Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1696590810661.pdf (Vanuatu)
MINISTRY OF HEALTH HEALTH SECTOR STRATEGY (HSS) 2017 - 2020 MINISTER’S FOREWORD I am very pleased to present this Health Sector Strategy (HSS) 2017 -2020 for guiding the development of our country’s health sector.

Seeking to create a healthy population that enjoys a high quality of physical, mental, spiritual and social well-being is at the heart of government policies and although we have been striving to improve our health services, much more remains to be done in the years ahead.
We are determined that our whole population will have equitable access to good quality health care.

This HSS is not a detailed prescription for activities, but rather the context that will guide our eﬀ orts until 2020, noting that strategic directions and expected outcomes may extend beyond the term of this HSS.
The HSS links the National Sustainable Development Plan (NSDP) 2016 – 2030: The People’s Plan, to operational delivery of health services through identiﬁ cation of the current health context in Vanuatu, roadblocks to the improvement of services and establishing speciﬁ c strategies to meet the policy objectives as outlined in the NSDP, which are: • • • • 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.
Reduce the incidence of communicable and non-communicable diseases Promote healthy lifestyle choices and health seeking behaviour to improve population health and well-being.

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 HSS has been established as a guide for all stakeholders working to improve the nation’s health services: government, national and international non-governmental organizations, international technical agencies, faith- based organisations, our development partners and the men and women who make up the organisation that is the Ministry of Health.
As we seek to meet the policy objectives of the NSDP, we have identiﬁ ed the requirement to set key strategic directions which will guide development of our systems and services over the next 4 years and these are outlined as follows: • • • Strengthening health service management and information systems.

Improving population access to health services through integrated planning, and fair allocation of resources.
Strengthening collaborative action across sectors and within the health sector to create a healthier environment and address major health issues.

This HSS calls for stronger and more eﬀ ective corporate services support to the delivery of health services, through improvements to planning, HR, ﬁ nance and audit.
This remains essential if the changes proposed in this HSS are to be achieved and is reﬂ ective of need at both national and provincial level, especially relating to planning and management capacity.

It involves an integrated approach that links planning, development and delivery of services, workforce and infrastructure.

This will provide consistent, practical tools and standards for planning health services and the staﬃ ng, facilities and equipment they require.
This will also help to ensure that resources are allocated fairly and will improve people’s access to the health services they need.

Many parts of the health sector play a role in creating and sustaining an environment that supports health, and that makes it easier for people to make healthy lifestyle choices.

The HSS proposes joining up these activities under the umbrella of ‘creating a healthier environment’.

Because resources are limited and health needs are many, it makes sense to work together.
By sharing resources and coordinating our services, we can give people better access to the health services they need.

This is most important in rural areas and places where people rely on visiting services and travel long distances to attend.
The HSS also seeks to reinforce the requirement for all stakeholders to work together on focused initiatives to tackle major health issues such as a concerted national initiative on diabetes, reducing maternal and child deaths and seeking to develop integrated models for emerging chronic care services such as mental health, rheumatic heart disease, rehabilitation and palliative care which are not well developed in Vanuatu.
I take this opportunity to thank our partners for all their help and to seek their support in introducing new ways of working together that will ensure our eﬀ orts are fully coordinated, harmonized and aligned with our new HSS and the detailed plans that will emerge from it.
Yours sincerely Honorable Jerome Ludvaune, (MP) Minister for Health 2 HEALTH SECTOR STRATEGY (HSS) 3 TABLE OF CONTENTS Acknowledgment Abbreviations Executive summary Introduction 1 2 National planning context 3 4 5 6 The legislative context The vision for health Guiding principles Where are we now?
Issues and challenges 7 Health report card 8 Health sector strategy 9 Monitoring and evaluation 10 Risk management ATTACHMENT 1: ATTACHMENT 2: ATTACHMENT 3: ATTACHMENT 4: ACKNOWLEDGMENT This discussion paper reﬂ ects an extensive consultation process with stakeholders both within and outside the Ministry of Health.

Within MoH this included senior executives, program managers, provincial managers, hospital staﬀ , corporate services and front line workers.
Beyond the MoH, it involved development partners, Malvatu Mauri, NGOs, churches and civil society representatives.

The content and direction of the 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 Working Group wishes to express its gratitude and appreciation.
Particular acknowledgement is extended to the Development Partners, National Program staﬀ , Provincial Health Managers, Medical Superintendents and remote facility staﬀ , who contributed to the consultations which informed the development of the HSS.
4 6 7 8 9 9 10 10 10 11 9 12 13 16 17 9 19 21 2.1 Health policy objectives – society goal 3 2.2 Other relevant goals and policy objectives The health of vanuatu: trends and issues The existing health system – delivery of health services in vanuatu The health report card Strengthen health sector management and information systems Improve health service access for the population through integrated planning and fair resource allocation 6.1 6.2 6.3 8.1 8.2 8.3 Strengthen collaborative action across sectors and within the health sector to create a healthier environment and address major health issues 23 HEALTH SECTOR STRATEGY (HSS) WORKING GROUP MEMBERSHIP LEGISLATION ADMINISTERED BY THE MINISTRY OF HEALTH ROLE DELINEATION POLICY 2004 HSS IMPLEMENTATION PLAN 28 28 29 29 30 34 4 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 5 NCD Screening, Counselling session NADP M&E MDG MMR NCD NGO MoYSD Ministry of Youth and Sports Development Monitoring and Evaluation Millennium Development Goals Maternal Mortality Retio Non-Communicable Disease Non-Governmental Organisation National Sustainable Development Plan Priorities and Action Agenda Package of Essential Non- Communicable Disease Interventions Public health Primary Health Care Plan Long Act Short Policy, Planning and Corporate Services Role Delineation Policy Reproductive Health & Family Planning PH PHC PLAS PP&CS RDP RH&FP PAA PEN RMNCAH Reproductive, Maternal, SDG SLO STEPS STIs TB UHC UNDP UNFPA Newborn, Child and Adolescent Health Sustainable Development Goals State Law Oﬃ ce STEPwise approach to Surveillance Sexually Transmitted Infections Tuberculosis Universal Health Coverage United Nations Development Programme United Nations Population Fund UNICEF United Nations Children’s Fund VNSO Vanuatu National Statistics Oﬃ ce Vanuatu Demographic and Health Survey Village Health Worker Village Health Worker Program Water and Sanitation Health World Health Organisation VDHS VHW VHWP WASH WHO ABBREVIATIONS ARI CSP DHIS DHS DPs EENC EH EMOC EPI FBOs FSB GoV
 GOPD H&CS HCF HIS HR HRM&D HPU HSS ICT IMCI IP INGO MALFFB MIPU MH MCCA MoET MoH MFEM MoTI Acute Respiratory Infection Clinical Service Plan Demographic Health Information System Demographic Health Survey Development Partners Essential Early Newborn Care Environmental Health Emergency Obstetric Care Expanded Program of Immunisation Faith Based Organisations Financial Support Bureau Government of Vanuatu General Outpatient Department Hospitals & Curative Services Health Christian Fellowship Health Information System Human Resources Human Resource Management and Development Health Promotion Unit Health Sector Strategy Information Communication Technology Integrated Management of Childhood Illness Implementing Partners International Non-Government Organisation Ministry of Agriculture, Livestock, Forestry, Fisheries and Biosecurity Ministry of Infrastructure and Public Utilities Mental Health Ministry of Climate Change and Adaptation Ministry of Education and Training Ministry of Health Ministry of Finance and Economic Management Ministry of Trade and Industry EXECUTIVE SUMMARY Vanuatu 2030 – The People’s Plan or the National Sustainable Development Plan (NSDP) published early in 2017, sets out the Government’s vision and provides a broad policy framework to guide planning in Vanuatu until 2030.
Each Ministry was required to develop its own planning strategy in response to the directions set out in the NSDP.

This Health Sector Strategy (HSS) focuses on the period from 2017 to 2020.

It reﬂ ects an extensive consultative process and incorporates policies and strategies already developed within the health sector.

Two further versions of the HSS will be prepared to cover the full period of the NSDP from 2021-2030.
The health issues now facing Vanuatu are increasingly complex, with the dual burden of communicable and non- communicable disease and the on-going challenges of delivering health services to a small but widely dispersed population, with a limited, ageing workforce.

The health system needs to become more resilient in the face of the emerging challenges posed by climate change.
Dealing eﬀ ectively with these challenges requires a multipronged approach, involving a greater level of collaboration and joint activities, both within the health sector and with other sectors.

Planning and implementing the range of strategies and actions needed to tackle the major issues requires strong leadership, supported by good planning, management and corporate support at both national and provincial levels.
The demands on provinces will increase as they take on greater responsibility for service planning and management.

For this reason, the HSS focuses initially on strengthening corporate services, particularly in terms of planning, HR and ﬁ nancial management capacity.

At the same time, it aims to develop planning tools and standards and to build the capacity of managers to apply these in provincial health service planning.
Finally, the HSS highlights the importance of collaborative action: with all parts of the health system working together across organisational boundaries, and with external partners, to: a) create a healthier environment; and b) tackle major health issues (diabetes, maternal and child mortality) through focused, multi-sectoral initiatives.

The impact of these strategies will be assessed through a monitoring and evaluation process and ultimately reﬂ ected in the report card of 2020.
6 HEALTH SECTOR STRATEGY (HSS) 7 2 NATIONAL 2.1 Health policy objectives – PLANNING CONTEXT Society goal 3 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: ‘A healthy population that enjoys a high quality of physical, mental, spiritual and social well-being.’ These policy objectives are discussed in the following section.

NATIONAL VISION 2030 Figure 1: NSDP Pillars 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.
This means that people should be able to access the health care that they need, reasonably close to where they live and without excessive costs.

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 Ni- Vanuatu.

While this means providing good quality health care, it also means helping to keep people healthy.
Reducing the incidence of disease means preventing people from getting ill by means such as immunisation, better nutrition 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: fast food diet, 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.

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 good managers, supported by eﬀ ective systems [e.g.

Information, Human Resources (HR), ﬁ nance] to make the right decisions.

Demonstration of tooth brushing on Oral health Day at Ecole Publique 1 INTRODUCTION Vanuatu 2030 – The People’s Plan or the National Sustainable Development Plan (NSDP) published early in 2017, sets out the Government’s vision and provides a broad policy framework to guide planning in Vanuatu over the period 2016 - 2030.
It succeeds the Priorities and Action Agenda (PAA) which guided national development between 2006 and 2015.

Importantly, in the NSDP, the Government of Vanuatu (GoV) recognises the need for collective ownership of the plan and for collaborative eﬀ orts across the diﬀ erent sectors to achieve its goals.

Each Ministry is required to develop its own planning strategy in response to the directions set out in the NSDP.
This Health Sector Strategy (HSS) replaces and builds upon the previous HSS, which concluded at the end of 2016.

It reﬂ ects an extensive consultative process and incorporates policies and strategies already developed within the health sector, including partnership arrangements.

The development of the HSS has been directed and guided by the HSS Working Group (Membership at Attachment 1).

The HSS is intended to guide health sector development until 2020 in line with NSDP targets.
The strategy and an implementation plan have been developed by the Ministry of Health (MoH), in consultation with a wide range of stakeholders involved in the health sector.

The HSS provides a broad strategic framework for the establishment national and provincial health service plans, which will then shape business plans and budgets.

These plans will also be inﬂ uenced by policies such as the Role Delineation Policy (RDP) and existing national Public Health (PH) program plans.
The planning hierarchy is shown in Section 8.2.

8 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 9 access to safe drinking water and sanitation infrastructure [Economy pillar 2.2] - Ensure that all public infrastructure including health, education and sports facilities are safe, accessible, secure and maintained in compliance with building codes and standards [Economy pillar 2.3].
- Improve partnerships and the cost- eﬀ ective use of resources to ensure sustainable asset management and maintenance [Economy pillar 2.5].

- Provide equitable and aﬀ ordable access to eﬃ cient transport in rural and urban areas [Economy pillar 2.6].

3 THE LEGISLATIVE CONTEXT In addition to its role in providing health services, the MoH is responsible for administering a wide range of legislation, generally directed at maintenance of public health and safety standards within Vanuatu.
A summary of this legislation is included at Attachment 2.

4 THE VISION FOR HEALTH A healthy population that enjoys a high quality of physical, mental, spiritual and social well-being … (NSDP Society Goal 3) However, many other NSDP policy objectives are also relevant to the health sector.

These are summarised below.
2.2 Other relevant goals and policy objectives • • • • • • • Preserve and enhance cultural and traditional knowledge, including appropriate medicines, natural remedies and healing practices [Society pillar 1.2] Increase higher education opportunities, including technical and vocational training and skills [Society pillar 2.4] 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 pillar 4 – Social Inclusion] A dynamic public sector with good governance principles and strong institutions delivering the support and services expected by all citizens of Vanuatu [Society pillar 6 – Strong and Eﬀ ective Institutions].

A nation that ensures our food and nutrition security needs are adequately met for all people through increasing sustainable food production systems and improving household production.
[ Environment pillar 1] A strong and resilient nation in the face of climate change and disaster risks posed by natural and man-made hazards [Environment pillar 3] Sustainable and well maintained infrastructure and services for all, through inclusive and eﬀ ective partnerships.

[Economy pillar 2] Speciﬁ c objectives include: - Ensure all people have reliable NCD Screening at Teouma Ville; Counseling Session 5 GUIDING PRINCIPLES Some important principles apply across all health sector policy and planning.
These include: • • • Universal Health Coverage (UHC) – ensuring that all citizens have equitable access to aﬀ ordable health care, including emergency, curative and rehabilitative services, regardless of their age, gender, race, socio- economic status or where they live.

Primary Health Care (PHC) is the foundation of the health system and remains the core strategy for addressing most health issues.
Responsibility for health requires multi-sectoral action – including partnerships with other government agencies, development partners, NGOs, the private sector and civil society.

• Health services should be ‘people-centred’ and the needs of disadvantaged and vulnerable populations, those with disabilities and victims of violence, must be addressed.

• • • • The health system should provide a continuum of care, through integration of public health and curative services.
Health services should be high quality, and delivered in a cost–eﬃ cient way by staﬀ with recognised skills and qualiﬁ cations.

Advocacy and active community engagement is important in encouraging communities and individuals to be responsible for their own health.

Health service planning, development and delivery must be evidence-based.

In turn, we must monitor and evaluate the way we deliver health services, so we can keep building the knowledge base to guide future service development.
10 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 11 6 WHERE ARE WE NOW?

ISSUES AND CHALLENGES 6.1 The health of Vanuatu: trends and issues Life expectancy in Vanuatu has increased and now stands at 69.6 and 72.7 years for males and females, respectively (VNSO, National Population and Housing Census, 2009).
But the country now faces the dual challenges of dealing with both communicable diseases and the rapidly growing incidence of Non-Communicable Disease (NCD), notably diabetes and hypertension.

People are living longer, but often with the burden of chronic illness and disability.

At all levels of the health system and in the community, people are concerned about the impacts of NCDs in terms of premature death and increasing levels of disability – e.g.

stroke, amputation, blindness and mental illness.


For the health system, the costs of managing the NCD crisis are huge and growing daily.

The 2011 NCD STEPS survey for Vanuatu (World Health Organisation, 2013) showed that 19% of the adult Ni- Vanuatu population were obese, 51% overweight and obese and around 29% had high blood pressure.

These rates are reported to have increased over the past decade.

High blood sugar levels are also increasingly common.
Treatment for diabetes is often delayed until traditional remedies have failed and diabetic related amputations are rising.

While there are now fewer malaria cases, Vanuatu still has worrying levels of other communicable diseases such as Tuberculosis (TB) and Sexually Transmitted Infections (STIs).

The challenge is to maintain the signiﬁ cant gains made as resistant strains of disease emerge, population mobility increases and development partner support decreases.
And although 90% of people now have improved water supply, almost half the population does not have proper sanitation.

Along with poor hygiene, this helps spread infectious diseases such as TB, Acute Respiratory Infection (ARI), diarrhoea and skin diseases.

NCD IN RURAL VANUATU - NDUIDUI OUTREACH VISIT NCD Screening, blood pressure check NCD is not just an urban problem.

In fact, it may be worse in some rural areas.


During a Health Christian Fellowship (HCF) outreach visit to Nduidui, West Ambae in April 2017, the Ministry of Health found surprisingly high levels of diabetes, high blood pressure and obesity among the adult population.

896 adults were screened - about half of the adult population aged 30+ years.

Almost 10% (83 people) of those who attended the clinic had diabetes with an additional 47 new cases identiﬁ ed over the ﬁ ve days.
Thirty – two percent had high blood pressure (including 184 new cases) and 397 people or 44% were overweight or obese.

The MoH/HCF visit highlights the importance of outreach services to improve early diagnosis and management of NCD and to provide aﬀ ordable, local access to health services for people in isolated rural areas.

Vanuatu still lags behind in terms of maternal and child health1.
Although nine out of ten women giving birth now have skilled birth attendants2, too many women still die in childbirth.

Numbers of maternal deaths have actually increased over the past 3 years3 although this may be due to improvements made in reporting processes.

While most babies are breast fed and most children immunised, death rates of children under ﬁ ve are still unacceptably high, particularly among newborns4.

Approximately 45% of these deaths are estimated to be associated with mal- nutrition5.
Many babies and young children are being fed poorly and the prevalence of stunting (low height for age) has been increasing over the past ten years6.

6.2 The existing health system – delivery of health services in Vanuatu The current health system structure is based on the RDP developed in 2004 [See description at Attachment 3].

While this is still a workable system, at present it is not able to achieve the ﬁ rst policy objective of ensuring equitable access to quality, aﬀ ordable health services.
There are obvious physical challenges.

Vanuatu has a small population (just over 270,000 in 2015) that is dispersed across 83 islands.

Villages in remote areas are often small and isolated, and people who live there pay high transport costs (via boat or truck) to reach health facilities.

In the wet season, travel by sea is often dangerous and roads may be cut by ﬂ ooding.
Consultations indicate that while some programs and services can be delivered Vanuatu Ministry of Health Vanuatu Reproductive, Maternal, Child and Adolescent Policy and Implementation Strategy 2017-2020 Vanuatu National Statistics Oﬃ ce, Demographic and Health Survey, 2013 Vanuatu Ministry of Health Maternal Death Review Committee 2016 Vanuatu National Statistics Oﬃ ce, Demographic and Health Survey, 2013 Vanuatu Ministry of Health Vanuatu Reproductive, Maternal, Child and Adolescent Policy and Implementation Strategy 2017-2020 Vanuatu Ministry of Health Vanuatu Reproductive, Maternal, Child and Adolescent Policy and Implementation Strategy 2017-2020 eﬀ ectively nationwide, and in some places services are working well together, overall the health system faces signiﬁ cant challenges in its quest to achieve UHC.
Reasons for this include: Workforce issues • • • • • Staﬃ ng shortages are seen as the major factor limiting the fair distribution of health services.

Many public health facilities are understaﬀ ed, particularly in rural areas, and some are not staﬀ ed at all.

Vanuatu has only 1.46 frontline health staﬀ (doctors, registered nurses, midwives) per 1,000 population, well below the standard recommended by the WHO.
Lack of HR workforce planning and development has led to the gap between staﬃ ng requirements, and available workforce, particularly in nursing.

Specialist skills are increasingly needed but are not being systematically developed, either in clinical services or primary healthcare.

In particular, the growing need for more specialist nursing roles [e.g.
midwives, nurse practitioners, diabetes educators, foot care nurses, mental health nurses, surgical nurses, critical care nurses] must be recognised and represented in strategic and operational plans with appropriate resourcing applied to address the need.

The medical workforce is increasing in size and oﬀ ers the chance to place more doctors in provincial settings, but most new doctors are quite inexperienced.
Decentralisation of clinical services is planned, and urgently required, however this will require careful planning and management to provide adequate support and supervision to doctors in the provinces, as well as having sustainable specialist services at referral hospitals.
12 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 13 Service model/system functioning • • • • There is a need for greater clarity about the range of services to be provided at diﬀ erent types of health facilities and the linkages between the diﬀ erent levels.

Referral policies and protocols are generally not in place or not being used eﬀ ectively.
Outreach services and supportive supervisory visits are an important means of improving service access in rural areas but these are not often happening.

This is mainly due to staﬀ shortages but might also reﬂ ect current management practices.

Systems for the supply and distribution of essential medicines, vaccines and other clinical supplies are not always able to keep up with demand.

This means that patients attending some health facilities do not get the treatment they need.
• There is limited integration of curative and public health services.

Separate ‘silos’ lead to poor coordination and • The return of the Village Health Worker Program (VHWP) to the MoH gives an opportunity to strengthen PHC at its roots.

There is a need for Village Health Workers (VHWs) to be recognised, trained, awarded and included in any future workforce planning and development linked to the RDP and subsequent provincial service plans.
Service mix/balance • • • • Resource allocation is currently skewed towards curative services particularly those at Vila Central Hospital (VCH): the policy commitment to PHC is not reﬂ ected in resource distribution.

Public health expenditure has remained static or declined slightly over the past ﬁ ve (5) years, and as more funding has ﬂ owed to hospitals, the PHC share has fallen.
The high level of dependence on VCH for clinical services is costly for both patients and health authorities in other provinces.

Increasing patient ﬂ ows to VCH General Outpatient Department (GOPD) reﬂ ect the inadequacy of PHC facilities in and around Port Vila, as well as apparent community dissatisfaction with those services.
Rural and remote areas are widely seen as disadvantaged: the further away from the capital, the weaker the service response and the greater the cost to consumers – both in terms of money and health.

Student; Tooth Brushing during Oral Health Day ineﬃ ciencies in resource use.
There are some models (like Integrated Management of Childhood Illness (IMCI), Malaria Program) that work well to link up separate parts of the system to provide a ‘continuum of care’, but this area needs more attention, particularly for people with complex and chronic health needs.

By comparison with other Public Health (PH) programs, there is no provincial staﬃ ng structure in place to address NCDs.
Partnerships with external agencies often help to tackle common problems and there is scope to further improve MoH direction and coordination of these eﬀ orts, so that these resources can be better used in line with the Ministry’s plans.

Working relationships with other government ministries must be strengthened, recognising that a multi- sectoral approach is needed to tackle the complex nature of many of today’s health problems.
• • • Management and ﬁ nancing • • • Although public expenditure on health is in line with expectations for a country with Vanuatu’s national income, there is evidence that the existing health budget is not being applied in a way that helps improve health system performance .

There is also considerable reliance on ﬁ nancial support from Development Partners (DPs).
DP funding through GoV ﬁ nancial systems has largely been directed at public health programs, so that government funding has tended to be spent elsewhere.

Better health service management and communications are needed within the existing structure in order to invest funding most eﬀ ectively, improve system performance and make better use of scarce resources.
• Currently, most people appointed to management positions within the health sector do not have management qualiﬁ cations or experience, even though they may be highly skilled health professionals.

At the corporate services level within the MoH, Human Resource Management & Development (HRM&D) and ﬁ nancial management has similarly lacked professional standing and expertise.

Infrastructure and equipment • • • • • Health services cannot be provided at the expected standard without adequate infrastructure.
This includes buildings, utilities, equipment, transport (trucks, boats etc.

), and Information and Communication Technology (ICT).

The proposed new staﬃ ng structure for MoH focuses on strengthening services at the provincial level, but infrastructure must also be developed in line with services so they can operate eﬀ ectively.

While there are some functional, modern health facilities in Vanuatu, a 2014 audit showed that many buildings are in poor condition due to lack of maintenance.
Increasing incidence of natural disasters in the region have caused further damage and accelerated needs to address preventative maintenance issues.

Many health facilities do not have the right kind of functional space and equipment needed for staﬀ to provide the services required.

Not all health facilities are in the best location in terms of access for the people who use them.

In some areas people have to travel many hours to reach the nearest dispensary or health centre.
• Telecommunications provide a valuable means of linking rural and remote health services with 14 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 15 higher level facilities.

Not all facilities have adequate mobile phone coverage, requiring other forms of communication to be in place to reduce their isolation.

• New technologies may provide alternative options for improving access to services.

For example, the use of drones to distribute vaccine supplies is being trialled in Vanuatu.
If successful, this could have broader use with distribution of drugs and essential supplies.

Information systems • • • • Good information is essential if health services are to be planned and managed so that they work better to improve the health of the people of Vanuatu.

Currently, a lot of data is being collected but there appears to be a lack of or limited analysis leading to little ﬂ ow of information back to staﬀ managing and delivering services, and for use in decision making.
Existing information systems are fragmented, only provide partial coverage and are hard to use when it comes to seeing ‘the big picture’ or using information to assess progress.

More research needs to be carried out so that managers and clinicians can better understand the problems they are dealing with and take action to resolve these.
6.3 The health report card 7 HEALTH REPORT CARD A simple ‘report card’ can use indicators or information that is already available to provide an overall picture of progress towards the four main health policy objectives listed under the NSDP Society Goal 3: ‘A healthy population that enjoys a high quality of physical, mental, spiritual and social well-being.’ The NSDP Monitoring and Evaluation Framework, July 2017, provides a detailed framework linking indicators included in the ‘report card’ to each NSPD policy objective.
The report card below uses selected indicators to provide a broad overview of the situation with health in Vanuatu.

A similar format may be used to report on the situation in provinces.
These indicators include: • • • • Impact indicators – the fundamental intended or unintended change occurring in organisations, communities or systems (for example, maternal mortality, child mortality) Outcome indicators – Speciﬁ c changes in behaviour, knowledge, skills, status and level of functioning (for example, skilled birth attendance, DPT3 immunisation coverage) Output indicators - Direct products of program activities (for example, Tracer medicines availability in health facilities, outpatient visits per person per year) Input and process indicators – the fundamental intended or unintended change occurring in organisations, communities, or systems.
(for example, health ﬁ nancing, health workers per 10,000 of population) Indicator Baseline year Target 2020 Impact Indicators Malaria annual parasitic incidence (API) 6.9 cases per 1000 pop’n (MoH Annual Report, 2016) API rate for all cases of malaria is no more than 1 per 1000 population nationally Incidence of TB per 100,000 population Diabetic lower limb amputations1 Number of maternal deaths 63 cases per 100,000 pop’n (2015 Data) (MoH Annual Report, 2016) Incidence of TB in Vanuatu has reduced by 20% compared to 2015 2016 – 22 (excl digits) (MoH, Health Information Statistics 2016) 2015 = 7 2016 = 9 (MoH, Health Information Statistics 2016) Diabetic related lower-limb amputations are < 23 total cases (excl digits) Maternal mortality ratio reduced to less than 80 per 100,000 live births (moving average) Under 5 mortality rate 2013: 31 deaths per 1,000 live births (estimate based on VDHS, 2013) Under 5 mortality rate is reduced to at least as low as 29 per 1,000 live births Neonatal mortality rate (infants <I month) 2013: 12 deaths per 1,000 live births (estimate, VDHS, 2013) *Prevalence of stunting 2013: 28.5% (VDHS, 2013) Outcome Indicators Neonatal mortality rate is no higher than 10 per 1,000 live births Number of children under 5 who are stunted is <23.5% *People with access to improved water supply (%) 2013: 90.4% (VDHS, 2013) 95% of population has access to improved water supply *People with access to improved sanitation facilities (%) 2013: 52% (VDHS, 2013) 80% of population has access to improved sanitation facilities Diphtheria, tetanus toxoid and pertussis (DTP3) immunisation coverage among 1 year olds (%) 2015: DPT 3: 80% 2015: MMR: 81% (MoH, Health Information Statistics, 2016) 1 * Represents diabetic lower limb amputations at Vila Central Hospital.
The number of diabetic lower-limb amputations presents a reliable and consistent measure of the impact of diabetes.

Denotes indicators not included in the NSDP Monitoring and Evaluation Framework.

95% of children aged between 12 – 23 months have received three doses of combined diphtheria, tetanus toxoid and pertussis vaccine in a given year, administered by a trained health professional.
16 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 17 Indicator Baseline year Target 2020 Prevalence of obesity in adult population 2011:19 % obese (NCD STEPS survey 2011) *Prevalence of high blood pressure in adult population 2011: 29% (NCD STEPS survey 2011) The prevalence of obesity amongst the adult population is <32.9% Prevalence of high blood pressure in adult population is < 24% *Deliveries with skilled birth attendant (%) 2013: 89.4% (VDHS, 2013) 95% deliveries attended by a skilled birth attendant #*Proportion of infants 0-5 months exclusively breast fed.
2013: 73% (VDHS, 2013) Input and process Indicators Maintain current % of infants (0-5 years) exclusively breast fed Total: 14.6 2015: Doctors:1.1 per 10,000; RNs: 12.2 per 10,000; Midwives:1.3 per 10,000 (MoH Human Resource Information System, 2015) Vanuatu has a density of 24 health workers (Doctors, Nurses and Midwives) to 10,000 population Baseline to be conﬁ rmed In Jan 2018 50% of positions within MOH ﬁ lled Baseline to be conﬁ rmed In Jan 2018 100% of units have current strategic plans in place that link with HSS No current baseline.
To be conﬁ rmed in 2018 42 % of IHR Component 2 attributes attained Number of skilled health workers to 10,000 population Corporate positions within MOH ﬁ lled on permanent basis (%) Units with current strategic plans in place that link with Health Sector Strategy (%) Attributes attained based on International Health Regulation Index (IHR) Component 2 (%) # Assume this includes infants<6 months On track with targets Some progress but room for improvement Falling behind Baseline TBC Reflecting the intent of the NSDP, the 2017-2020 HSS rests on three main strategic directions: • • • Strengthening health service management and information systems.
Improving population access to health services through integrated planning, and fair allocation of resources.

Strengthening collaborative action across sectors and within the health sector to create a healthier environment and address major health issues.

8 HEALTH SECTOR STRATEGY These strategies combine to address not only the four core health policy objectives (Section 2.1), but also most of the other relevant goals and policy objectives summarised in Section 2.2.
The NSDP calls for ‘a dynamic public sector with good governance principles and strong institutions delivering the support and services expected by all citizens of Vanuatu’.

The need to improve health service management, particularly around the corporate services areas of HR ﬁ nancial management and audit has been identiﬁ ed as a top priority.
The collaborative action strategy is about taking the diﬀ erent parts of the health system out of their organisational boxes and reassembling them in a ‘team’ approach so that they can work better together to tackle the complex problems that face the health sector.

Importantly, the strategy is not restricted to the MoH.

Instead, it aims to engage the wider range of players who inﬂ uence health and health care in Vanuatu.
The main strategies and actions arising from these strategic directions are summarised below and are shown in the Implementation Plan for the Health Sector Strategy (see Attachment 4).

Establishment of risk management controls and treatments are necessary for the MOH to ensure the best chance of success in achieving listed outcomes within the HSS period.
8.1 Strengthen health sector management and information systems 8.1.1 Strengthen Health Sector Management and Corporate Support Strong and eﬀ ective corporate services support – planning, HR, ﬁ nance and audit - is essential if the changes proposed in this HSS are to be achieved.

Provincial planning and management capacity must also be enhanced to take account of the increasing responsibilities of provinces.
The proposed strategy requires the MOH and partners to work together in order to: • Upgrade Corporate Services - as a matter of priority, upgrade and build capacity in HR, ﬁ nancial management and audit within MoH, both centrally and at provincial level.

• • • • Ensure that staﬀ appointed to HR, ﬁ nance and internal audit roles have the right qualiﬁ cations/ credentials to perform these duties.
Provide orientation training to all staﬀ commencing duty in these areas and ensure that in-service training/professional updates are provided routinely to staﬀ .

Develop career pathways and professional development opportunities within Corporate Services to attract high calibre staﬀ .

Work with development partners to obtain necessary technical support.
18 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 19 • • • • Implement health service management/leadership training for staﬀ appointed to management positions.

This includes strategic and business planning and communications.

Develop routine mechanisms to facilitate communication between corporate services and staﬀ responsible for service provision, including regular workplace visits.
Ensure that systems and tools are in place to support management decision-making and that managers are familiar with their use.

For example, RDP and standards; Health Information System (HIS) reports; HR and ﬁ nancial performance reports.

Design information systems to provide useful reports for managers.

Provide training and support for managers in interpretation and use of information in reports.
8.1.2 Build information Systems that tell us how we are doing Consultations have highlighted the importance of having good quality information on which to base decisions about service management and resource allocation.

The HSS focuses on reducing the complexity of existing arrangements for collecting and reporting information on health system performance; improving the quality of information collected; and making it easier for managers to make informed decisions.

This approach has six key elements.


• • • • • information systems but where necessary, additional reporting would be introduced.

Strengthen quality control on data collection and entry – simplify reporting systems and strengthen supervision and feedback to staﬀ responsible for data collection.
Provide regular performance reports to managers responsible for providing information on health indicators, health service utilisation, staﬃ ng and expenditure, with a ‘feedback loop’ to inform staﬀ collecting the data.

Ensure that provincial health service reporting systems are consistent and linked with MoH reporting systems.

Share information across provinces and programs on lessons learned, in implementing programs and strategies and monitoring/evaluating these.
Capitalise on new technologies for capturing, storing, analysing and disseminating information to stakeholders.

Ensure that new and existing information systems and technologies are integrated and coordinated in line with MoH strategies.

• Progressively develop local research capacity, initially using existing information systems to support monitoring and evaluation and then encouraging independent research.

This may require a formal organisational structure within the MoH.
A system of research grants around priority issues could attract external funding as well as Government support.

8.2 Improve health service access for the population through integrated planning and fair resource allocation The proposed strategy involves an integrated approach that links planning, development and delivery of services, workforce and infrastructure.

This will provide consistent, practical tools and standards for planning health services and the staﬃ ng, facilities and equipment they require.
This will help to ensure that resources are allocated fairly and will improve people’s access to the health services they need.

Figure 2 shows the planning hierarchy, highlighting the links between the diﬀ erent levels and types of plans.

Note that two further versions of the HSS will be prepared to cover the period from 2021 to 2030 and so align with the NSDP time frame.
Speciﬁ c actions required to strengthen service planning and improve resource allocation include: • Revising the Role Delineation Policy (RDP) to update and clearly deﬁ ne the roles of diﬀ erent levels of health facilities and identify the relationships between these.

This includes deﬁ ning essential service packages for primary health facilities.

The RDP should also provide a basis for linking service planning to population, taking account of geography and isolation factors.
• Deﬁ ning Minimum Standards, linked with the RDP, for • Human Resources; • Infrastructure (Functional Space, Utilities and Support Services); and • Essential equipment • Simplify essential reporting.

Agree on a set of ‘minimum performance indicators’ then develop and implement a common ‘report card’ using these indicators to report on performance and progress towards HSS goals.
Indicators would mainly be drawn from existing Career Day; Physiotherapy demonstration to students Figure 2: Planning Hierarchy 20 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 21 At each level of health facility (aid post, dispensary, health centre, provincial hospital).
• Preparing National and Provincial Health Service Plans – applying the RDP, referring to national PH program plans and setting priorities for service development for the medium to long term with clear targets established deﬁ ning an aspirational levels of services achieved by time.

These planning exercises should also involve other government agencies (e.g.

Education, Agriculture, Youth and Sports, Infrastructure and Public Utilities, Provincial Governments) as well as external partners (e.g.
DPs, NGOs, FBOs and private sector services) The National Service Plan should incorporate a Clinical Services Plan (CSP) to guide systematic and sustainable development and decentralisation of specialist clinical services (internal medicine, surgery, orthopaedics, obstetrics, paediatrics, psychiatry, anaesthetics, pathology, radiology) including linkages with PHC services.
The CSP plan will also provide a basis for specialist medical and nursing workforce development and training, and procurement of specialised equipment.

incentives, such as consideration of future posting preferences, prioritisation of training and development opportunities that fall within the PSC guidelines, and opportunities to lead projects or task forces so as to attract health professionals to provincial, rural and remote settings.
• A medium to long term Infrastructure and Equipment Plan, aligned with service plans and with proposed rolling budget.

This would provide for the development, replacement and maintenance of: • Health facilities; • Transport assets (vehicles, boats); • • ICT; Major equipment (including biomedical); and Inventory equipment.
• These policy documents and plans are intended to provide a framework for business planning and budgeting/ resource allocation and also form a basis for discussion and coordination with external partners.

• Drafting a National Workforce Plan – this aligns with national and provincial service plans, to cover both HR supply (i.e.
numbers of staﬀ , in line with RDP), development of specialised skills (in line with the CSP and national program plans) and possibly routine assessment and maintenance of core competencies.
The plan should include non – ﬁ nancial Reopening of Tavalapa local health dispensary and staﬀ house at Tongoa which has been damaged by tropical Cyclone Pam 8.3 Strengthen collaborative action across sectors and within the health sector to create a healthier environment and address major health issues 8.3.1 Collaborative action for a Healthier Environment Many parts of the health sector play a role in creating and sustaining an environment that supports health, and that makes it easier for people to make healthy lifestyle choices.
The HSS proposes joining up these activities under the umbrella of ‘creating a healthier environment’.

The priority given to these strategies and activities adopted is likely to vary among provinces.

Provincial service plans are expected to focus more strongly on the environmental challenges that have particular impact on the health of their populations.
Actions covered by this strategy might include: • • • • • • Implement the ‘Healthy islands’ policy, including healthy villages, healthy schools, healthy markets and healthy clinics.

Increase sanitation and clean water coverage, and work with Water and Sanitation Health (WASH) partners and VHWs to promote hand washing.

Monitor standards of food safety and train food industry workers, particularly street vendors.
Increase immunisation coverage and cold chain maintenance so that 95% of children are fully protected against major vaccine preventable diseases.

Ensure universal access to quality assured vector control, malaria diagnosis and malaria treatment.

Strengthen the application and integration of disease notiﬁ cation and surveillance systems, contact tracing and outbreak response to • • • • address key issues such as: • Achieving malaria elimination.

• • • Neglected tropical diseases control and elimination.
Eﬀ ectively monitoring and managing the threat of multi drug resistant TB and Preparedness for regional public health issues such as ZIKA virus, and Chikungunya Develop and apply infrastructure/ facility standards [Section 8.2] to ensure that health facilities are safe, accessible and user-friendly.

This links with the ‘Healthy Clinics’ part of the ‘Healthy Islands’ program.
In line with responsibilities under the International Health Regulations (IHR), develop disaster and emergency response plans, including identiﬁ cation of responsible agencies and provision for rapid and coordinated responses to natural disasters and emergencies.

Engage with other Government ministries and external stakeholders to identify the potential health impacts of climate change and the actions required to deal with these.
Support and expand cross-sectoral activities directed at encouraging healthier lifestyles though environmental change.

• • • Legislative and regulatory changes including maintenance and possible broadening of ‘sin taxes’ - taxation on sugary drinks and other unhealthy foods.

Support the establishment of a mechanism to administer revenue from ‘sin taxes’ to support and expand health promoting activities.
Work with Ministry of Agriculture, Livestock, Forestry, Fisheries and Biosecurity to improve the 22 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 23 as well as external stakeholders.

8.3.3 Working together on focused initiatives • • • • • • supply and availability of fresh food – ‘Gud kaikai’ policy.
Work with the Ministry of Customs and Inland Revenue to control and reduce the availability of cheap, unhealthy imported food stuﬀ s. Work with Ministry of Infrastructure to promote the development of safe, well-lit walking paths, to encourage people to walk more.

Work with Ministry of Youth and Sport to promote more physical activity through sport and recreation.

Work with Ministry of Education and Training to implement healthy schools as part of the Healthy Islands policy.
Work with the Ministry for Lands - Department of Water on improving national coverage of safe water and sanitation in line with the National Water Strategy, 2008- 2018.

• • • • • Joint development of referral policies and protocols by hospital and public health staﬀ .

Joint implementation of health services through inter-departmental coordination and delivery of services and formalising aid in kind services, inclusive of public-private partnerships to supplement existing services, or cover service gaps.
Extension of integrated outreach/ supportive supervision visits involving a mix of health professionals and support staﬀ , with planned schedules and shared transport.

Using more team approaches to tackle complex issues such as NCD, nutrition and reproductive health.

Develop routine mechanisms to facilitate communication between corporate services and staﬀ responsible for service provision, including regular workplace visits (8.1.1).
8.3.2 Joint initiatives to make the health system work better Because resources are limited and health needs are many, it makes sense to work together.

By sharing resources and coordinating our services, we can give people better access to the health services they need.

This is most important in rural areas and places where people rely on visiting services and travel long distances to attend.
• Joint service planning activities (8.2 above) involving all public health, curative and corporate services staﬀ NCD Screening, blood pressure check to tackle major health issues ‘Fight Sik Suka’ This is a concerted national initiative on diabetes, bringing together all parts of the health sector to focus on a common goal – reducing the incidence and impacts of diabetes (‘sik suka’).

This is a long term strategy which will carry over to the next HSS to achieve its impact.
Importantly, many of the interventions proposed will also apply to other NCDs such as hypertension and other cardiovascular disease.

‘Fight Sik Suka’ also aims to strengthen working relationships, both within the health sector and with external stakeholders.

Together with the ‘Healthy Environment’ strategy, it will work to improve the overall prevention, early detection and management of diabetes and other NCDs.
This is meant to be a high-level initiative, to be led by the Minister and Director General of Health, with high proﬁ le community support.

The campaign includes a range of diﬀ erent strategies which combine to have a greater impact.

These might include: • • • Developing a ‘road map’ for the diabetes initiative and engaging other sectors, development partners, non-government organisations (NGOs) and faith based organisations (FBOs) in a co-ordinated, joint approach to implementation.
A National media campaign targeting young adults particularly, with high proﬁ le support from public ﬁ gures (e.g.

Chiefs, sporting stars, church ministers, entertainers) coordinated by Health Promotion.

Support and expand cross-sectoral activities directed at encouraging healthier lifestyles though environmental change [Section 8.3.1].
• • • • • Support a Model Healthy Villages program [Healthy Islands Section 8.3.1] – within selected Area Councils, develop coordinated healthy village programs, focusing initially on diabetes.

Build strong community leadership and link in with external partners for activities such as nutrition, physical activity, gardens, WASH.

Provide training to VHWs and upgrade their role to include diabetes screening, monitoring and education.
Expand the Healthy schools program in collaboration with the Ministry of Education and Training as a primary sector partner [Healthy Islands Section 8.3.1] Set up a project team to work with traditional healers to deﬁ ne their roles and relationships with health services in recognising and responding to people with diabetes.

Strengthen community based screening activities from the village level upwards.
This should involve health workers at hospitals, health centres and dispensaries and aid posts as well as public health staﬀ providing screening services at community venues and events.

Private sector providers (doctors, pharmacies) may also take part in screening activities.

Scale up of the WHO Package of Essential Non-Communicable Disease Interventions (PEN) as a basis for achieving wide coverage of essential but aﬀ ordable diagnostic and treatment services in all health centres.
Provide multidisciplinary outreach clinics (doctors, specialist nurses, dietitians) from VCH to provincial hospitals and from provincial hospitals to health centres, including supportive supervision to PHC staﬀ .

(Section 8.3.2) 24 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 25 • • • • Establish Diabetes Centres or NCD clinics at all health facilities – with additional capital funding if necessary.
Develop and implement clear referral guidelines and protocols to improve management of diabetic patients within the health system (Section 8.3.2) Develop foot-care programs in all provinces, with linked media coverage.

Ensure that educational programs are in place to support service development: • • • Ongoing PEN training for all levels of provincial staﬀ , including medical staﬀ .

Training of selected nursing staﬀ in specialist roles including foot care, nutrition and diabetes education.
Give priority to internal medicine in the medical specialist training program.

• Monitor and evaluate initiatives: use these ﬁ ndings and other research to build the evidence base for future intervention.

Work Together to Reduce Maternal and Child Deaths The comprehensive Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) Strategic Plan will be implemented progressively.
For the HSS though, the particular focus will be on those activities that strengthen primary health care and build linkages within the health sector.

This highlights the importance of an integrated approach to Improving maternal and child health and preventing unnecessary deaths.
Key actions could include: • The Maternal and Infant Deaths Advisory Committee to investigate KIK AOT NCD (TOBACCO) Football Tournament and report on all maternal and infant deaths, with the report ﬁ ndings to be used to inform changes in practice Progressively strengthen skilled birth attendant/midwifery coverage (via RDP, service plans and workforce plan) with accredited training through national providers.
Provision of regular training for all PHC and relevant hospital staﬀ in new Antenatal and Postnatal Care guidelines; Emergency Obstetric Care (EMOC); Essential Early Newborn Care (EENC) and the updated IMCI programs.

Develop and implement clear referral guidelines and protocols to improve management of pregnant women and deliveries within the health system.

Plan and implement integrated outreach/supervisory visits – RMNCAH, EPI, Environmental health – on an annual basis in each province.
Review of facility standards and audit of existing infrastructure to • • • • • ensure that health facilities are functional and adequately equipped for safe deliveries [Facility standards - Section 8.2].

• Monitor and evaluate strategies: use these ﬁ ndings and other research to build the evidence base for future intervention.
Develop Integrated Models for Emerging Chronic Care Services Services such as mental health, rheumatic heart disease, rehabilitation and palliative care are not well developed in Vanuatu.

Now though, the need for these services is becoming more evident as the pattern of morbidity is increasingly dominated by NCDs and more people are living with chronic illness and disabilities.
While these people are mostly cared for in community settings, they are also likely to have regular contact with hospital services.

The HSS recognises the importance of linking up PHC and hospital based services through a nation-wide service network to provide better continuity and quality of care for people living with chronic conditions.

• • • Identify types of patients/ services requiring integrated models e.g.
mental health, asthma/ chronic respiratory disease, heart failure, rheumatic heart disease, rehabilitation, palliative care.

Review existing service models (i.e.

the way services operate across PHC and hospital settings) and identify strengths and weaknesses of these arrangements.
Highlight ways of successfully linking community and hospital based services, including NGOs/FBOs and visiting specialists as well as interaction with the private sector, particularly for services which are not provided through the public health care system.

Use these ﬁ ndings to develop and progressively implement an integrated model of service delivery, showing the roles of community and hospital based services and the links between these sectors.

This model should also be reﬂ ected in the RDP.
26 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 27 9 MONITORING AND EVALUATION 10 RISK MANAGEMENT ATTACHMENT 1: Health Sector Strategy (HSS) working group membership ATTACHMENT 2: Legislation administered by the Ministry of Health Legislation regulating the business undertakings of the MoH and relating to its activities are as follows: • • • • • • • • • 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 Act Mr Viran Tovu Health Sector Policy Analyst, Prime Ministers Oﬃ ce Mr Len Tarivonda Director Public Health, MoH Dr Willie Tokon Director Curative and Hospital Services, MoH Mr Morris Amos Provincial Health Administrator, SHEFA Province Ms Carol Rovo Acting Principal Health Planner, MoH Ms Rachel Takoar Health Information Sytems Manager, MoH Ms Alexandra Masteia Health Sector Financial Analyst, MFEM Mr Michael Buttsworth Health Systems Strengthening Technical Oﬃ cer, WHO Mr Scott Monteiro Technical Advisor, Corporate Services, VHRM Ms Joan Nankervis Policy and Planning Support Oﬃ cer (AVID), MoH Mr. John Jovi Projects and Aid Coordination Oﬃ cer, MoH The Ministry of Health, in coordination with other sectors, is responsible for monitoring and evaluation of the HSS 2017 – 2020.
While the report card can use indicators or information that is already available to provide an overall picture of progress towards the four main health policy objectives listed under the NSDP Society Goal 3, this is indicative of health status and not of the HSS progress.
A separate Monitoring and Evaluation Framework (MEF) will be developed to further encompass both NSDP progress and establish progress indicators for the HSS based on deﬁ ned outcomes, outputs, inputs and processes as listed in the implementation plan.

The framework is to be results based, and would be intended to serve as a guide for implementing, monitoring, evaluating and reporting on the progress of the HSS as well as any subsequent operational plans.
Critical elements of the MEF will include: • • • • • • Baseline data to describe the situation prior to the HSS Indicators aligned to deﬁ ned targets Ongoing data collection on indicators, relating to achievement Systematic reporting with both qualitative and quantitative measures M&E matrices completed in coordination with other sectors and health stakeholders Information on success or failure in reaching targets The MEF is to be a continuous process of planning, implementation, monitoring (data collection) and evaluation (data analysis) in order to determine how well the health sector is reaching expected results.
Links with global and regional targets are to be reﬂ ected, similar to the development of target results for the NSDP aligned to SDG targets.

Given the complexity in delivering on health related strategies, due to the potential number of stakeholders and external inﬂ uences on the sector, identiﬁ cation of potential risks to the implementation of the three strategic directions will be completed by implementation leads with oversight by management bodies within the MOH.
Based on information provided from other resources, managers should conduct task and outcome speciﬁ c risk analyses to determine potential risks.

The analysis should identify: • • • • • • What could possibly happen?

How likely is something to happen (measuring risk)?

How severe will the outcome be if something did happen?

How can the likelihood something will happen be mitigated on the forefront and to what degree?

What can be done to reduce the impact (and to what degree)?
What is the potential for exposure or what cannot be proactively avoided?

Using analysis results, managers within the MOH can compare the likelihood of diﬀ erent adverse events along with their impacts and rank potential risks in terms of severity.

Plans for mitigating risks and handling them appropriately can then be developed.

Any developed Risk Management Plans (RMPs) should also undergo quality assessments so the interventions and actions proposed are addressed as real potential issues.
Reporting on risk events will be part of the MEF.
28 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 29 ATTACHMENT 3: Role Delineation Policy 2004 ROLE DELINEATION FOR HOSPITAL FACILITIES (2004) Level Access2 Services3 Skills Resources Level Six NATIONAL REFERRAL HOSPITAL Pop: Whole of nation 190,000+ 80% within 36 hours Level Five REGIONAL REFFERAL HOSPITAL Pop: 60000+ 80% within 24 hours *Provides acute care with specialist involvement *Determines referrals to out of country services Medical Specialists in all core specialties Ambulance service *Recognized to provide Postgraduate Training Specialist nurses e.g.
Infection Control Level 6 Diagnostic services *Hosts Nursing School on Site * Provides acute care with senior or general medical oﬃ cer involvement *Receives referrals * May provide sub-specialty services if personnel and funding available e.g.
Eyes *Hosts international medical teams *Participates in Intern Training Some medical specialists Level 5 pharmacy, Lab and radiology Range of Allied Health Ambulance service Level Four 4a PROVINCIAL HOSPITAL Pop: 25,000+ 80% within 8 hours * Provides acute care with general medical oﬃ cer/nurse practitioner involvement * Provides selected procedures in life threatening situations e.g.
Caesarean section *Capacity to assess, stabilize and transfer complex cases *May host international medical teams Medical Practitioner Some Allied Health Nurses on all shifts Laboratory with staﬀ Basic radiology 4b OUTREACH HOSPITAL (Proposed) Pop: 7000 if remote Outreach: Specialist visiting teams Overnight staﬃ ng Basic Lab for Dx 2 3 As measured by the ability of at least 80% of the population to travel to the facility by whatever means (truck, walk, boat, plane) Services are cumulative with each level expected to also provide the services of the lower level Laboratory with trained nurses Domestic Services 30 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 31 ROLE DELINEATION FOR PROVINCIAL HEALTH SERVICES (2004) Level Population Travel Services Skills Resources Health Centre Level 3 1000-5000 80% pop within 4 hr; Hospital access requires air travel 2000-5000 80% pop within 4 hr; Hospital access does not require air travel As for Level 2a plus: Acute: Inpatients with access to overnight staﬃ ng.
Higher risk deliveries; Minor surgery including POP; Dental Care Primary: Visiting teams e.g.

eye, medical Supervisory Role for other MOH facilities Nurse Practitioner Midwife Staﬀ Nurse + Aid Nurse, handyman, cleaner, cook when fully supported by community As for Level 2 a plus: Transport for supervisory visits and outreach Malaria lab.
Dispensary Level 2a Remote (also Zone Supervisor) 300-2000 300-2000 Dispensary Level 2b 80% pop within 1 hr; Hospital or Health Centre access requires air travel 80% pop within 1 hr; Hospital, Health Centre or Remote Dispensary access does not require air travel 2000-4000 80% pop within 1 hr; Also 1 hr from Hospital or Health Centre Aid Post Level 1 100-300 80% pop within 30 mins As for Level 2b plus: Acute: Some higher risk deliveries; admissions Primary: RH IUD insertions Midwife Extra Training + Nurse Aid supported by community As for Level 2b plus: Vaccine fridge Separate consultation and treatment areas, 2-bed general and 2-bed female wards; Locked room or shed for storage for Zone e.g.
nets, insecticide, excess supply Acute: Normal deliveries; Minor suturing; Stabilise and refer Primary: Immunisations, RH, MCH Public: As for Level 1 Supervisory Role for VHWs and TBAs Acute: Basic treatment; counsel and refer Primary: Information, condom distribution, assists with mobilisation for EPI, mass treatments etc Public: sanitation, bed nets Supervisory Role: for community based activities e.g.

bednets Staﬀ nurse +Aid Nurse supported by community Secure communications (e.g.
Public phone or Clinic Teleradio) solar, generator or community power supply; Lighting to delivery and treatment areas.
Steriliser (use cooking ﬁ re); Water supply (multi rain tank/community supply); Water seal toilet and soakaway/septic; secure area for medical waste disposal Consultation/ treatment area with secure drugs storage; delivery and 2-bed maternity ward; patient shower/ washroom; covered waiting area Aid Nurse supported by community Water supply nearby Building form community Drugs and basic supplies form MOH 32 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 33 ATTACHMENT 4: HSS Implementation Plan 2017 - 2020 1 STRENGTHEN HEALTH SECTOR MANAGEMENT AND INFORMATION SYSTEMS Outcome Actions Priority Timing Responsibile Partners Goal 1.1 Strengthen health sector management and corporate support 1.1.1 Corporate staﬀ at all levels (national and provincial) are qualiﬁ ed, well directed and managed with access to learning and development opportunities 1.1.1.1 Ensure that staﬀ appointed to HR, ﬁ nance and internal audit roles have the right qualiﬁ cations/credentials to perform these duties.
1.1.1.2 Provide orientation training to all staﬀ commencing duty in these areas and ensure that in-service training/ professional updates are provided routinely to staﬀ .

1.1.1.3 Develop career pathways and professional development opportunities within Corporate Services to attract high calibre staﬀ .

1.1.1.4 Work with development partners to obtain necessary technical support.
1.1.2 Health professionals that hold management positions are adequately trained in corporate responsibilities Source/develop training programs Schedule training for identiﬁ ed staﬀ .

1.1.2.1 1.1.2.2 1.1.2.3 Report on participant numbers.

1.1.3 Routine communication systems are in place between health service and corporate service functions 1.1.3.1 1.1.3.2 Working party to identify and agree communication mechanisms.
Establishment of relevant committees / governance structures 1.1.4 Systems and tools are in place to support management functions and timely decision- making 1.1.4.1 1.1.4.2 1.1.4.3 Develop Role delineation policy and standards.

Develop and implement standard reports to managers – HIS, HR, ﬁ nance.

Provide training and support for managers in interpretation and use of information in reports.
1 2 2 1 2 3 1 1 1 Ongoing from Q4, 2017 HRM&D PSC Ongoing from Q1, 2018 HRM&D PPU Directors Q2 – Q3, 2018 Director PP&CS HRM&D PSC Unit Managers Periodic from Q4 2018 Director PP&CS DPs Ongoing from Q1, 2018 Director PP&CS DPs VIPAM External agencies Q3, 2018 Q1, 2019 Director PP&CS PSC MFEM Q4, 2017 -Q1, 2018 Q1, 2018 Q2, 2018 PPU Corporate Service Units HIS, HR, Finance) DPs 34 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 35 Outcome Actions Priority Timing Responsibile Partners Goal 1.2 Build information systems that tell us how we are doing 1.2.1 Essential reporting is simpliﬁ ed, based on performance indicators, and produced routinely 1.2.2 Quality of data collected is continually improved through supportive supervision 1.2.3 Regular health service performance reports are generated with feedback provided to managers 1.2.4 Reporting is consistent across all Provincial health services and linked with MoH reporting systems 1.2.1.1 Agree on a set of ‘minimum performance indicators’ then develop and implement a common ‘report card’.
1.2.2.1 Strengthen quality control on data collection and entry, including supervision and feedback to staﬀ responsible for data collection.

1.2.3.1 Performance reports developed to include health indicators, health service utilisation, staﬃ ng and expenditure.

1.2.4.1 Review existing systems: identify and resolve major disparities.

Agree common reporting format.


1.2.5 Information on programs and lessons learned is disseminated widely 1.2.5.1 Annual meeting of Provincial Administrators, PHMs, Medical Superintents and Program Managers to discuss experience in implementing programs and strategies and monitoring/evaluating these.
1 2 2 3 3 From Q1, 2018 PPU HIS HRM&D WHO Ongoing from Q2, 2018 PPU / HIS Development partners Q1 - Q3 2018 Corporate services: PPU, HIS, HR, Finance Development partners Q1, 2019 Corporate services: PPU, HIS, HR, Finance Directors Provincial Teams From 2019 PPU Directors Provincial Teams DPs Central Agencies 1.2.6 Embrace new data management technologies, ensuring integration with national priorities 1.2.7 Health research within Vanuatu is increased in a progressive manner within ethical boundaries 1.2.6.1 Develop and implement eHealth Strategy Devel’t from Q2, 2018 and then ongoing HIS, IT DPs (particularly WHO, UNICEF, ADB) 1.2.7.1 Develop local research capacity using existing information systems to support monitoring and evaluation and encouraging independent research.
3 Q1 – Q2 2020 MoH Private practices, Overseas institutions 36 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 37 2 IMPROVE HEALTH SERVICE ACCESS FOR THE POPULATION THROUGH INTEGRATED PLANNING AND FAIR RESOURCE ALLOCATION Outcome Actions Priority Timing Responsibile Partners Goal 2.1 Ensure resources are allocated fairly to improve people’s access to health services 2.1.1 Role Delineation Policy (RDP) is in place, reﬂ ective of the delineation of health facilities and access by local population 2.1.1.1 Deﬁ ne the roles of diﬀ erent types of health facilities and identify the relationships between levels.
2.1.2 Minimum standards are clearly deﬁ ned for functional space, human resources and equipment at each level of health services 2.1.2.1 2.1.2.2 2.1.2.3 Form a working group to develop staﬃ ng standards Form a working group to develop facility standards Form a working group to develop standards for essential equipment.
2.1.3 National and Provincial Health Service Plans are established, applying minimum standards, reﬂ ective of current state and clearly identifying maintenance and growth of health services 2.1.3.1 2.1.3.2 Applying the RDP establish assessment of staﬃ ng, facilities and essential equipment to identify gaps and develop medium to long term priorities for service development.
As part of the National Service plan, develop a Clinical Services Plan to guide development and decentralization of specialist curative services.
1 1 1 Q4 2017-Q2 2018 PPU Q4 2017-Q2 2018 PPU Q3, 2018 Q1- Q2 2018 Director H&CS Director Curative Services 2.1.4 A National Workforce Plan is in place, which reﬂ ects aspirational targets for service development across all cadres and links with National and Provincial service plans 2.1.5 A National health infrastructure and equipment planplan is in place which reﬂ ects aspirational targets for service development across all cadres and links with National and Provincial plans 2.1.4.1 Workforce planning to cover both total supply of the main cadres; development of specialist skills and maintenance of core competencies.
1 Q1 – Q2 2018 HRM&D 2.1.5.1 Prepare a medium to long term capital plan with a proposed rolling budget to provide for the development, replacement and maintenance of health facilities, transport (vehicles, boats), ITC and major equipment.
1 Q2 – Q3, 2018 AMU WHO Other DPs HRM&D PNO VCNE AMU Director H&CS PPU Director PH Other Gov’t Partners Provincial Governments DPs PPU Directors Provincial Teams TA via DPs MFEM PSC PPU Directors Provincial Teams TA via DPs MIPU 38 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 39 3 STRENGTHEN COLLABORATIVE ACTION ACROSS SECTORS AND WITHIN THE HEALTH SECTOR TO CREATE A HEALTHIER ENVIRONMENT AND ADDRESS MAJOR HEALTH ISSUES.
Outcome Actions Priority Timing Responsibile Partners Goal 3.1 Collaborative action for a Healthier Environment 3.1.1 Maintenance and expansion of public health programs contribute to building an environment that protects population health and promotes healthy behaviour 3.1.1.1 Implement the ‘healthy islands’ policy, maintaining and expanding healthy villages, schools, markets and clinics.

3.1.1.2 Increase sanitation and clean water coverage and work with WASH partners and VHWs to promote hand washing.
3.1.1.3 Monitor standards of food safety and train food industry workers, particularly street vendors.

3.1.1.4 Increase immunisation coverage and cold chain maintenance so that 95% children are immunised.

3.1.1.5 Ensure universal access to quality assured vector control, malaria diagnosis and malaria treatment.

3.1.1.6 Strengthen application and integration of disease notiﬁ cation and surveillance systems, contact tracing and outbreak response.
3.1.1.7 Develop and apply facility standards to ensure that health facilities are safe, accessible and user-friendly.

1 1 1 1 1 1 Ongoing HPU Ongoing Ongoing Ongoing Ongoing Ongoing EH EH EPI VBDC SR Refer Action 2.1.2 MOET MALFB WASH Partners VHWs DPH Municipalities MALFB Customs DPs DPs DPs 3.1.1.8 Develop disaster and emergency response plans.
2 Q2 – Q3 2018 and 2019 PPU DPH 3.1.2 Potential health impacts of climate change and the actions required to deal with these are known and incorporated in program development 3.1.2.1 Form a Task Force to identify health impacts of climate change and ensure these are addressed in national cross- sectoral forums and programs.
2 Q1, 2019 DPP&CS DPH DH&CS MCCA 40 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 41 Outcome Actions Priority Timing Responsibile Partners 3.1.3 Healthy lifestyle choices are supported through a multi-sectoral approach, developed in partnership with other government agencies, development partners, NGOs and FBOs 3.1.3.1 3.1.3.2 Support legislative and regulatory changes including maintenance and possible broadening of ‘sin taxes’ - taxation on sugary drinks and other unhealthy foods.
Support the establishment of a mechanism to administer revenue from ‘sin taxes’ to support/expand health promoting activities 3.1.3.3 Work with Ministry of Agriculture to improve the supply and availability of fresh food.
3.1.3.4 Work with the Ministry responsible for Customs and Inland Revenue to control and reduce the availability of cheap, unhealthy imported food stuﬀ s. 3.1.3.5 Work with Ministry of Infrastructure to promote the development of walking paths 3.1.3.6 Work with Ministry of Youth and Sport to promote more physical activity through sport & recreation 3.1.3.7 3.1.3.8 Work with Ministry of Education and Training to implement healthy schools as part of the Healthy Islands policy Work with the Ministry for Lands - Department of Water on improving national coverage of safe water and sanitation in line with the National Water Strategy, 2008- 2018.
Goal 3.2 Joint initiatives to make the health system work better 3.2.1.1 Conduct joint service planning activities involving public health, curative and corporate services staﬀ + external stakeholders.
3.2.1.2 Jointly develop referral policies and protocols 3.2.1 Eﬃ ciencies in health service delivery are created through eﬀ ective joint planning, communications, and supportive supervision at all levels 3.2.1.3 Joint implementation of health services through inter- departmental coordination and delivery of services and formalising aid in kind services, inclusive of public-private partnerships to supplement existing services, or cover service gaps.
3.2.1.4 Extend integrated outreach and supportive supervision visits.

3.2.1.5 Develop routine mechanisms to facilitate communication between corporate services and staﬀ responsible for service provision.
3 Q2, Q3, 2018 Q2, 2018 HPU HPU SLO MFEM SLO MFEM Ongoing NCD - Nutrition MALFF Ongoing NCD – nutrition EH From 2020 HPU / NCD Ongoing from Q4 2017 HPU / NCD Ongoing Ongoing From Q2, 2018 PPU MoIA MoTI MFEM MIPU Provincial Governments MoYS Provincial Governments NGOs MOET Provincial Governments MoL-Department of Water NGOs Provincial Governments DPH, DH&CS, DPP&CS Development partners NGOs IPs From Q2, 2018 DCS / DPH PPU Provincial Teams From Q2, 2018 Q1 – Q3 2018, 2019, 2020 DPH, DCS Provincial Teams FBOs NGOs Other ministries Refer Outcome 1.1.3 1 2 2 1 42 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 43 Outcome Actions Priority Timing Responsibile Partners Goal 3.3 Work together on focused initiatives to tackle major health issues 3.3.1.1 3.3.1.2 Develop a ‘road map’ for the diabetes initiative and engage in a coordinated, joint approach to implementation.
Mount a national media campaign targeting young adults particularly, with high proﬁ le support from public ﬁ gures.

3.3.1.3 Support and expand cross-sectoral activities to encourage healthier lifestyles though environmental change.

3.3.1.4 3.3.1.5 3.3.1.6 Support a Model Healthy Villages program within selected Area Councils.
Expand the Healthy schools program in collaboration with the Ministry of Education and Training [Healthy Islands] Set up a project team to work with traditional healers to deﬁ ne their roles and relationships with health services in relation to people with diabetes.

3.3.1.7 Strengthen community based screening activities.
3.3.1.8 Scale up of WHO PEN Interventions 3.3.1.9 Provide multidisciplinary outreach clinics (doctors, specialist nurses, dietitians) from VCH to provincial hospitals and from provincial hospitals to health centres.

3.3.1.10 Establish Diabetes Centres or NCD clinics at all health facilities.

3.3.1.11 Develop and implement clear referral guidelines and protocols to improve management of diabetic patients within the health system 3.3.1.12 Develop and promote foot-care programs in all provinces.
3.3.1 The incidence of diabetes and its complications are reduced through addressing key risk factors and improving diagnosis and management (“Fight Sugar Initiative”) 3.3.1.13 Ensure that education programs are in place to support service development: • Ongoing PEN training for all levels of provincial staﬀ , including medical staﬀ .

Training of selected nursing staﬀ in specialist roles including foot care, nutrition and diabetes education.
Give priority to internal medicine in the medical specialist training program.

• • 3.3.1.14 Monitor and evaluate initiatives: use these ﬁ ndings and other research to build the evidence base for future intervention.
1 1 3 1 1 2 3 1 2 2 1 Q4, 2017 Q1, 2018 NCD Other Sectors, DPs, NGOs FBOs Q1, 2018 NCD / HPU Sporting VIPs MoYS MALFB Refer Strategy 3.1.3, Actions 3.1.3.1 – 3.1.3.6 Refer Action 3.1.1.1 Refer Action 3.1.1.1 Q1, 2020 Q1 – Q3, 2018 Q1 – Q3, 2018 HPU NCD NCD NCD team VHWP WHO PP Malvatu Mauri Provincial Teams FBOs NGOs Provincial Teams FBOs NGOs Q1 - Q3, 2019 DH&CS NCD VCH PHMs DPs From Q2, 2020 Q1 – Q2, 2018 NCD NCD From Q1, 2019 NCD & Podiatrist Ongoing NCD PNO DCS AMU DPs FBOs NGOs DPH DCS VCH PHMs PNO DPH FBOs NGOs DPs WHO HRM&D DPs HRM&D DPs Periodic 2018- 20 PPU DPH 44 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 45 Outcome Actions Priority Timing Responsibile Partners 3.3.2.1 Maternal and Infant Deaths Advisory Committee to investigate and report on all maternal and infant deaths.
3.3.2.2 Progressively strengthen skilled birth attendant/midwifery with accredited training through national providers.

3.3.2.3 Provide regular training for all PHC and relevant hospital staﬀ in new Antenatal and Postnatal Care guidelines; EMOC; EENC and updated IMCI programs.
3.3.2 Maternal deaths and mortality rates among children aged <5 years are reduced 3.3.2.4 Develop and implement clear referral guidelines and protocols to improve management of pregnant women and deliveries within the health system.

3.3.2.5 lan and implement integrated outreach/supervisory visits – RMNCAH, EPI, Environmental health – on an annual basis in each province.
3.3.2.6 Review facility standards and audit existing infrastructure to ensure that health facilities are functional and adequately equipped for safe deliveries 3.3.2.7 Monitor and evaluate strategies: use these ﬁ ndings and other research to build the evidence base for future intervention.

3.3.3.1 Identify types of patients/services requiring integrated models.

3.3.3.2 Review existing service models and identify strengths and weaknesses of these arrangements in providing continuity of care.
3.3.3.3 Use these ﬁ ndings to develop and progressively implement an integrated model of service delivery, across community and hospital based services.
3.3.3 Integrated models for emerging chronic care services, such as mental health, rheumatic heart disease, rehabilitation and palliative care, are used to improve service delivery 1 1 2 2 1 2 2 3 3 3 Periodic 2018- 20 RH&FP From Q1, 2018 PNO Q1 – Q3 2018 and 2019 RH&FP Q2 2018 RH&FP Q1 – Q3 2018 -2020 DPH Q2, 2018 AMU Periodic from 2018 PPU DPH DH&CS PNO VNC HR HRM&D DPs DCS DPH RH&FP EPI EH DPs RH&FP WHO Other DPs Q2, 2019 DH&CS / DPH Q2, 2019 DH&CS / DPH NCD – MH PH Programs NGO FBO DPs NCD - MH PH Programs NGO FBO DPs Q1, 2020 DH&CS / DPH Provincial Teams National PH Programs DPs 46 HEALTH SECTOR STRATEGY (HSS) AND IMPLEMENTATION PLAN 2017 - 2020 47 MINISTRY OF HEALTH