4.1] # of diabetic related lower limb amputations [existing indicator from Core Indicator Framework] Prevalence of obesity amongst the adult population [NSDP indicator] The HSS builds upon our demonstrated eﬀ ectiveness in public health to prioritise and address Lifestyle Diseases (also known as NCDs) with particular emphasis on preventing premature deaths associated with cardiovascular disease, diabetes and cancers.
Interventions will improve early clinical identiﬁ cation and management (including improved oral health and eye care services) and strengthened legislation and compliance or ﬁ scal measures to protect the population against harmful products such as tobacco, alcohol and foods with high fat, trans-fat, salt and sugar content.

Additional revenues from health taxes could expand the ﬁ scal space for generic public spending, which would potentially beneﬁ t the health and other public sectors.
Commitments to improving nutrition and subsequent, long-term health outcomes, particularly for infants, children and adolescents, is a major strategic focus of the HSS, as is resourcing the emerging priority of mental health through promotion and provision of Mind Care services.

The HSS recognises that the determinants of lifestyle diseases extend well beyond the direct inﬂ uence of the health sector.
Commitment and investment at all levels, and across all sectors will help build environments which enable communities and individuals to make healthy choices about their behaviours and practices, particularly with regards to physical activity, nutrition and mental health.
We commit to continue to work collaboratively with other sectors to advocate for legal and ﬁ scal measures and ensure legislative compliance with importation and marketing of harmful products, and across all media to enhance individuals’ decision-making (see Goal 6).

Multisectoral approaches required to address this goal are included under Goal 6.

The health sector will strengthen its overall public health management to better position ourselves to promote and support healthy lifestyles.
We will invest in a trained and supported, decentralised health workforce, providing appropriate technical guidance and oversight from the national level, and aﬀ ording provincial and sub-provincial oﬃ cers and stakeholders autonomy to establish contextually relevant interventions which enable communities and individuals to make healthy choices about their behaviours and practices.

4.1.

4.2.

4.3.

4.4.

4.5.

4.6.

4.7.

4.8.

4.9.


Reduce the onset of Lifestyle Diseases through promoting individuals’ awareness, conﬁ dence and opportunities to make informed, healthy behavioural choices.

Reduce the burden of NCDs through improved quality and coverage of prevention and management interventions.
Transform the state of oral health, especially amongst vulnerable children, through targeted, systematic outreach to schools and urban communities, and the maintenance of active data collection and analysis.

Improve health and development outcomes of communities (with an emphasis on children - especially the reduction of stunting - adolescents, women of child-bearing age and the elderly) through improved health security, nutrition awareness and practices, and availability of healthier food options.
Improve health and development outcomes for communities (with an emphasis on children, women of child-bearing age and breast-feeding mothers) through improved environmental health (inclusive of hygiene and sanitation awareness, practices and infrastructure, promotion of hand and face washing, waste disposal and food preparation and storage).
Improve the well-being and productivity of individuals and communities through the promotion of mental health awareness and community dialogue, and the establishment of mental health outreach services (inclusive of assessment, counselling, referral and treatment).

Promote community ownership, leadership and engagement in community health promotion and disease prevention processes, based on their assessment of health and social needs, and implementation of their plans to address these.
Strengthen health-related policies and legislation across relevant sectors that address NCDs and associated risk factors (such as the Public Health and Tobacco Acts, or regulations for alcohol, nutrients of concern and marketing of unhealthy foods) to inﬂ uence an enabling environment that promotes healthy behaviours and reduces harmful practices Strengthen the MOH’s mandate, capacity and authority to ensure sector-wide compliance with public health legislation, including resourcing and mechanisms to ensure coverage.
24 | | 25 supervisory processes which hold personnel to account for delivery against their roles and responsibilities.

Sustained, structured leadership and management training and support for senior and mid-level corporate, clinical and public health personnel will promote improved management now, and over the longer-term as mid-level managers progress to senior leadership roles.

This will include greater representation from women, disabled people, rural communities and hard-to-reach populations.
As the workforce continues to expand to meet evidence-informed sectoral targets, we will consider our capacity to manage current and projected demand.

We will establish a Health Services Commission to improve human resource management inclusive of healthcare worker welfare, safety, accreditation, discipline and advocacy.
Investment in ﬁ nancial management procedures, staﬀ capacity and system performance will support decentralised implementation of the sector, and timely ﬁ nancial analysis to inform resource allocation.

Priority will be given to ensuring activities are costed correctly, funds are spent as planned and reports are accurate and on time.
Expenditure rates will align with plans and schedules, both for regular system and service delivery, and for complex, strategic procurements, such as infrastructure and multi-year investments, which will be formalised through the establishment of a Capital Plan and Capital Works Oversight Committee.
Revitalise health sector management capacity and systems at all levels, including accountability through corporate and clinical governance and leadership with evidence-based policies and plans supported by strong monitoring and information systems.
Key Performance Indicator: % of MOH staﬀ , health managers and administrators who report that they have access to and have used information to manage their unit or program [proposed new indictor] The HSS will continue to strengthen Corporate Governance towards improved management of the sector.
Corporate Services structures will be more clearly deﬁ ned at the national and provincial levels, including formalised channels and processes for engagement with clinical and provincial/local leaders to inform decision- making and resource allocation.

More focus will also be placed on clinical governance which will be supported by better data.
These will likewise be informed by renewed commitment to planning and reporting, including revised policy and legislation, streamlined Corporate and Business Plans, and accountable management of ﬁ nancial expenditure and risk.

Key to this is strengthening provincial/local management capacity and autonomy over resource allocation to draw upon provincial or sub-provincial contextual perspectives of the factors which inﬂ uence eﬀ ective health service delivery.
Greater investment in strengthened management and leadership capacity of clinicians is a key priority, in order to better incorporate clinical experience and perspectives in corporate governance, system planning and resource allocation.

A ﬁ rm, sector-wide commitment to linking evidence with practice will see resource allocation and clinical service distribution determined through strengthened sectoral research and timely health information.
Quality data collection, analysis and dissemination systems for information on disease burden, interventions, governance, management and working conditions will be achieved through improved systems and expanded capacity of the health sector workforce to understand and utilise data for planning and decision-making .
The linking of all health facilities with internet access and increased mobile phone usage will allow telemedicine, better communication between health facilities, public health awareness campaigns and digitalisation of medical information management systems.

The HSS commits to strengthening System Management and Primary Health Care through enhanced decentralised management and human resources, improved data collection and analysis and greater eﬃ ciencies in resource management.
Periodically revised sectoral policies such as the Role Delineation Policy and the National Referral Policy will guide the continued decentralisation of Primary Health Care service management, delivery and quality assurance.

The HSS emphasises strengthening of human resources management capacity and performance across the sector, including greater adherence to performance management systems, and supportive 26 | | 27 Strategic Objectives: 5.1.
Strengthen awareness of, and adherence to the HSS at all levels and across all relevant sectors.

5.2.

Support eﬀ ective corporate and clinical governance at national and provincial levels including involving clinical leadership in decision making processes.

5.3.

Strengthen MOH capacity at all levels to ensure Corporate Plans, Business Plans, and periodic program and activity reporting reﬂ ect HSS priorities.

5.4.
5.4.

Strengthen Primary Health Care through supported, decentralised health system management which draws on clinical and sub-national experience for service prioritisation and resource allocation.

5.5.

Ensure a needs-based primary health care structure and resource allocation to reﬂ ect the standards at each health service level in accordance with the Role Delineation Policy.

5.6.

5.7.

5.8.
5.6.

5.7.

5.8.

In line with the Role Delineation Policy, ensure adequate ﬁ nancial resources are available, linked to planning and equitably managed at national and decentralised levels to support delivery of health services and the HSS.

Strengthen national referral systems in line with the Role Delineation and National Referral Policies through systematic chains of authority, approval and communication, adequate resourcing, and logistics management.
Expand the health information system and improve access of managers and clinicians at national and provincial levels to timely and accurate information to support evidence- based decision making for managerial, clinical and system planning, decision making and reporting.

5.9.

Establish and strengthen systems and oversight mechanisms for the promotion and support of structured, operational and clinical research to inform program/service delivery planning and implementation.

5.10.
5.10.

Through implementation of the MOH’s Workforce Development Plan, ensure an eﬀ ective, well managed health sector workforce at national and sub-national levels that is suﬃ cient to meet current and future health needs, and which supports the implementation of the Clinical Services Plan and Role Delineation Policy.

5.11.

Form a Health Services Commission tasked with healthcare worker welfare, safety, discipline and advocacy.

5.12.
5.12.

Improve personnel performance management systems at all levels which draw on and hold personnel to account for delivering against the strategic priorities of the HSS, Role Delineation Policy standards, Corporate Plans and Business Plans.

5.13.

Improve eﬀ ectiveness and eﬃ ciency of the Medical Supply Chain system across all levels of MOH service delivery points including national, provincial & lower levels 5.14.
Prioritise and strengthen capital projects and procurement to meet projected needs across the health sector to 2030 and beyond.

5.15.

Ensure equipment and resourcing meets and supports strategic targets through the establishment of multi-year pipeline procurement and maintenance systems including the supply of essential medicines and operational equipment.

28 | | 29 Redefine collaborative action and expand our partnerships to meet the greater health needs of the people of Vanuatu.
Key Performance Indicator: % of new and existing partners who are aligning their support to the HSS (disaggregated by on plan, on system and on budget support, type of support) [proposed new indicator] must play in supporting, and sometimes leading multi-sectoral eﬀ orts.

Health sector management, too, can beneﬁ t from strengthened relationships with central government agencies.
In this way, the HSS presents an opportunity for the MOH to establish our sectoral direction, and to more eﬀ ectively dictate both what we need from, and what we can bring to other sectors and organisations, including government agencies, development partners, NGOs and civil society.

Where required, and as feasible, we will commit human resources and necessary health sector budgetary support to our partnerships.

The HSS recognises that the health sector cannot deliver this strategy alone.
There is a need for greater MOH engagement across multiple sectors.

We will extend and redeﬁ ne our partnerships to deliver against the strategic priorities and sectoral direction established by the HSS.

We will embrace new partners to establish cross-sectoral and private sector partnerships.

We will engage with non-traditional development partners who have resources and/or capabilities that can beneﬁ t the health of the population and complement skills-sets for planned innovations.
For example, in the inclusive health space, we will require initial and ongoing support from other sectors and partners both from within and outside government that implement an inclusion agenda.

We will develop and resource inclusive partnerships with government and non-government agencies to improve sustainable health outcomes for targeted groups.
At the same time, we will continue to draw on existing relationships with valued development partners for technical support and resourcing to further the HSS goals and objectives.

Natural disasters and national emergencies (such as COVID-19) have highlighted the important role that the health sector Strategic Objectives: 6.1.

6.2.

6.3.

Use of the HSS, and key non-health sector strategies, to strengthen MOH’s donor, stakeholder and cross-sectoral engagement and coordination.
Strengthen partnerships and innovations through contributing MOH resources and identifying key partners who can contribute to resourcing gaps.

Develop and resource partnerships to deliver sustainable inclusive health outcomes for targeted groups.

30 | | 31 4 | Health Report Card The period of the previous HSS saw the sector embrace the Health Report Card as a tool to monitor and report incremental progress each year.
This new HSS builds on this ownership and support through the inclusion of an expanded Health Report Card, which comprises the existing indicators (to further build on the trend data of the last three years) and additional indicators to facilitate tracking of progress for the emerging strategic priorities of the coming period.

The new Health Report Card aligns with the Key Performance Indicators (and reference numbers) of the HSS M&E Plan.
It will be used to measure and report progress on the implementation of the HSS.
Key Performance Indicator Baseline (and year) Source: HIS unless otherwise stated Target (and year) M&E Plan ref VISION 1.1a Number of under 5 years of age deaths 1.1b Number of maternal deaths Note: All targets to be established by MOH in late 2021 Under 5 mortality rate: 25.9 (2019) (WHO, 2019) MMR: 72 (2017) estimate (UNICEF, 2019) # deaths: 6 (2017) estimate (UNICEF, 2019) Neonatal mortality rate: 11.4 (2019) (WHO, 2019) 1,154 (2018) Note: Data disaggregation TBD Number neonatal deaths (infants <I month) Number of deaths (disaggregated by cause) Proportion of open health centres and dispensaries with all of the selected subset of essential equipment 0% (2018) Proportion of health facilities that have a core set of relevant essential medicines available and aﬀ ordable on a sustainable basis 80% (2018) Percentage of fully functional Health Facilities according to Role Delineation Policy 0% (2018) Note: No health facilities in Vanuatu meet the essential standards of the RDP Coverage of essential health services 60% (2018) Examples of locally driven initiatives N/A 1.1c 1.1d 1.2a 1.2b 1.2c 1.2d 1.2e 32 | M&E Plan ref 1.3a 1.3b 1.3c 1.4a 1.4b GOAL 1 2.1a GOAL 2 2.2a Key Performance Indicator Baseline (and year) Source: HIS unless otherwise stated Target (and year) Number of referred patients with standardised patient referral form complete 0% (2018) Note: Data not previously recorded Number of outpatient visits (per 100,000) (disaggregated by facility level) Number of specialists (doctors and nurses) compared against the standards in the Clinical Services Plan TBD TBD Number of changes in the senior health management structure in the last year 20 (2019) (HRMIS) MOH Executive and Provincial Health Executive committees convening on a regular basis TBD Average number of outpatient visits to hospitals, health centres, dispensaries and aid posts per person per year (disaggregated by sex, age, location and disability at a minimum with identity and other socio-economic attributes as relevant) Hospitals: 19% (2018)
 Hospital Specialised Clinics: 13% (2018) Health Centre & Dispensary: 52% (2018) Aid Posts: 11% (2018) Note: Data disaggregation TBD Number of skilled health workers to 10,000 population 15.7 (2018) 2.2b Deliveries with skilled birth attendants (%) 91.9% (2018) Note: As per previous estimates, this is a proxy measure and likely slightly overestimated 2.2c Diphtheria, tetanus toxoid and pertussis (DTP3) immunisation coverage among 1 year olds (%) Penta 1: 63.2% (2018) Penta 3: 53.7% (2018) MMR: 43.6% (2018) | 33 M&E Plan ref 2.3a GOAL 3 2.4a 2.5a 2.5b 2.5c Key Performance Indicator Percentage of the public who report that their experience with the health system is high quality, accessible and aﬀ ordable (disaggregated sex, age, location and disability at a minimum with identity and other socio-economic attributes as relevant) Baseline (and year) Source: HIS unless otherwise stated Target (and year) TBD Note: This will be monitored through a client satisfaction survey as part of planned 2022 STEPS survey.
Percentage of attributes attained based on International Health Regulations Index (IHR) including health emergency preparedness 55% (2020) (MOH Annual Report, 2020) Malaria annual parasitic incidence (API) 1.7/1,000 (2018) Incidence of TB per 100,000 population 41/100,000: 93 cases (2020) Number of people that have been detected and appropriately treated for HIV, STIs, TB, NTDs, VBDs, viral hepatitis, ARI, ILI HIV: 12 (2018) STIs: 9,915 (2018) TB: 51 (2018) NTDs: 48 conﬁ rmed Yaws, 1,753,660 worm treatment and 2750 cases of Scabies (2018) VBDs: 2.2 per 1,000 population (2018) Viral Hepatitis: TBD ARI: TBD ILI: TBD 2.5d Number of monthly surveillance reports received on time by each reporting health facilities TBD GOAL 4 2.6a Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease TBD 2.6b Number of diabetic lower limb amputations 63 (2018) AKA: 18 (2018) BKA: 39 (2018) Forefoot: 6 (Toe: 37) (2018) M&E Plan ref 2.6f 2.6g 2.6h 2.6i GOAL 5 2.7a 2.7b 2.7c 2.8a GOAL 6 2.9a 2.6c Prevalence of obesity in adult population 23.5% (2019) estimate (WHO, 2019) Key 2.6d Prevalence of high blood pressure in adult population 29% (2011) (NCD STEPS Survey, 2011) 2.6e Prevalence of stunting 29% (2013-2018) (UNICEF, 2019) Key Performance Indicator Baseline (and year) Source: HIS unless otherwise stated Target (and year) Percentage of children attending health facilities who are: a) moderately or b) severely underweight a) TBD b) TBD People with access to improved water supply (%) 91.4% at least basic (2020) (WHO, UNICEF 2021) People with access to improved sanitation facilities (%) 52.7% at least basic (2020) (WHO, UNICEF 2021) Proportion of infants 0-5 months exclusively breast fed.
72.6% (2014) (VDHS, 2014) Number of clinicians in leadership positions 47 (2020) (HRMIS) Percentage of corporate positions within MOH ﬁ lled on permanent basis Percentage of units with current strategic plans in place that link with Health Sector Strategy (%) Percentage of MOH staﬀ , health managers and administrators who report that they have access to and have used information to manage their unit or program Total: 945 (2020) (HRMIS) DG: 4; Corporate: 76; Public Health: 93; Hosp & Curative: 516; Community Health: 256 11 Strategic Plans TBD Note: This will be monitored through a health managers’ survey, tentatively scheduled for 2022 Percentage of new and existing partners who are aligning their support to the HSS (disaggregated by on plan, on system and on budget support, type of support) 0% ■ ■ On track with targets Some progress but room for improvement ■ Falling behind Additional Sources: UNICEF, 2019; The State of the World’s Children 2019 Statistical Tables; https://data.unicef.org/resources/dataset/sowc-2019-statistical-tables/; WHO, 2019; Vanuatu key indicators; https://apps.who.int/gho/data/node.cco.ki-VUT?lang=en; WHO, UNICEF, 2021; JMP; Source: https://washdata.org/data/household#!/table?geo0=country&geo1=VUT; accessed 27/7/21.
34 | | 35 5 | Implementation Health Planning and Budgeting This HSS is high-level, setting the strategic direction for the 2021-2030 period.

It articulates the strategic priorities and the means for monitoring sectoral performance.

It serves as the basis for the content of ﬁ ve-year Corporate Plans and the annual Business Plans that allocate funds to priority activities and operationalise the HSS.
These operational plans provide the strategies and direction for implementation of the goals and objectives in the HSS, complete with outputs or results, activities and detailed budgets.

Five-year Corporate Plans will be developed for 2021 to 2025 and 2026 to 2030.

These will include measures for risk management and performance monitoring.

They will be reviewed annually to capture slippage and allow modiﬁ cations as and when situations change.
Emerging priorities will be captured through the annual Business Plan.

The planning hierarchy is illustrated in Figure 2.

This shows how the policy objectives in the NSDP are cascaded down though the sector policies and strategies to Ministry medium term and annual planning.

This HSS will be implemented by ensuring the Corporate and Business Planning processes are closely linked to costing and budgeting.

It is important that the best use is made of all resources for health.
Ensuring that plans fully inform our budget submissions will promote alignment between our health sector priorities outlined in this strategic plan and the funds that are allocated to the health sector through the budgeting process.

This will reinforce accountability.

In this way we will use the planning process to seek adequate funding for fulﬁ lling our objectives and to ensure the MOH is “ﬁ t-for-purpose” including with appropriate human resources.
Development Partners continue to play a signiﬁ cant role in funding health services in Vanuatu especially for targeted public health programs such as malaria, HIV, TB and immunisation.

Development partner resources are part of our total health expenditure.
We will continue to strive to include these external resources in planning and budgeting especially for those critical programs that rely on external ﬁ nancing (recognising that there is a need to transition to domestic ﬁ nancing over time where feasible).

Including external resources in planning and budgeting is more straightforward when such funds are on budget/on system.
In-kind, oﬀ -budget/oﬀ -system support requires more information from development partners, placing demands on time, and contributing to reduced eﬃ ciency of corporate services personnel.

Therefore, we will advocate with development partners to progressively provide funding in alignment with national plans and ﬁ nancial management processes.
Health Monitoring and Evaluation Implementing an eﬀ ective M&E system to support HSS implementation will be important for making the strategic goals and objectives a reality.

This will enable the Ministry and partners to measure progress, demonstrate accountability and to learn.

The M&E system for the HSS will be guided by the HSS M&E Plan (a separate attachment to this document).
The M&E Plan details the purpose and Figure 2: Hierarchy of Planning scope of the M&E system, the key performance standards/indicators (in a results framework), how the M&E system will be developed and how M&E will be implemented across the health sector.

It includes information on how data will be collected, when, by who and where from, as well as information on how data will be analysed, communicated/reported and used.
NSDP • National Development Plan • Sets out Government National Priorities Policies • Aligned with NSDP • Consistent with Sector or Ministry priorities Corporate Plans • Aligned with Sector Strategies (where relevant) • Inform Business Plans • Aligned with NSDP Business Plans • Aligned with Ministry Corporate Plan • Aligned with Budget Narrative Budget narrative • Aligned with programs in the Corporate Plan and the resources in the National Budget Source: Guidelines for Preparing Ministry Corporate Plans, Public Service Commission 2021 36 | | 37 to reinforce performance, management and accountability.
A cascading approach to M&E enables the Ministry and partners to measure resource use and results at diﬀ erent levels.

At the HSS level, the Ministry and partners will seek to measure high level results and impact.

M&E Plans developed at the Corporate Plan, Business Plan and Program/Unit levels will measure shorter-term or smaller scale results that are expected to contribute to the bigger picture change (see Figure 3).
It is envisaged that the M&E system developed for the HSS will be staged and cascading.

A staged approach to M&E system development will enable the Ministry and partners to start small, understand what works, and build a robust M&E system and culture over time.

This will allow gradual expansion of the number of performance measures and data sources, while at the same time addressing the important information needs of key audiences.
Timelines deﬁ ned during operational planning will help to determine priority policy actions to resource and operationalize the HSS, and Figure 3: Cascading Approach to M&E Health Sector Strategy 10-year performance measures and targets Corporate Plan 5-year performance measures and targets Annual Business Plan performance measures and targets Annual Business Plan performance measures and targets Annual Business Plan performance measures and targets Unit/program performance measures and targets Unit/program performance measures and targets Unit/program performance measures and targets n o i t u b i r t n o C monitoring of the HSS.
The purpose of the HSC is to assist and support the MOH in the delivery of Business Plans and the HSS.

The HSC is also intended to be the mechanism through which the MOH maintains oversight and monitors the progress of development partner programs delivered through the health system and their coherence with national policy, the emerging reform agenda and business plans.
It is chaired by the MOH and includes representatives of major development partners contributing to the sector (including DFAT, UNICEF, WHO, World Bank) and representatives from relevant central agencies (such as the Prime Minister’s Oﬃ ce, Ministry of Finance and Economic Management, Public Service Commission and Department of Women’s Aﬀ airs).

Governance and Accountability The MOH is led by the Minister of Health and Cabinet in the development and oversight of policy direction.
Ultimately the Minister of Health is responsible to Cabinet for the delivery of this strategy and the policy directions it includes.

The Executive team comprises the Director General and the Directors of Corporate Services, Policy and Planning, Public Health, and Hospital and Curative Services under the one health department .

Provincial health teams are accountable to the Executive.

The Executive team is accountable to the Minister for the implementation of the HSS.
A core feature of successful strategy implementation is good governance and accountability within the health sector.

Corporate governance will be adhered to at the national, provincial and sub- provincial levels, as per Goal 5 including strategic objectives 5.2, 5.3, 5.6 and 5.8.

This includes monitoring of performance in accordance with the M&E Plan and the Government’s approach to performance measurement, including annual reports.
To do this eﬀ ectively the Executive and provincial health teams will require that strategic information is generated against targets and indicators and used for reporting, risk management and decision- making.

Implementation of the M&E Plan will generate information that will provide a knowledge base to guide health service planning and the best use of resources.

Five-year Corporate Plans and Annual Business Plans and budgets will be used as tools to support management oversight.
To be best placed to implement the HSS eﬀ ectively, all MOH service delivery personnel and managers need to be aware of the strategy and understand its vision and intended results (Goal 5, strategic objective 5.1).
In addition to the mechanisms above, the Health Steering Committee (HSC) under the Joint Partnership Arrangement will support the MOH in the joint performance 38 | | 39 6 | Membership of the HSS Steering Committee and Working Groups Health Sector Strategy Steering Committee Members Director General, Russel Tamata Principal Pharmacist, Agnes Mathias Principal, Vanuatu College of Nursing Education, Evelyne Emil/ Eric Jacob Nalau Director of Policy, Planning and Corporate Services, Posikai Samuel Tapo Manager, Asset Unit, Edmond Gee Tavala A/Director of Curative & Hospital Services (former), Johnson Wabaiat Acting Manager, Health Information System Unit, Mahlon Tari A/Director of Curative & Hospital Services (current), Dr. Sereana Natuman, Medicine Manager, Information Technology, Julian Lasekula Director Public Health, Len Tarivonda Health Sector Analyst Department of Strategic Policy, Planning & Aid Coordination, Viran Tovu Hospital and Curative Services Working Group Members Manager, Environmental Health Unit, Nelly Ham SHEFA Provincial Health Administrator, Morris Amos Vanuatu Health Program, Team Leader, Shirley Tokon (Development partner representative) WHO Oﬃ cer in Charge, Michael Buttsworth, (Development partner representative) (former) WHO Country Liaison Oﬃ cer, Dr. Eunyoung Ko (current) Acting Manager Policy and Planning Unit, Rebecca Iaken Strategic Health Adviser, Vanuatu Health Program, Jackie Mundy (Adviser to Steering Committee) M&E Adviser, Vanuatu Health Program, Erin Blake (Adviser to Steering Committee) Gender Equality and Social Inclusion Adviser, Vanuatu Health Program, Emele Duituturaga (Adviser to Steering Committee) Public Health Working Group (PHWG) Members Director of Public Health, Len Tarivonda (Chair) Manager Integrated Unit, Jenny Stephen (Secretary) WHO Technical Adviser, Primary Health Care, Myriam Abel Manager, Environmental Health Unit, Nelly Ham Manager, Health Promotion Unit, Jean-Jacques Rory Manager, Vector Borne Disease Control Program Unit, Wesley Donald National Coordinator, TB and Leprosy Program, Edna Iavro Executive Assistant (to Director of Public Health), Melannie Tari Public Health Working Group Adviser, Vanuatu Health Program, Chris Hagarty Corporate Services Working Group (CSWG) Members Director of Corporate Services, Policy and Planning, Posikai Samuel Tapo (Chair) Corporate Services Working Group Adviser World Bank, Kenslyne Lele (Secretary) Acting Manager Policy and Planning Unit, Rebecca Iaken Manager, Human Resources Management and Development, Charlie Harrison Manager, Finance Unit, Jessica Alilee Malosu Manager, Central Medical Store, Wilson Lilip A/Director of Curative Services (former) Johnson Wabaiat A/Director of Curative Services (current) Dr. Sereana Natuman, Medicine Principal Nursing Oﬃ cer, Harriet Sam Consultant Dr. Trevor Cullwick, Surgery Consultant Dr.
Crystal Garae, Pathology Consultant Dr. Jimmy Obed, Psychiatry Dentist Dr. Jenny Noekrac Dentist Dr. Nelson Tanghwa Manager of Allied Health Junior George Pakoa Hospital and Curative Services Working Group Adviser, Dr. Matthew Cornish, Paediatrics Inclusive Health Working Group Members Principal Nursing Oﬃ cer, Harriet Sam (Chair) Gender Coordinator, Vanuatu Health Program, Berlinrose Nimbtik (Secretary) National Coordinator, Vanuatu Disability Promotion & Advocacy Association, Nelly Caleb Disability Social Welfare Coordinator, Child Desk, Ministry of Justice, Ginette Morris Gender Protection Cluster Coordinator, Department of Women’s Aﬀ airs, Rossette Kalmet Gender Base Violence Oﬃ cer, Department of Woman’s Aﬀ airs, Celine Bareus Executive Director, Vanuatu Society for People with Disability, Elison.S.
Bovu Community Based Inclusive Fieldworker, Vanuatu Society for People with Disability, Ashiana Basil Vanuatu Pride, Executive Director, Gillio Khaleezzi Baxter Disability & Inclusion Coordinator, Vanuatu Health Program, Leniker Thomas Acting Manager, Policy and Planning Unit, Rebecca Iaken Inclusive Health Working Group Adviser, Systems Strengthening for Eﬀ ective Coverage of New Vaccines in the Paciﬁ c, Leisa Gibson 40 | | 41 Annex 1 | Acronyms and Abbreviations Annex 2 | Government Policies and Legislation relevant to the HSS COVID-19 Coronavirus Disease 2019, or 2019 Novel Coronavirus (SARS-CoV-2) DFAT Australian Government Department of Foreign Aﬀ airs and Trade HR HSC HSS ICT IHR Human Resources Health Steering Committee Health Sector Strategy Information Communication Technology International Health Regulations MDR-TB Multi-Drug Resistant Tuberculosis M&E MOH NCD NGO NSDP PHC Monitoring and Evaluation Ministry of Health Non-Communicable Disease Non-Government Organisation National Sustainable Development Plan Primary Health Care RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health RDP Role Delineation Policy SOGIE Sexual Orientation, Gender Identity and Expression STI TB TC Sexually Transmitted Infection Tuberculosis Tropical Cyclone UHC Universal Health Coverage UNICEF United Nations Children’s Fund VCNE VHP WHO Vanuatu College of Nursing Education Vanuatu Health Program World Health Organization Ministry of Health Plans Clinical Services Plan National Malaria Strategic Plan 2015-2020 Vanuatu Health Information System Strategic Plan 2016-2020 Workforce Development Plan 2019-2025 TB Strategic Plan 2016-2020 UNICEF Primary Health Care and Referral Hospital Planning Guide National Health Plan for Disaster Risk Management and Climate Change 2017- 2020 Role Delineation Assets Plan Health Cluster Strategic Plan Relevant Government Acts/ Legal Documents Nurses Act Public Health Act Health Practitioners Act Health Legislation Nursing Legislation Food Control Act Tobacco Act Health Committee Act Pharmaceutical Legislation Mental Health Act Business License Act Sales of Medicine Control Act Dangerous Drugs Act Quarantine A Government Policies National Sustainable Development Plan 2016-2030, Prime Minister’s Oﬃ ce Vanuatu Aid Management Policy, Department of Strategic Policy, Planning & Aid Coordination Vanuatu National Child Protection Policy 2016-2026, Ministry of Justice and Community Services National Disability Inclusive Development Policy 2018-2025, Ministry of Justice and Community Services National Gender Equality Policy 2020-2030, Ministry of Justice and Community Services Vanuatu National Youth Development Policy and Strategic Plan of Action 2012-2022, Ministry of Youth and Sports Development Ministry of Health Policies Role Delineation Policy National Referral Policy Sanitation and Hygiene Policy National Environmental Health Policy and Strategy 2012-2016 Medical Equipment Donor Policy National Medicines Policy Mental Health Policy and Strategic Plan 2016-2020 Non-Communicable Diseases Policy National Policy Working Group Oral Health Policy 2019-2023 Health Sector Policy National Policy and Strategy for Healthy Islands 2011-2015 Reproductive Maternal, Newborn, Child and Adolescent Health Policy, Strategy and Implementation Plan 2021-2025 (forthcoming) Vanuatu Nutrition Policy & Strategic Plan 2016-2020 42 | | 43