Health Service Delivery Profile
Solomon Islands
2012
Developed in collaboration between
WHO and the Ministry of Health, Solomon Islands
Solomon Islands health service delivery profile
Demographics and health situation
Situated in the South Pacific Ocean, Solomon Islands is a diverse country with more than 900 islands and 70
language groups.1-2 Its capital, Honiara, is situated in the main province of Guadalcanal, and there are eight
other provinces (see Annex 1). Like many other small island countries in the Pacific, parts of the Solomon
Islands are at risk due to rising tides and sea levels. At the time of the 2009 Census, the population was
515,870 and estimated to be growing at 2.3% per annum.3 The median age in 2009 was 19.7 years, with 54%
of the population aged 15-59 years and only 5% aged 60 or older.1
Its Human Development Index (0.51) places Solomon Islands 142 out of 187 countries, showing an overall low
level of development (based on health, education and income).4 Urbanisation in Solomon Islands is 20%, and
3
increasing at more than twice the overall rate of population growth.
Government thus faces the twin
challenges of continuing to service largely dispersed and often remote communities, while also striving to
respond to the pressure of urban growth. Access to improved sanitation is very low (18%) with a huge urban to
5
rural difference (77% versus 5%). Public health priorities include rural water supply, improving health centres,
and addressing tuberculosis, malaria, HIV/AIDS and sexually transmitted infections and common childhood
illnesses.6
Table 1 Key development indicators, Solomon Islands
Indicator
Human development index
Adult literacy rate (%)
Total health expenditure (% of GDP)
Proportion of people living below national poverty line (%)
Life expectancy at birth (years)
Crude birth rate (per 1,000 population)
Crude death rate (per 1,000 population)
Infant mortality rate (per 1,000 live births)
Maternal mortality rate (per 100,000 live births)
Measure
0.5
76.6
5.5
22.7
71.0
32.2
6.7
26.0
110.0
Year
2011
2007
2009
2010
2009
2009
2009
2007
2008
Sources: WHO 2010;1 Mishra, Hargreaves & Moretto 20107
Like many developing countries, the Solomon’s is undergoing an epidemiological transition and now faces a
double burden of communicable and non-communicable diseases. Malaria continues to be a leading cause of
mortality and morbidity, especially among children and infants. In 2007 clinical malaria and fever accounted for
8
28% of acute care attendances. At the same time, non-communicable disease (NCD) risk is rising with a
recent Government and WHO study reporting 46% of the study population at high risk for NCDs; 67%
overweight; and 33% diabetic.8
Health strategies, objectives and legislation
The Ministry of Health and Medical Services (‘the Ministry’) is organised through four major divisions under the
leadership of an Undersecretary: health improvement; health care; health policy and planning; and
administration and management.9,10 Current health sector priorities, as set out in the National Health Strategic
Plan 2011-2015, reflect the growing significance of NCDs and the need to focus on whole-of-government
approaches to health promotion and disease prevention.
Solomon Islanders are also protected by key legislative instruments that are implemented and up held by the
Ministry. They include:
•
Mental Treatment Act (1978). Addresses patient care and the management and control of mental
health hospitals
Health Service Delivery Profile, Solomon Islands, 2012
1
•
•
•
•
•
Health Workers Act (1989). Regulates the functions and duties of various categories of health
workers and establishes a Health Workers Board
Quarantine Act (1978). Regulates vessels, persons, goods and ‘things’ to prevent the introduction or
spread of disease
Tobacco Control Act (2010). Regulates labeling, distribution, sale, advertisement and smoking of
tobacco products
Medical and Dental Practitioners Act (1988). Regulates medical and dental practitioners
Nursing Council Act (1987). Establishes a Nursing Council to register and regulate nurses, midwives
and auxiliary nurses.11
Service delivery model
The Ministry of Health and Medical Services is the central actor in the Solomon Islands health system: it
functions as funder, regulator and provider of nearly all services. The national health system is based on the
12
public health care approach. Responsibility for service delivery rests entirely with publicly-owned facilities that
9
are funded via fixed budget allocations, and available to all Solomon Islanders. Non-government organisations
and faith-based organisations also make significant contributions in terms of additional funding and service
delivery, however the Ministry is heavily involved in the work of these organisations. The private sector plays a
9
very minimal role in health.
Recent years have also seen a number of programs and projects operating which, while being conducted
outside the health sector as conventionally defined; have the potential to impact positively on health outcomes.
The Ministry of Education provides free basic education and the Ministries of Agriculture and of Fisheries
operates food security programs.
The provider network
Of the nine provinces in the Solomon Islands, eight have access to a public hospital. There are also four
private hospitals, owned and operated through various church organisations. Most of the provinces have
access to a health network comprised of health centres, aid posts and village health workers, based on the size
and distribution of their population. There are five different levels of care:
1. Nurse Aid Posts are the basis of all health services. Nurse aid posts are commonly located in remote
areas and offer very basic primary care as well as public health and prevention services
2. Rural Health Clinics offer the next level of care; play a supervisory role to multiple Nurse Aid Posts
within the same area, and arrange outreach activities
3. Area Health Centres provide inpatient, outpatient, outreach and public health care services to a wide
population, and act as referral facilities for a number of rural health clinics. Area Health Centres offer
specific birthing facilities, as well as administration space, and staff housing
4. Provincial Hospitals are often the highest level of care logistically available; particularly to people
residing in remote outer islands. Provincial Hospitals generally lack infrastructure and staff to offer any
surgical or specialist services
5. National Referral Hospital is the highest level of care offered in the Solomon’s. This facility is staffed
14-16
by local clinical specialists and invited or visiting specialists from abroad.
Health Service Delivery Profile, Solomon Islands, 2012
2
Table 2 Summary of health services by facility type, Solomon Islands, 2012
Facility
Nurse aid
post (187)
•
•
•
•
•
•
•
•
•
•
Rural
health
clinic (102)
Essential Services
Public health, prevention
Clinical (primary and secondary)
and outreach
Counseling
• Basic medical services
Family planning and nutrition • First aid treatment for emergencies
Sanitation and hygiene
• Treatment of mild ailments or
Community development
injuries
Environmental health
• Patient stabilisation for referral
Health promotion and
• Management of antenatal care, low
education
risk birthing and postnatal care not
Immunization (EPI)
requiring hospitalization
Infection control
School health
Vector-borne disease control
As for nurse aid posts
Disaster preparedness
Health surveillance
HIV/AIDS and STI prevention
including screening,
surveillance and education
• Programs for the reduction of
tobacco, alcohol
consumption and substance
abuse
• Reproductive health
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Area health
centre (38)
• As for rural health clinics
• Inspection of food facilities
• Programs for the reduction of
tobacco, alcohol
consumption, substance
abuse and obesity
Provincial
hospitals
(7)
• As for area health centres
Expanded Services
Child health including IMCI
Community-based rehabilitation
Dental care (extraction)
Family planning services
Management of antenatal care, low
risk birthing and postnatal care
Management, treatment and care
of STIs including HIV/AIDS
Medical and minor surgical
emergencies
Mental health including counseling
Outpatient consultations with full
clinical assessment
Primary eye care
Treatment for chronic diseases
including follow-up care
Limited outreach
activities to
provinces
• Village meetings
• School visits
• Mobile satellite
clinics
• As for rural health clinics
• Basic X-ray
• Dental care (extraction, fillings,
Limited mental
health outreach by
12 nurse
coordinators
dentures)
• Management of antenatal care,
birthing and postnatal care
Minor pathology of blood
collections and basic analyses
• As for area health centres
• Between 25-150 beds each
• Mental health
o National Psychiatric Unit at
Visiting specialist
teams
• Outreach visits
from national
referral hospital
Kilu’ufi Provincial Hospital
o Outpatient services
National
referral
hospital (1)
• As for provincial hospitals
5
•
•
•
•
•
•
•
Visiting specialist
teams
• Ear-nose-andthroat
• Plastic surgery
• Paediatric surgery
• Vascular surgery
• Cardiology
• Cardiac surgery
Overseas referrals
to
Sydney, Australia
As for provincial hospitals
300-400 beds
Full range of secondary clinical care
Operating theatre
Emergency department
Outreach to provinces (twice a year)
Mental health
o Acute Care Unit
o Inpatient and outpatient care
9
12
13
Sources: Jack 2011; Davies, Hodge & Skiller 2011; Maike 2010; Waqatakirewa n.d; MHMS 2005;
17
18
19
20
21
22
and Bishop 2009; Negin 2011; Sade 2005; WHO 2011; MHMS 2006; FSM 2011
Health Service Delivery Profile, Solomon Islands, 2012
14
Sio
3
Traditional medicine practice
Traditional healers and birth attendants play an important role in most parts of the country. A 2006 survey
12
found that 2.7% of the surveyed population use traditional healers first for all sickness.
Kastom medicine
refers to a wide range of practices and botanical remedies used to treat a wide range of illnesses including;
diarrhoea, malaria, ulcers, constipation, diabetes, cancer, STIs, high blood pressure, asthma, yellow fever,
pneumonia, and hepatitis30.
Health financing
Total spending on health in Solomon Islands in 2009 was estimated to be USD $39 million; around 5.4% of
1
gross domestic product, or USD $74 per capita. The government accounts for 65% of total financing, external
donor resources 29%, and out-of-pocket payments, including user fees, six percent. At present, private health
23
insurance accounts for a negligible share of total financing. Notably, government share of total health
financing relative to the development partners has increased since 2004, when the tensions ended. From 2006
to 2009, the health sector accounted for between 12 and 14 percent of total Solomon Islands government
expenditures.23 The current system of health financing and delivery has resulted in better than average health
outcomes relative to income per capita, and has been resilient to the political and economic crises that have
affected the country in recent years.9,23
Curative care services account for the largest share of government health spending. In 2008, primary health
23
care accounted for 29% of expenditure; followed by hospital and specialised health services at 26%. Vertical
programs and other preventive and public health expenditures were only about nine percent of total
government spending. However, the primary health care category also includes some additional preventive
and public health expenditures incurred by provincial health facilities. General administration accounted for
23
25% of spending, with the remaining 11% spent on medical supplies and equipment.
User fees are charged for specific services such as certain dental procedures, radiology and laboratory
services, the issue of medical records and documents, as well as specialty outpatient clinic visits. The Health
Services (Hospitals) Regulations specify a range of fees to be charged in public hospitals but also indicates that
they may be waived for “certain persons or classes of persons” by the Permanent Secretary of the Ministry.
There is no formal reporting of funds raised via patient fees. Anecdotal evidence suggests there is
considerable variation in the services that attract fees, and the rates at which fees are levied, with most
9
revenues being retained to offset operating costs at the facility level.
While there is no legislative definition of entitlement, tourists and expatriates are expected to meet the costs of
goods and services. General outpatient clinic services and hospitalisation are provided free of charge to all
Solomon Islanders. As such, unlike in many countries in the region, out-of-pocket payments do not represent a
significant burden in the Solomon Islands. Households in the poorest quintile allocate less than 0.05% of their
monthly household budget for health care expenses. The 2005/6 Household income and Expenditure Survey
found less than 1% of total household income was spent on health care.10
Human resources
Like Papua New Guinea, Solomon Islands are classified as one of 57 countries deemed to have a critical
24
shortage of health workers. There is a significant workforce deficit on every level of care in Solomon Islands,
with 0.21 doctors per 1,000 people; 0.11 dentists; 0.11 pharmacists; 1.7 nurses and 0.26 midwives.25 As well
as limited absolute numbers, there is also a heavy bias in workforce distribution with approximately 24% of the
13
total health workforce based in the National Referral Hospital, including more than 73% of doctors, 100% of
specialists and 33% of nurses. There are no fully trained anaesthesiologists, surgeons, or obstetricians based
at the provincial hospitals.26 Furthermore, high staff turnover has been a major problem in the Solomon’s,
24
especially since the ethnic tensions.
The Solomon Islands Government signed a cooperation agreement with Cuba in 2001, which has led to the
supply of Cuban doctors working in the Solomon’s; and Solomon Islands students being offered scholarships to
Health Service Delivery Profile, Solomon Islands, 2012
4
study medicine in Cuba.24,27 As of December 2009, there were 10 Cuban doctors working in the Solomon
Islands and another 75 Solomon Islanders studying medicine in Cuba. To address issues of permanent
migration, one of the requirements for entry in the program is that the doctors must return to their home
province to practice medicine for five years.
Table 3 Health professionals, Solomon Islands, 2005-2011
Registered healthcare
professional
Total
Physicians
Number per
1,000 population
(515,870)
Year
Other information
20 with specialist training;
22 currently undergoing specialist
training
135
0.26
2011
Dentists
Nurses
Nurse aides
Midwives
Allied health
Administrative
Other support roles
Total
52
936
524
70
569
126
420
2,832
0.10
1.81
1.02
0.14
1.10
0.24
0.81
5.49
2005
2010
2010
2011
2010
2010
2010
-
Source: Asante et al 2011;
27
FSM 2011
22
Medicines and therapeutic goods
As with many other countries in the region, Solomon Islands face difficulty in accessing essential medicines.
There are no existing drug manufacturers in the country and pharmaceuticals are imported from foreign
wholesalers and manufacturers in Australia, New Zealand, Japan, the United States and Singapore. Some
28
medicines are re-exported from Fiji as a regional hub. In 2008, Solomon Islands spent approximately 11% of
23
its total health budget on medical supplies and equipment (USD $3.2 million).
A network of 34 second-level medical shipments of vaccines stores (also known as Vaccine Distribution
Centres) located at area health clinics and provincial hospitals receive directly from the National Medical Store
and coordinate further distribution to facilities in their catchment areas.15 The National Drug and Therapeutics
Committee monitors the regulation of pharmaceuticals. Each year, the committee is responsible reviewing,
monitoring and updating the Essential Medicines List, a directory of all pharmaceuticals recommended for use
in the public health system.9
Referrals and linkages through the provider network
Ideally, referrals flow from nurse aid post to rural health clinic and so on; to the provincial hospitals and finally,
19
the National Referral Hospital. It is the responsibility of each facility to provide the patient with a referral to the
next health facility. According to the Ministry’s Guideline for Patient Referral to the National Referral Hospital,
patients can only be referred to the National Referral Hospital if they have been seen at the provincial hospital
18
and their case referred by the Medical Superintendent or designate of the provincial hospital.
In practice however, this is rarely the case (Figure 1). As the health system is highly centralised and resources
are skewed towards the National Referral Hospital, most patients with serious ailments directly seek treated
there. Another issue with the referral system is related to the cost involved with transport for a patient who
does follow the referral guidelines. In many cases, it is less time consuming and more cost-effective to seek
health care at the National Referral Hospital in the first instance, rather than having to work all the way through
the different facility levels.20 There is also general consensus that the Ministry and facilities would rather err on
18
the side of caution than be unnecessarily strict when dealing with referrals.
Health Service Delivery Profile, Solomon Islands, 2012
5
Figure 1 Referral pathway to hospital, Solomon Islands, 2012
Overseas Referrals
The Overseas Referral Committee is in charge of the approval process for patients requiring care overseas,
and membership includes the Medical Superintendent and three Heads of Clinical Departments. Overseas
referrals are mainly to St Vincent’s Hospital in Sydney with a few paediatric cases to Randwick Children’s
Hospital and to Greenlane Hospital, New Zealand. The arrangement between the Solomon Islands government
and St Vincent’s hospital has been in place since the 1993. Treatment is provided free of charge and the
government pays for airfares and accommodation.9
Cross border referrals to other countries within the Pacific with a higher level of care or more available
technology are not a significant burden on the health budget. Airlift evacuations occur infrequently, despite the
10-bed referral program offered by St Vincent’s Hospital. There is approximately USD $150,000 dollars
20,22
allocated to this program annually within the Ministry’s budget, which is around 0.33% of total budget.
Quality
There are no formalised patients’ rights advocacy group or watchdog in Solomon Islands; no formalised
complaints system; or system for public commentary on the provision of health services.9 The Ministry does
have two tools used in assessing the quality of equipment and health facilities, however implementation and
follow-up are unclear:
1. The Quality Management Checklist can be used by all health workers and supervisors and is used to
check the equipment, medicines, transport, buildings and community participation. The checklist was
originally developed in 1996, and revised in 2003 and again in 2005. Checklists are used by senior staff
who report findings back to the Ministry
2. The Clinic Infrastructure Evaluation Tool was developed for monitoring the quality of health clinic
infrastructure. The tool assesses power supply, access to water, infection control measures, sanitation
facilities, water disposal methods, and building conditions. The evaluation is normally completed by a
community health nurse consultant and then reported to the provincial health director or the Ministry
14
executive. A full assessment should be undertaken every three to five years.
Equity
Health service contact rates are high by regional comparison and have been resilient to the service disruptions
caused by political instability and unrest.23 A survey in 2006 found that nearly 87% of people sought care when
ill, and of those, 85% went to a public sector provider. By comparison, only 60-75% of the population seek care
9
when ill from a modern medical provider in many low income countries in East Asia and the Pacific.
Health Service Delivery Profile, Solomon Islands, 2012
6
However the geographic distribution of health spending is skewed in favour of Honiara and is not consistent
with the pattern of population health needs. For instance, recent survey and health system data indicate that
Malaita presents comparatively more serious health challenges than other provinces, in terms of its health
outcomes and service delivery needs. It also accounts for 30% of the country’s population. Yet it receives a
23
significantly lower share of total health expenditures than would be expected. Despite a resource allocation
formula developed in 2003 to determine the level of grants to be paid to the provinces, the National Referral
Hospital currently accounts for one-third of the health budget and employs two-thirds of all doctors: indicating
28,9
that actual allocations do not appear to reflect those suggested by the application of the formula.
Access, outreach and utilisation of preventative, promotive and rehabilitative care is lacking in most of the rural
areas as:
•
•
•
•
•
Preventative and control programs are urban-based (mostly in Honiara) and only make a limited
number of trips to the provinces (once every two months)
A number of health promotion positions remain vacant in the provinces
Public health care staff lack the skills, knowledge and information to deliver programs that are not
integrated into general health services
Public health care facilities are understaffed and burdened with curative services
12
Provincial health budgets are insufficient to carry out the necessary work.
Demands and constraints on the service delivery model
One of the major issues characterising large, scarcely populated and remote island states such as the
Solomon’s, is the delivery of health services, difficulty and cost of transport in regard to increasing demand and
stable or declining supply.7 Transportation between the country’s many islands is mainly by ferry, outboard
motorboat or canoe; there are limited and expensive interisland flights. The average distance a patient must
26
travel to get treatment at the National Referral Hospital is more than 240km, with a range of 40-600km.
Various factors combine to prevent or delay visiting a clinic, including inaccessibility of transport, travel logistics
30
and costs, misdiagnosis, and self-medication.
Among the impacts of the ethnic tension from 2001 onward, were declining health services capacity for
outreach activities resulting from limited financial and transport resources, or restrictions imposed on movement
16
in response to safety concerns.
In the clinic utilisation review of 2005, it was estimated that only 52% of
clinics conducted health outreach activities. Lack of transport was the most commonly cited reason for lack of
outreach, followed by lack of staff and distance.
The same 2005 review found that up to 70% of area health clinics required significant upgrade, repair or
13, 16
renovation.
The degradation of health facilities has happened over many decades, and while some have
been damaged by cyclones and other natural disasters, most are not properly and regularly maintained.
Initiatives taken by the Ministry of Health under the infrastructure policy in 1996 have continued, however work
of this nature is needed for many years to come.
Indicators of progress
While the period of civil unrest at the turn of the century had a negative impact on health outcomes, the health
system continued to function more or less satisfactorily, and mortality rates have reduced with both men and
women living longer.7 In the National Health Strategic Plan (2011-2015), the Ministry of Health and Medical
Services overall goal is stated as an improvement in ‘overall health status by one to two percent by 2015’. To
achieve this goal, 20 key indicators have been established, however many of the indicators are missing data
and benchmarks and targets are yet to be agreed.
•
•
Determinants of health. Shows limited progress. A benchmark of 70% of the population with access
to clean water and sanitation was set in 2011, however a target for 2015 has not been agreed, and
evidence suggests only 5% of the rural population has access to improved sanitation
Health system (inputs and outputs). Shows mixed progress. While health worker to population
ratios remain very low; 85% of deliveries occur with a skilled birth attendant in a health facility and
measles immunisation coverage among one-year olds has been steadily improving (90%). Sixty-eight
Health Service Delivery Profile, Solomon Islands, 2012
7
•
percent of children under-five received treatment for fever from a trained provider or health facility,
compared to an average of 54% in low and lower-middle income countries in the Asia-Pacific region.
Tuberculosis detection and cure rates are also high (70% and 85% respectively). Baseline data and
targets are missing for outpatient department service utilisation; proportion of centres offering basic
emergency obstetric care; and population satisfaction with services
Health status. Both the under-five and infant mortality rates have been decreasing, as with the
maternal mortality ratio. A very small number of confirmed cases of HIV have been detected in the
Solomon’s, however underreporting is likely. Malaria continues to be a major public health concern,
especially among pregnant women and children under five. Tuberculosis also continues to be a
serious problem. Non-communicable diseases such as cardiovascular and cerebrovascular diseases,
7,9,28,31
neoplasms, respiratory diseases and diabetes mellitus are increasing.
Table 4. Key population health indicators, Ministry of Health and Medical Services, Solomon Islands
Indicator
Benchmark
date?
Status
2010
Target
2015
Determinants of health
Access to clean water and sanitation (%)
Health system
Outpatient department service utilisation (visits per capita)
Proportion of health centres offering basic emergency obstetric
care (%)
Doctor: population ratio
Nurse: population ratio
Nurse aid: population ratio
Proportion of children under five with diarrhoea in the preceding
two weeks who received oral rehydration therapy (%)
Proportion of one-year-old children immunised against measles
(%)
Proportion of population satisfied with services (%)
Proportion of births attended by skilled health personnel (%)
Proportion of pregnant women and children who slept under an
insecticide-treated net the previous night (%)
Tuberculosis detection rate (%)
Tuberculosis cure rate (%)
Health status
Infant mortality rate (per 1,000 live births)
Neonatal mortality rate (per 1,000 live births)
Under five mortality rate (per 1,000 live births)
Maternal mortality rate (per 100,000 live births)
HIV prevalence among 15-24 year old pregnant women
Incidence of malaria (per 1,000 people)
Sexually transmitted infection incidence rate (per 1,000 people)
70.0
-
-
-
1.9
-
2.2
-
37.7
1: 7,510
1: 883
1: 1,279
-
-
87.3
90.4
93.0
84.5
36.5
85.0
38.0
< baseline
90.0
60.0
46.0
82.0
70.0
85.0
-
26.1
16.8
37.2
184
250
13.1
30.0
36
140
77
-
25.0
29
120
< baseline
50
-
Source: MHMS 201131
Health Service Delivery Profile, Solomon Islands, 2012
8
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