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                                      CHAPTER SEVEN

                                             VANUATU


             I. INTRODUCTION                              7.3      In addition to the extremely dispersed
                                                          settlement patterns, two population trends have
7.1    Vanuatu is a "Y" shaped archipelagoof              significant implications for health service
some 80 islands,68 of which are inhabited,with            delivery and planning. First, the ni-Vanuatu
                          2
a land area of 12,200 km . The islands which              population growth rate is very high at 2.8
can be divided into eleven main groups, stretch           percent per annum over the period 1978-89,
over a distance of 850 kilometers in a north-             although this represents a decline on that
south direction and lie between 13 and 22                 recorded for the previous inter-censal period
degrees south of the equator and between 166              1967-79 of 3.4 percent per annum. Over the
and 172 degreeseast of Greenwich. Most of the             inter-censalperiod the crude birth rate fell from
islands are volcanic in origin, and the majority          a very high 45 per thousandto 38 per thousand.
of people live on the coastal plains where the            The death rate also declined from 12 to 8 per
soil is fertile and the rainfall generally                thousand,a significantpart of which is explained
predictable. While the north of the country is            by the fall in the infant mortality rate from 94 to
wetter and more humid than the south, there are           71 per thousand. It is estimated that the total
two distinct seasons, one "hot" and "rainy"               fertility rate fell from about 6.5 to 5.3 (Table
(Novemberto April) the other "cool" and "dry'             7.1). As a consequenceof these trends, there is
(May to October). During the earlier season,              a high dependencyratio (around 100) with the
the country is vulnerable to cyclones which               under five population estimated to be almost
periodicallyinflict damage on economic, social            24,000 and the numberof births each year being
andphysicalinfrastructureand oftencausemajor              about4,700.
economicand social dislocation.
                                                          7.4     Second,there is considerablemobilityof
7.2 The population,currentlyestimatedto be                the populationwith the two major urban areas
about 155,800,' is extremely dispersed. Thus,             growing significantly faster than the rural
while almost eighty percent of the population             population as a consequence of rural-urban
lives on seven major islands, the 1989 census             migration. The urban center of Port Vila, the
indicated that there were 1,708 villages or               capital on the island of Efate, has a population
village areas 2 with 3,233 separately inhabited           of about20,000 growing at a rate of 8.7 percent
localities identified throughout the country.             per annum while Loganville on the island of
Only 8 percent (253) of localities have a                 Santo has a population of just over 7,000
population of 100 or greater, while 79 percent            growing at 5.2 percent per annum. The
are in localitieswith a populationof less than 50         proportion of the population in urban areas is,
people.                                                   however, relatively small, accounting for only
                                                          18 percent of the total population, but if these
                                                          -   266 -


Table 7.1: KEY NI-VANUATU DEMOGRAP}IC                                 government area are presented in Table 7.2 for
               STATISTICS                                             the inter-censal period 1979-89.3

                                                                      7.5     Vanuatu gained its independence in 1980.
Indicator                               1979     1989/a               Prior to independence, it had been governed by
                                                                      an Anglo-French     condominium.       Under   the
                                                                      Condominium, there were duplicate French and
Crude Birth Rate          (per 1,000)     45      38                  British delivery systems for most services,
Crude Death Rate          (per 1,000)     12       9                  ranging from schools and hospitals to customs
                                                                      officers.    As a consequence, the newly
Infant Mortality Rate     (per 1,000)     94/b    71                   inepne       cn    d notqeven   he  n
                                                  -               ~~~independent
                                                                             country did not even have an
Life Expectancyat Birth (Years)                                       integrated budget and expenditure program. The
                       - males            56     61.5                 severe effects and implications of inefficient
                       - females          54     64.2                 infrastructure development in the pre-
                                                                      independence period are evident today in many
Total Fertility Rate /c                  6.5      5.3                 sectors of the economy, including the health
                                                                      sector. Thus, after Independence considerable
Population0-4 years                19,207 23,700                      rationalization of resource use had to take place
                                                                      including the closing of duplicate hospitals in the
Sex Ratio                                113     106                  two major urban areas.          The location of
                                                                      duplicated infrastructure often bore little
DependencyRatio/d                        101      99                  relationship to either the distribution or the
                                                                      health needs of the ni-Vanuatu population.
                                                                      Further, the inherited administration (both within
                                                                      the Ministry of Health and Government more
/a Provisional.                                                       generally) was clearly overly burdened with
/b Figureis thoughtto be too high on re-analysis                      administrativepositions, concentrated in urban
   of 1967censusdata.                                                 areas, and independentadministrations  have not
/c TheTotalFertilityRaterefersto thenumber   of                       been able to effect major structural changes in
   birthsa womenis expected haveduringher
                             to                                       this regard.
   reproductiveyears.
           as
Id Defined the ratioof the young(0-14years)                           7.6 Another important factor which adds
   and elderly(over64 years)population the
                                        to                            significantlyto the problems of administration
   adult(15-64years)population.                                       and to the costs of quality service provision is
                                                                      the existence of two colonial languages as
trends continue (as is likely) the proportion                                                              in
                                                                      official languagesof communication addition
living in urban areas will rise significantlyover                     to Bislama, the most commonlyspoken Pidgin
next decade. Overall the urban population is                          language in the country. Bislama is a most
growing at 7.5 percent per annum, while the                           important language as it enables effective
rural population is growing at a rate of 2.1                          communication   between the 150 local language
percent per annum. There is also considerable                         groups as well as between those educated in
inter-island migration which has considerable                         Francophone and Anglophone schools
implications for location planning of health                          (40 percent and 60 percent respectively). While
facilities. The islands of the Shepherdsgroup                         Bislama is the major language of
and Paama island have seen a fall in their                            communication, and the nursing school, for
populations over the last decade. Trends in                           example,teaches in the Bislama language,there
population size by Health District and local                          are many problems in getting appropriate
                                                                      materialsfor teaching and reference libraries.
                                                      - 267 -


 Table 7.2: Nl-VANUATU   POPULATION GROWTH1979 - 1989 7.8     The political system has been
                    By HEALTH DiSrRICT                copied from both the French and the
                                                      British, with some important local
                                                      conventions incorporated.         The
               Area
District/Council                           C
                       1979 1989 Absolute Per         resulting    effect on service
                                                      administration (including Health) is
                                                     __
Northern District                                     that the Ministry (consisting of the
  Banks-Torres        4,881   5,959   22      2.0     Ministerand Ministerialstaff) makesa
   Santo-Malo              17,591      25,144   43              3.5      range     of   administrative           and
EasternDistrict                                                          management decisions for the public
  Ambae-Maewo               9,509      10,902   15              1.3      service (includingpersonneldecisions)
   Pentecost                9,341      11,298   21              1.9      and is not confined to the policy
Central District 11                                                      approval process. This is significantly
  Malekula                 14,832      19,222   30              2.5      different from the situation in the other
  Ambrym                    6,146       7,170   17              1.5     PacificIsland Stateswhichhave largely
CentralDistrict I                                                       followedthe Westminstertraditions in
  Paama                     2,222       1,695   -24         -2.6        this regard and have established
   Epi                      2,511       3,611    44          3.6         relatively strong and independent
   Shepherds                4,407       3,965   -10         -1.0         Public Services Commissions charged
   Efate                   15,615      28,133   80           5.9         with the responsibility for appointing
                                                                                                    5
                                                                         and promotingcivil servants.
SouthemDistrict
   Tafea                   17,316      22,373   29              2.5
  Total                  104,371 139,475        34              2.8     7.9   This report considers health
                                                                        2outcomes the general performance
                                                                                and
Ruraln                     11,074/a 23,486      112             2.5     of the health system in the light of
                                                                        _evolving health trends, resource
                                                                        availability and the sustainability of
                                                                                              The following
Source: National Census 1979and 1989, NationalPlanningand               current services.
         Statistics Office.cufnsevc.                                                             Th      folwg
                                                                         section draws together informationon
/a 1979urban populationadjusted to match 1989urban boundaries. health outcomes, service utilization,
                                                                          and financial and human resource
7.7     This situation has added significantlyto                allocations. The subsequent section considers
the costsof service delivery. Additionalstaffing                prospects for health improvementin Vanuatu,
needs causedby the need to duplicate effort in                  presents possible priorities for service
French and English in a situationwhere human                    improvement,and suggestshow the government
resourcedevelopment,educationaldevelopment                      can develop a more systematic approach to
and self sufficiencyin resourcesare laggingpose                 priority setting.
considerable  problemsto the Ministryof Health.
That human resource constraintscontinueto be
a major impedimentto developmentis indicated                     II. Health Patterns and Determinants
by the observation that 16 percent of the
populationin 1989had never been to schooland                    7.10 Overall Mortality and Morbidity
less than 5 percent of those aged 20-24 years                   Trends. Availabledeath and disease indicators
had completed 10 years of schooling. The4                       show that Vanuatuhas achievedvery significant
educationstatus of the population is, however,                  improvement in mortality and morbidity rates
improving and by 1989, 72 percent of the                        over the last two decades with the infant
population had completed6 years of schooling                    mortality rate falling from around 95 per 1,000
comparedto 58 percent in 1979(Table 7.3).                       in 1979 to 45 per 1,000 in 1989. Evidence
                                                        - 268 -


         Table 7.3: AGE-SPECIFIC                                  conjunctivitis) and ear diseases dominate
      EDUCATION STATus,1979 AND1989                               morbidity patterns (Tables 7.4 and 7.5).'      In
                     (Percent)                                     1988, this group of diseases accountedfor 57
                                                                  percent of all out-patient visits, indicatingthat
                                                                  the majormorbiditypatterns in Vanuatuare very
Level                                                                     9
                                                                  focused. This conclusion can be made with
Attained               AgeGroup 1979 1989                         considerableconfidencedespitethe well known
                                                                  problems associated with facility based disease
                                                                  reporting when coverage and data quality are
Never been to school 6 - 19 years       20       16               problematic.
Spentsome time                                                    7.11 While the reported morbidity rates
 at school              15 - 19 years 85         90               indicate that more than 400 per thousand seek
Spent at least 6 years                                            assistance from health centers for skin diseases,
 at school             15 - 19 years 58/a        72/b             the very high rates of malaria reported (between
                                                                  124 and 345 per thousand) suggest that malaria
Achievedprimary                                                   is the single most important disease facing
 schoolcertificate     15 - 19 years 22          49               Vanuatu given its debilitating impact on quality
                       20 - 24 years 14          41               of life, productivity and its contribution to
                                                                  mortality-particularly in infants. There was a
Completedyear 10       20 - 24 years         <   5                significant rise in the recorded levels of
                                                                  plasmodium falciparum cases in the late 1970s,
                                                                  and while blood slide examinations over the last
Source: A SituationalAnalysisof Children and                      six years have shown am10aercnt fali the
        Womenin Vanuatu,UNICEF, 1991 and                          srx years have shown a 10 percent fall in the
        NationalPlanningand StatisticsOffice.                     ratio of plasmodium falciparum cases to other
                                                                  types of malaria they remain extremely high
/a 61 percent of males and 54 percent of females.                 (Table 7.6). Plasmodium falciparum cases result
/b 75 percent of nales and 70 percent of females.                 in significantly higher levels of mortality
                                                                  particularly    among children.            Further
                                                                  significantly lower birth weights are recorded for
                                                                  babies born to women who contract it during
suggests the infant mortality rate is higher in                   pregnancy. Lower birth weights result in higher
rural areas than urban areas.6       The child                    probabilities of both morbidity and mortality.
mortality rate (1 - 4 years), for which there is                  Overall, malaria is second only to neonatal
only fragmentarydata, is much lower than the                      causes as the leadingdeterminantof death in the
infant mortality rate indicating that the first year              0 - 4 years age group (Table 7.7). Malaria in
of life is a major danger period in Vanuatu. In                   Vanuatu is a seasonal disease and the highest
1987, infants represented 17 percent of all                       incidence of infection occurs during the rainy
reporteddeaths althoughthey accountedfor less                     season at the beginning and end of each year.
than4 percentof the total populationwith a very                   The problem is also greater in the more northern
significant proportion being neonatal deaths.7                    (warmer) islands of the group.      The pre-wet
The relatively high infant mortality rate is                      season residual spraying program to control the
indicative of the significance of infectious and                  disease ceased around 10 years ago.       Recent
environmental diseases in overall morbidity                       trials using insecticide-treated mosquito nets
patterns. The strategic health problem of                         have shown good protective results, and this
Vanuatu remains the need to address                               program is being extended to cover more areas
communicable diseases. Thus, skin infections,                     of the country.
malaria,    ARI,     diarrhea,    eye    (including
                                                                         -   269 -


                     Table 7.4: OUTPATIENT VISITS BY DISEASE AND HEALTH DISTRICTLa
                                                            (Per '000 Population)

                                                             (suspec-                                                                                 (susPec-
Disease                     1987         1988     1990       ted)/b                     Disease                      1987        1988      1990       ted)/b

Northern District                                                                       Central District I
Malaria                  124.70       166.60     149.57 (318.7)                         Malaria                   110.50        143.30       59.50 (225.3)
Pneumonia                 13.60        46.00      84.90                                 Pneumonia                    5.60        11.40       22.30
Diarrhoea                 69.80        74.60      54.80                                 Diarrhoea                  76.60         58.00       27.17
Skin infections          328.00       254.60     585.80                                 Skin infections           305.00        244.30      234.00
Meningitis                  0.32        0.76        0.36       (1.6)                    Meningitis                   0.51          0.48        0.05
New TB                      0.47        0.83        0.32       (2.5)                    New TB                       0.38          0.57        0.15
Gonorrhoea                  1.83         1.83       1.00       (9.4)                    Gonorrhoea                   5.67          6.41        0.15         (1.9)
Conjunctivitis            18.10        46.10      47.30                                 Conjunctivitis             18.00         45.30       17.00
Diabetes                    0.12        0.64        0.036      (0.1)                    Diabetes                     1.74          0.84        0.02
Hypertension                2.50        3.73        1.46                                Hypertension                 8.50          4.38        2.40
Anaemia                   13.10        10.10      12.16                                 Anaemia                      6.80          8.00        5.90

Eastern District                                                                        Southern District
Malaria                  229.60       267.00     207.70     (534.0)                     Malaria                   190.00         84.20      113.15     (331.9)
Pneumonia                 17.10        26.80      91.80                                 Pneumonia                  10.70         14.50      119.20
Diarrhoea                 58.50        52.20      48.12                                 Diarrhoea                  90.30         65.40       37.90
Skin infections          617.20       527.30     793.50                                 Skin infections           599.30        355.70      433.80
Meningitis                  0.13         0.09       0.15                                Meningitis                   3.62          1.87        0.37        (0.95)
New TB                      0.74         1.00       0.25       (1.8)                    New TB                       0.94          1.17        1.37        (2.6)
Gonorrhoea                  0.78         2.42       0.56       (2.06)                   Gonorrhoea                   1.61          1.00        0.10        (1.85)
Conjunctivitis            28.90        61.90      43.98                                 Conjunctivitis             39.20         18.40       17.16
Diabetes                    0.06         0.39       0.21       (0.41)                   Diabetes                     0.00          0.00        0.00
Hypertension                2.80         4.00       4.60                                Hypertension                 0.65         0.92         2.86
Anaemia                   32.60        22.80      34.88                                 Anaemia                      9.70        11.80         8.90

Central    District II                                                                  National     Rates
Malaria                  314.90       269.80     124.80     (460.0)                     Malaria                   182.30        179.70      124.00     (345.8)
Pneumonia                 13.10        35.50      52.10                                 Pneumonia                  11.40         26.60       58.60
Diarrhoea                 84.00        74.50      33.40                                 Diarrhoea                  76.00         65.10       36.84
Skin infections          595.50       337.00     456.70                                 Skin infections           459.30        326.80      435.50
Meningitis                  0.22         0.25       0.08                                Meningitis                  0.86           0.67        0.14        (0.5)
New TB                      0.77         1.06       0.27      (2.1)                     New TB                      0.62           0.87        0.33        (1.6)
Gonorrhoea                  1.17         2.74       0.35      (2.3)                     Gonorrhoea                  2.53           3.19        0.38        (3.3)
Conjunctivitis            47.40        77.80      35.90                                 Conjunctivitis             28.50         49.80       29.76
Diabetes                    0.56         0.18       0.28                                Diabetes                    0.57           0.46        0.06        (0.15)
Hypertension               2.90          2.06       1.60                                Hypertension                4.01          3.17         2.30
Anaemia                   16.90        15.70      20.30                                 Anaemia                    14.70         11.70       14.36



Source:   Ministry   of Health     Information   System     and Annual       Reports.

/a    Combination    of most common and reported diseases.
7/    For 1990 data suspected   cases are those clinically diagnosed                at health     institutions.   The   other   figure    is the number
      confirmed   by laboratory at hospital level.



7.12 The infectious diseases of pneumonia                                               are lower levelsof operationalpotable water and
(including moderate and severe ARI) and                                                 sanitationservices and environmental(housing)
diarrhoea are the next most important cause of                                          standardsin thesedistrictswhen comparedto the
reported morbidity. There are significant                                               rest of the country.
differences in the regional distribution of
morbidity patterns. The highest incidence of                                            7.13 Other vector-borndiseases have also had
infectionover the years 1987 - 1990occurred in                                          an importantimpacton health statuswith dengue
the Southern, Eastern and Northern Health                                               fever being particularly notable. There have
Districts (Table 7.4). It is probable that there                                        been four outbreaks of dengue fever over the
                                                      - 270 -


     Table 7.5: OVERALL DISEASE RATES La                        overseas (around 5 per year), and this number is
              (Per '000 Population)                             expected to increase due to both increased
                                                                prevalenceand improved case detection.'°  "

Disease                   1987     1988     1990                         Table 7.6: MALARIA BLOOD SLIDE
                                                                               EXAMINATIONS, 1986 - 1991

ARI                      448.0     355.5    125.5
Skin Infections          459.0     326.8    435.5
Injuries                  62.0     151.5       -                                        Slide   Plasmodium
Positive Malaria         182.0     115.0    124.0                    No. of No. of Positivity Falciparum %
DiarrhositiveMa          182.0     115.0    124.8               Year Slides Positives Rate - 9 of Positives /a
Diarrhoea                 76.0      66.0     36.8                _   _    _    _   _   _   _   _   _   _   _   _   _   _   _   _   _   _   _

Eye Disease              41.0      53.2      -
Ear Disease              32.0      31.3      -                  1986          73,945       22,546          30.5                74.7
AsthmaICQAD      Asthma/COAD
                         1.0
                         18.0       11.7
                                    11.7     8.751987
                                             8.75               1988          78,972
                                                                              90,820       26,625
                                                                                           26,464          33.7
                                                                                                           29.1                71.6
                                                                                                                               74.2
Anaemia                  14.7       11.7    14.36               1989          94,632       25,241          26.7                66.7
Underweight 0-4 per                                             1990          88,691       28,558          32.2                65.1
 1,000 Children 0-4      91.0     124.5    150.2                1991          54,751       17,150          31.3                62.9
Rheumatic Fever
 and Carditis             0.1        0.001   0.06               Source: National Health Development Plan, 1992.
Valve Disease             0.05       0.17    0.04
Road Accidents            0.32       0.24    0.45               /a The decreasing percentage of falciparum malaria
         attemp.
   Suicide                0.17s0.17          0.15                  indicated by the data may indicate an
.Suicide attempt          0.17       0.17    0.15                  improvement in the malaria control situation,
Fish & Shell                                                       however there are considerable variations in the
 Poisoning               46.5      55.7      0.36                  number of blood slides taken each year.
PPH                                          0.11
Cirrhosis of Live                            0.06
Tumors                                       0.97
                                                                7.15 The incidence of gonorrhoea has
                                                                increased slightly over the past five years.
Source: Ministry of Health Annual Reports.                      Significantlya survey of antenatal mothers in
                                                                Port Vila showed a prevalence of STD of 36
/a    Rates as seen at outpatientsand dispensaries.                                                  2
                                                                percent; 18 percent due to chlanydia." There
                                                                has been no case of AIDS or HIV as yet
last five decades. During the last epidemicin                   reported in Vanuatu. However blood for
 1989- 1990, 7,000 people were treated, and 30                  transfusionis only screenedfor HIV in Port Vila
people reportedly died from the disease.                        and is transfusedunscreened elsewhere.
Filariasis was commnonearly this century
affectingaround 60 percent of the population.                   7.16 Tuberculosishas become a less important
Mass drug treatment programs and residual                       causeof hospital-recordedmortalityover the last
house spraying for mosquitoeshas reduced the                    five years. However, the numberof new cases
incidenceto a few cases in isolated areas each                  being found each year has increased, which
year.                                                           appears to correspond to the number of people
                                                                being examinedfor the disease (Tables 7.8 and
7.14 Rheumatic fever is of a very low                           7.9).    There is no instituted regimen of
incidenceas are the non-communicablediseases,                   collecting sputum from those suffering from
diabetes and hypertension, when taken in                        persistent coughs and examining them for
comparisonto the prevalent infectiousdiseases                   tuberculoidbacteria.
(Table 7.5). However, heart valvular damage
has been the main reason for patient transfers
                                                    - 271 -


                         Table 7.7: LEADING CAUSES OF DEATH, 1987 - 1990 L&


                                1987                              1988                        1990
Diagnosis                  Number        Percent        Number           Percent    Number           Percent


ALL AGES
Cardiovascular               48           11.1           52                11.5        56            11.9
Malignancy                   35            8.1           43                 9.5        36             7.6
Malaria                      34            7.8           32                 7.1        32             6.8
Tuberculosis                 28            6.5           27                 6.0        16             3.4
Resp. infection              25            5.8           20                 4.4        32             6.8
Neonatal                     21            4.9           25                 5.5        20             4.2
Renal disorders              17            3.9                                         14             2.9
Liver disease                              2.5           21                4.6         17             3.6
COAD/Asthma                  16            3.7           21                4.6         17             3.6
Meningitis                   15            3.5           21                4.6         13             2.8
Diarrhoea                                  3.2           19                4.2         20             4.2


0 - 4 YEARS (Excluding Stillbirths)
                                       1987                       1988                    1989
                                      Percent                    Percent                 Percent

Neonatal                                 20                       23.6                      14.0
Malaria                                  14                       17.0                      10.7
Congenital abnormality                    7                       12.3                       7.1
Meningitis                                5                        9.4                       6.4
Malnutrition                              3                        8.5                       7.8
Resp infection                           10                        7.5                      14.3
Diarrhoea                                 8                        4.7                       7.1
Trauma                                    6                        4.7                       1.4


Source:   Ministry of Health Annual Reports.

/a Based on data of 10 leading causes of death recorded in health institutions. In 1988, 454 deaths were
    recorded for an estimated 1,200actual deaths.


7.17 There is a high level of infection with                  control hepatitis B could result in significant
hepatitis B in Vanuatu. A survey of children                  growth in the incidence of liver cancer.
showed that 52.3 percent had HBV seromarkers
and 26.9 percent had hepatitis surface                     7.18 Dental caries are not yet the problem that
antigen."        An earlier     South Pacific              is seen in some other Pacific Island countries.
Commission Survey found slightly lower levels              Caluilies are very wide spread even amongst 12-
in children, but 70 percent of adults showed               year olds and affects 80-90 percent of 15-19
signs of infection. Around 8 cases of liver                year olds." In 1991, it was found that among
cancer are diagnosed each year, with three                 12-year olds on Norsup and Tanna islands, the
quarters of these occurring in men. A failure to           mean decayed missing filled teeth (DMFT) was
                                                   - 272 -


     Table 7.8:       TuBERCULoSIS   REPORTS   1986-1991         7.19     Nutrition and Dietary Factors.
                                                                 Nutrition     is a significant   health problem    in
                                                                 Vanuatu. It is estimated that between 10
     No. of New New CaseRate No of TB TB mortality               and 15 percent of ni-Vanuatuchildrenhave
Year Cases of TB per 1,000    Deaths per 100,000                 a low birth weight (less than 2,500 grams).
                                                                 This is importantbecause low birth weight
1986            131        0.99          21         15.9         strongly affects the likelihood of survival.
19878       1918           0.685         12         98.6         In one hospital-based study, the neonatal
1989        144            1.00          15         10.5         death rate for this group was more than six
1990            161        1.10          13          8.9         times higher than the overall rate. Service
1991        214            1.42           9          6.0         statistics   suggest     there    is some
                                                                 undernutrition in Vanuatu with some 7
Source: Ministr of Health AnnualReports and National             percent of infants and 3 percent of 1 - 4
                        Plan
         HealthDevelopment 1992.                                  year olds being affected. While data need
                                                                  to be interpretedwith some cautionnational
higherthan that for 15 to 19 year olds indicating            aggregatesseem to hide some importantregional
a possible rapid increase in caries amongst the              variations. The health districts most affected are
young. Higher than average DMFT in 12-year                   Northern(32 percentunderweight),Central1(15
olds were also observedon Anbae islandand in                 percent underweight), and Tafea\Southern
Mele and Port Vila on Efate Island.                          (10 percent under weight)(Table 7.10).

                                                             7.20 The interaction between high levels of
                                                             malnutrition/undernutritionand the extensive
                                                                 range and high incidenceof communicable
                                                                 and vector-born diseases adds to the
       Table 7.9: TUBERCULOSIS DETECTON,
                              CASE                                severity of both. Multiple infections and
                      1987-1991                                   inadequatenutrition reduce an individual's
                                                                  capacity to resist and recover from ill
                                                                  health. This is particularly true for
      No. of             No. of        No. of      Rate/          pregnant women and their children. The
      Cases               Cases        Cases       1,000          high total fertility rate further contributesto
Year Examined            Positive     Negative    Positive        this problem.

                                                                  7.21 The growing practice of bottle
1987    69                  26           43         19.2          feeding,currently confinedmainly to urban
1988    88                  43           45         31.0          areas, gives cause for serious concern.
1989    89                  38           51         26.7          Around one quarter of the admissions to
1990    83                  49           34         33.5          the Port Vila Central Hospital of 1 to 4
1991La 193                 130           63         86.7          year old children suffering from diarrhoea
                                                                  are bottle    fed and     not breast   fed infants.
                                                                  There is no legislation restricting the sale
Source: Ministry HealthAnnualReports National
               of                  and                            of infant feeding devices to doctor's
                        Plan 1992.
        HealthDevelopment                                         prescription nor has the WHO/UNICEF
                                                                  breast milk substitutecode been enforced.
/a     Contamination the laboratoryresultedin a 'false'
                    in
       outbreak. Thus 1991 datawas not indicative a real
                                                of                7.22 The incidence of anaemia has
       trend.                                                     changedlittle over the last five years, with
                                                                  the greatest problem being found in the
                                                   - 273 -


Table 7.10: UNDERWEIGHT     CHILDREN  ANDINFANTS cultural activitiesstill play an importantpart in
                        1991 La                   the lives of ni-Vanuatu,with many traditional
                                                  practicesbeing adapted and integratedintothe
                                                  emerging lifestyles of a society undertaking
           Underweight        Underweightchildren rapid change. For example, the practice of
              Infants              1-4 years      drinking Kava has increased significantlyin
District Cases Percent Cases             Percent  recent years, whereas formally it was
                                                  restricted to formal customary occasions.
                                                  Today in Port Vila, many "Nakamals' have
Northern 88         32          86         8      been established where, (mainly) men go to
Eastern     22        3         27         1      drink Kava in the evenings. It is believedthat
CD II       70        4        173         6      the increase in Kava drinking has resulted in
CD I       111       15        140         5      a lessening of the incidence of alcoholic
Tafea       78       10        140         3      intoxication and associated violence in town
                                                  life. Nevertheless,violence(usuallydomestic)
Vanuatu 369           7        566         3      against women is identified as a specific
                                                  problem in the National Health Development
                                                  Plan. Field health staff in urban and peri-
                                 Plan, 1992.
Source: NationalHealth Development                             urban health    facilities view this as an
                                                               important health problem, and have also
/a   Estimatedlow birth weight babieswere 10-15                indicated that a significant number of women
     per 1,000 live births in 1989. Data derived               (and men) seek medical treatment for injuries
     from clinic Visits.                                       sustained on pay nights.

Eastern and Central II Districts. The WHOSPC                 7.25 Available evidence is suggestive that
survey on non-communicable      diseases in 1985             urban health status maybe vulnerableto lifestyle
showedthat over 9 percent of rural women had                 changes. Already the relatively recently
haemoglobinlevels of less than 10 grams.                     establishedurban populationis developinghealth
                                                             characteristicsdifferentfrom the rural population
7.23 Lfestyle Factors. A numberof lifestyle                  in regards to non-communicable    diseases. For
factors which have the potential to have a very              example,hypertensionprevalencewas found in
pervasive impact on the health status of ni-                  1985to be higher in the urban area of Port Vila
Vanuatu are emerging in Vanuatu. Smoking is                  affecting6.3 percentof malesand 4.2 percent of
now very common and while there has been                     females. Rural figures were between2 and 3.6
growth of tobacco imports, much smokingis of                 percent for both sexes.
homegrown/traditional  products. A 1985survey
indicatesthat between54 and 80 percent of men                7.26 The 1985 non-communicable disease
smoke tobacco, with the higher rate in the rural             survey also found diabetes prevalenceto be low
areas. Significantly, less than 4 percent of                 in all areas, affecting around 1 percent of the
women smoke." The survey also showed that                    rural populationand 2 to 3 percent of the urban
between70 and 82 percentof men drank alcohol                 population. However, hospital authoritieshave
and 68-73percent drank Kava, whilefor women                  noted there is an increasingproblem of infected
the proportions were 3-19 percent and 1-9                    feet, requiring hospital treatment (including
percent respectively.                                        amputations)in latent diabetics.'

7.24 There is a complex interplay between                    7.27 Specific Health Problems of Women.
traditional and modern culture and these                     Women are largely responsible for the welfare
emerging consumption habits. Traditional                     of children in Vanuatu society. They also are
                                                    - 274 -


significant providers of food for families.                    Table 7.11: CONTRACEPTIVE PREVALENCE
Anemia, particularly among pregnant women,                                 RATES (Percent)
has been identified as a significant problem
particularly in the context of frequent
confinementsand exposure to malaria during                                    Reversible Sterilization Total
pregnancies. The 1983nationalnutritionsurvey
showedthat womentended to eat foods with less
protein than men and had a lower overall                      Rural Areas
nutrition status than men.                                    1990                  4           5          9
                                                              1991                  5           6         11
7.28 Maternalmortalityis estimatedto be low,
less than 1 per 1,000. More than two thirds of                Urban Areas
women deliver their children under medical                    1990                 10           5         15
supervision, mainly in health facilities which                1991                 16           6         22
generally have adequatebasic facilities (except
for lighting) and medications for this                        National
responsibility. Even though the majority of                   1990                  7           5         12
nursesattendingwomenand childrenare female,                   1991                  9           6         15
there are few restrictions on male nurses
fulfillingthis role in most areas.
                                                                              (adjusted)
                                                              Source: Estimated        contraceptive
7.29   Only 12 percent of women of child-                                prevalence ratesfor oralcontraception,
bearing age use modern contraceptives. As a                                         and           as
                                                                         IUCD,condoms sterilization
consequence, the fertility rate has fallen slowly                        measuredby Child Survival Household
over the last decade from 6.5 to 5.3 per                                 RegistrationSurvey,Ministryof Health.
thousand (Table 7.1). Although the use of
contraceptives is slowly increasing, there is a               7.31 WaterSupplyand Sanitation         Practices.
markeddifferencebetweenurban and rural areas                  There have been significantinvestmentsin rural
(Table 7.11). While many factorsclearly affect                water supplies and sanitation services over the
contraceptive prevalence including education                  past 10-15 years with official estimates
levels, IMRs, etc. a significant issue is that                indicating that almost 75 percent of the rural
health authorities in Vanuatu have banned the                 population have been provided with a water
use of depo-proverain 1983becauseof concern                   supplysystem. It is estimatedthat 80 percent of
for side effects. This is a family planning                   the installed systems currently work properly.
method of strong potential relevance to a                     However, only 17 percent of the rural
significantproportion of couples, and which is                population is covered by improved sanitation
                                in
used extensivelyand successfully otherPacific                 facilities. Official estimatesindicate that some
Island countries and in most other parts of the               58 percent of the rural populationuse basic pit
world.                                                        latrines, 25 percent rely on bush or beach
                                                              disposal and 17 percent use ventilated improved
7.30 Cancer of the cervix is the most common                  pit latrines (VIP) or pour flush toilets.
malignancyaffectingwomen, accountingfor 25
percent of the malignanciesrecorded in females                7.32 The rapid development of urban
between 1980 and 1986, with an average of 8                   populations and the fragility of urban water
cases found each year.       A pilot cervical                 supplies and sanitation infrastructure are also
screening project has been initiated, and it is               cause for concern. Port Vila's water supply
planned to begin a more generalized screening                 comes from an underground aquifer. Little is
program in the near future.                                   known about the aquifer source, and there is
                                                    - 275 -


increasingconcern that it could be close to the               7.35 Currently, responsibility for the
limits of sustainable extraction. Loganville's                administration and management of urban and
water comes from a well which because of                      rural water supply and sanitation programs in
increasingencroachmenton the catchment area                   Vanuatuis diffuse, with a range of government
by urban settlement is also under threat of                   agencies and local authorities playing a
contamination.While municipalauthoritieshave                  significantrole. The Department of Geology,
legislative powers over urban sanitation,                     Mines and Water Resources is responsible for
individual households and private and                         the investigation and regulation of water
government institutions are responsible for                   resources. Until late 1991 the Rural Water
constructingand maintainingtheir ownsanitation                Supply Section of the Department was
facilities,most of whichare septicsystems. The                responsiblefor the design and implementationof
1989 census indicates that 63 percent of urban                all govermnentrural water supplyprojects. This
householdsuse flush toilets, 25 percent use pit               function has now been transferred to the
latrines and the rest use water-sealedtoilets or              Departmentof Health. In addition to its newly
have no accessto sanitary facilities.                         acquired function of rural water supplies, the
                                                              Environmental Health Section within the
7.33 Increasingurbanizationand development                    Department of Health is responsible for rural
of a small manufacturingbase in Port Vila and                 sanitation, while the Department of Public
Loganville are also resulting in increased                    Works is responsiblefor urban watersupplies in
productionof solid and hazardouswastes which                  Port Vila, Loganville, Isangel, Lakatoro and
require appropriate storage and disposal. A                   Norsup. Urban sanitationand waste disposal is
recent study of solid and hazardous waste                     currently the responsibility of the municipal
disposal systems in the capital and Loganville                authorities in Loganville and Vila. Local
noted that the principal need was for new and                 Government Councils through the Ministry of
secure waste disposal sites to accommodate                    Home Affairs are responsiblefor the operation
                  7
increaseddemand." Leechingof chemicalshas                     and maintenanceof rural water supply systems
the potentialto contaminatewater sources.                     and for identifying new rural water supply
                                                              projects. They also employ village sanitarians
7.34 There is a need to sustain (and increase)                who advise villagers on sanitation issues and
past investment levels in these services,                     assist with construction and maintenance of
particularly in rural areas, as quality water and             facilities.'
sanitation services have the potential to make
dramaticimprovements the health statusof ni-
                         to                               7.36 A major study of rural water supply and
Vanuatu. Diarrhoea and skin infectionshave a              sanitation needs was undertaken in 1990 by
direct association with water supply and                  AIDAB. This study notedthat despite abundant
sanitation facilities. It is estimated that each          annual rainfall, most of the islands do not have
child suffers an average of 3.3 episodes of               perennial streams because of marked climatic
diarrhoeaper year, and that 7.1 percent of child          seasonality, the small size of the islands and a
deaths are associated with diarrhoea. Skin                combination topographicand geologicfactors.
                                                                        of
infections, as noted above, are the major cause           As a consequence, most water supplies were
of attendance at outpatient facilities. Skin              sourced from spring lines (75 percent). Where
diseases and diarrhoea are two of the major               springsare not available,wells havebeen dug or
causes of morbidity, and make a significant               drilled to tap groundwater. In areas wherethere
contributionto mortality (particularlydiarrhoea           are no springsor readily availablegroundwater,
to infant mortality), and could be reduced                roof catchments are used. While significant
through better water supply and sanitation                progress has been made in the provision of rural
supplies and practices.                                   water supplies, the study and official estimates
                                                          indicated that many systems are not being
                                                - 276 -


maintainedby the recipientcommunitygroups.                including expensive hospitals were often
 It is apparentthat the primary constraint to the         duplicated in some population centers, some
             of
development sustainablewater suppliesis that              small population centers had large facilities
communities view the installation of water                (e.g., a hospital in the Epi region with a
suppliesas the responsibilityof governmentand             population of only 3,000) while other larger
see water as a free good. The lack of a cost              communitieshad no accessto hospitalfacilities.
recovery system at the village level means that           Integrationof these facilitiesinto a singlesystem
basic maintenance is not being carried out.               has now largely been completed but the
Lack of maintenanceis clearly underminingthe              rationalizationprocess has still to be completed
achievements the rural water supplyprogram.
              of                                          and regional equity in terms of accessimproved.
The focus to date seems to have been on                   Nevertheless, major improvementshave been
establishing technical solutions for specific             achieved. The Council of Ministers formally
locations, with comparativelyless time devoted            adopteda nationalpolicy on primaryhealth care
to community participation and consultation.              in 1984. Recent improvementsin mortalityand
This has contributedto a lack of commitmentto             morbidity trends indicate this approach was
projects from some villages.                              soundly based. Further improvements in
                                                          delivery systems are needed with particular
7.37 Progress in the developmentof improved               emphasison improved outreach, commitmentto
sanitation systems and practices has been                 improvedMCH servicesand the introductionof
hampered by a lack of funds and entrenched                a strong familyplanningeffort in the light of the
traditional sanitationpractices. A program is             continuedhigh rate of populationgrowth. The
currentlybeingundertakenby the Departmentof               priority for this is emphasized by the well
Health, with UNICEF support, to upgrade                   known links between frequent pregnancies,
inadequate facilities to VIP latrines. As with            communicableand vector born diseases and the
watersuppliesimprovedrural sanitationservices             health of both mothers and their children. It is
are seen as a public good to be provided for by           thusimportantto examinehowthe current health
government. Households currently contribute               service delivery system works in Vanuatu,how
labor and bush materials to the constructionof            it is financed (by Government, donors and the
latrines, but are not required to pay for the             public) and what concernshave emerged.
capital cost of improvedsanitationservices.
                                                          7.39 With the exception of a small urban-
7.38 Health Services. The organization of                 based private sector and some church supported
health services have undergone significant                facilities, Governmentcurrentlyprovides nearly
changes since independence, when the                      all health services in Vanuatu. The Government
Condominium administration handed over an                 health services in Vanuatu are headed by the
uncoordinated French, English and mission                 Ministry of Health and administered by the
health systems which had different methods of             Department of Health headed by a Director.
providing care, different types of facilities             The new Ministry of Health, headed by the
staffed by different health cadres trained in             Minister, has in consultation with the new
different traditions. Prior to the unification of         Governmentdecided to create two departments
health services (undertaken during the First              to administerGovernment    health functions. This
NationalDevelopmentPlan, 1982-86),missions                will consist of the Department of Curative
were responsiblefor running 2 district hospitals,         Services and the Department of Preventative
14 health centers and 31 dispensaries.                    Services and Rural Water Supply. While the
Fundamentally, systemwas curativein focus
                  the                                     proposed new structure has not been formally
and dominated strongly by expatriate doctors              approvedby the Public ServicesCommission,it
with little or no emphasison primaryhealth care           is expectedthat futurebudgetappropriationswill
and preventative health principles. Facilities            reflect the new structure, and staff at the
                                                   -277   -


headquarters level, at least, have in the main                bed occupancyrate of 47 percent. Overallthere
beendividedbetweenthe two new Departments.                    are 374 hospital beds with a bed occupancyrate
Two Heads of Departmenthave been identified                   of 43 percent, indicatingthat there is significant
by the Ministry and are now operatingwith full                unused capacity in the hospital system at
authority pending formal Public Service                       present. The Vila Central Hospital has more
Commission approval. The Department of                        extensive X-ray and laboratory facilities than
Curative Services is to be responsible for all                does the Northern District referral Hospital.
health workers performingcurativetasks across                 The Pharmaceutical Section is located on the
the country, including those working on                       groundsof the Vila Central Hospital.
pharmaceuticaland dental activities, whilst the
Departmentof Preventative Servicesand Rural                7.42 A health district-based system of
Water Supply is responsiblefor all staff dealing          peripheralhealth facilities supervisedin the first
with preventative services and rural water                 instance by the District Health Office has
supply. The rural water supplysection,as noted            evolvedin Vanuatu. The base level structurefor
above, was formed by movingit away from the               the health services is the Aid Post staffed by a
Department of Geology, Mines and Water                                             9
                                                          Village Health Worker." This level of service
Resources.                                                delivery developed along with the concepts of
                                                          Primary Health Care over the last decade. The
7.40 Crucially,         however,      Planning,           responsibilityfor establishing an Aid Post and
Administration and Training are concurrent                supportingthe Village Health Worker lies with
functions falling between the two new                     the community. The government supplies the
Departments, and many staff at the service                medicines and trains the staff selected by
deliverylevel work in institutionsor have duties          community authorities. The Village Health
which currentlycut acrossthe responsibilities of          Worker dispensesa limitednumber of palliative
the two Departments. All peripheralhealth staff           and curative medications, but not injectables,
who clearlyhave both curative and preventative            and performshealth promotionalactivities. The
health functionscontinue to work as they have             demandfor aid posts increasedsignificantly   over
previously, i.e., as one health service in the            the last severalyears with requests for assistance
absence of any lines of responsibility at this            from the Ministry to establish aid posts
level. In order to avoid further confusionit is           continuing to materialize. By 1988, 113 aid
crucial for lines of responsibilityfor peripheral         postshad beenestablishedand this had increased
health services and for concurrent functionsto            to 162 in 1991. Many requests for the
be determined.                                            constructionof aid posts are supported by aid
                                                          donors (and tacitly by Government and the
7.41 For health service delivery, the country             Ministry), althoughthis underminesthe concept
has been divided into five Health Districtseach           of self help and communityresponsibilitywhich
with a Central District Health Office and a               underpins current policy. Many aid posts have
Hospital. There are two referral hospitals,those          recently closed for lack of communitysupport
for the Northern District and the Vila Central            and finance, in most cases coincidingwith the
Hospital which is also the Central II District            abolishingof health fees for outpatientservices
Hospital. The Northern District Hospital is               at higher level facilities managed by the
staffedwith four medicalofficers, one of whom             Governmentearlier in 1992 (see below).
is a specialistsurgeon. It has a bed capacityof
118 with a 45 percent bed occupancyrate. The              7.43 The Dispensaryis the smallestperipheral
Vila Central Hospital has five positions for              facility under the full responsibility of
medical specialists in the fields of internal             Government health services. It is typically
medicine,paediatrics,obstetricsand gynecology             staffed by a nurse and has a delivery room as
and surgery. It has a bed capacityof 129 and a            well as a consultationand treatmentroom. The
                                                - 278 -


followingservices are typically provided from             7.46 Dental curative services are provided at
most dispensaries: outpatient, admission, and             the Port Vila Central, Northern and Eastern
referral services, the treatment of medical               District Hospitals and school preventative
ailments,provisionof maternal and child health            programs extend to some other parts of the
services including family planning, and health            country. The services are, however, still in the
promotion.                                                early stages of development, with the vast
                                                          majorityof people not receiving either curative
7.44 The Health Center is the institution                                       21
                                                          or preventativeservices. In 1991, there were
between the hospital and the dispensary. It is            less than 10,000 dental visits recorded for all
generally staffedby two or three nurses and the           Government facilities.      The preventative
officer in charge is often a Nurse Practitioner,          program is still also rudimentary and highly
an experiencednurse who has undergonea one                dependenton aid financing.
year post graduate program to upgrade clinical,
diagnostic,and community   educationskills. The           7.47 The Immunization    Program is operatedas
Health Center is generally larger than the                part of the services emanatingfrom those health
Dispensary and has inpatient ward facilities.             centers       and d i s p e n s a r i e s with
Communicationbetween health institutionsand               refrigerators-around one-third of dispensaries
with the District Health Office and to referral           and health centers have mostly gas-powered
hospital(s)is by radio or telephone. However,             refrigerators. Considerableinvestmentby both
there are still many centers, particularly in             Government and donors have been made in
remote areas, where communication is                      establishingthe cold chain in recent years, but
particularly important without either of these            maintenance repair have presentedcontinual
                                                                        and
facilities.'                                              problems due to lack of recurrent budget
                                                          funding. In areas without the cold chain, the
7.45 The distribution of health facilities by             program is run in a vertical manner from the
Health District is summarized in Table 7.12.              districtcenter with assistancefrom headquarters.
This gives a general picture of the average               The program was successful in achieving a
populationserved by a Health Center (7,575), a            relatively high coveragerate by 1991, compared
Dispensary(2,230) and an Aid Post (935). The              to 1986 (Table 7.13). Nevertheless there is
average work loads at these institutions are              scope to improve coverage particularly for
discussedbelow.                                           measles, polio 3, DPT and hepatitisB.


          Table 7.12: DISTInBurioN    OF HEALTH FACILITIES BY HEALTH DISTRICT,              1991



                                             District                                               Pop./
Facility Type           North        East       Cent 1        Cent 11      South      Total        Facility


Hospital                   1          1             1            1           1          5          30,300
Health Center              5          5             5            4           1         20           7,575
Dispensary                17         14            17            9          11         68           2,230
Aid Post                  33         37            33           34          25        162             935

  Total                   56         57            56           48          38        225


Source: National Health Development Plan 1992-1996.
                                                   - 279 -


7.48 In 1990, it was reported that 75 percent                relative role of local governmentsin the delivery
of births took place in health facilities with 96            of services, including their financing. Local
percent of pregnant women receiving some                     govermments, despite being formed at
antenatal care, but only 25 percent were                     independencewith responsibilitiesfor a rangeof
examined soon (up to six weeks) after birth.                 serviceprovision includingparts of health, have
There is clearlyscope to improvecoverage, but                not been financiallyor administrativelyviable.
these are remarkable achievements in the                     Countering this proposal is an alternative to
Vanuatu context. A relatively high proportion                reducethe numberof local governmentdivisions
of those delivered in health facilities were in              so as to correspondto the presentfive health and
hospitals where fees of Vatu 200 to 600 were                 educationdistricts. This debate is crucial to
charged. These fees, which are relativelyhigh                service delivery strategies in Vanuatu, and it is
when compared to average incomes, have                       important that the concept of deconcentrating
historicallynot deterred most womenfrom using                many service delivery responsibilities within the
relatively high quality maternity services by                Departmentto line managersat the five District
                                                             Offices and hospitals is not confused with
                                                             political decentralization and any attempts to
  Table 7.13: VACCINATION
                        COVERAGE                             move responsibilityfor the financingof health to
 FOREPI TARGET           1988 - 1991
                 DISEASES,                                   non-viable institutions. (See further discussion
                  (percent)                                  below).

                                                             7.50 Human Resources. There are four main
Year BCGDPT3 Polio3 Measles Hep. B                           cadresprovidingclinicaland primary healthcare
                                                             in Vanuatu. These are the Village Health
1986 75      31       31      24       0                     Worker,        the    Nurse,       the Nurse
1987 79      56       53      34       0                     Practitioner/Health Extension Officer and the
1988 73      58       58      46       0                     Medical Officer.' At the front line of health
1989 80      61       63      46       0                     service delivery, at least until recently, is the
1990 96      76       78      66      34                     VillageHealthWorker who operatesfrom an aid
1991 100     83       82      63      46                     post, is selectedby the village, undertakesa 12-
                                                             week training program (currently funded by
                                                             Save the ChildrenFund Australia)and performs
Source: Annual Reportsand NationalHealth                     the following duties:      treatment of minor
        Development
                 Plan.                                   conditions,referral of patientsto dispensariesor
                                                         health centers, dispensing a range of defined
bypassing health centers with lower levels of            palliative drugs (including malaria tablets) as
service and lower fees. These fees are no                well as participationin communityhealth service
longer applicable given the establishmentof a            activitiesand health promotion.
"free" health services policy by Government,
and it is doubtful that the quality of existing          7.51 In 1991, there were about 170 Village
services can be maintainedin the absence of a            Health Workers, but the number currently
cost recoveryprogram (see below).                        operatingeffectivelyin late 1992is estimatedto
                                                         be only one-third of the 1991 total as a
7.49 The Ministry of Health is currently                 consequence of the collapsed financing
reviewing a proposal to further divide the               arrangements. This is clearly a critical issuefor
countryinto health districtswhich correspondto           Vanuatu health authorities as Village Health
the 13 local government divisions. A major               Workers are a cost effective mechanism to
impetusfor this is a longstandingcommitment   to         deliver health services to a widely dispersed
decentralizeservice delivery and to increase the
                                                  - 280 -


population without effective        access   to             7.54 A key problem for the nursing center is
dispensariesand health clinics.                             the necessityto train in Bislama, because of the
                                                            need to take both French and English speaking
7.52 The core of qualifiedni-Vanuatumedical                 students and the inability to justify separate
professionals are the nurses who largely staff              programs in English and French. This creates
dispensaries and health centers and are the                 problems in finding appropriate supporting
nucleusof staffing in the five hospitals. There             materials,given constraintsto translatematerials
are currently 216 nurses engaged in clinical                to Bislama. While Vanuatuhas many problems
activities as staff nurses with an additional 26            specific to its situation, there are clear
qualified midwives as well as 8 nurse tutors                opportunities for cooperation in curriculum
makinga total of 250 nurses in the Government               developmentwith other nurse training centers in
system. They are supported by 44 nurse aids.                the region, particularly in the Solomon Islands
Typically,nursesmanage dispensariesand work                 which is developing its public health nursing
in health centersand hospitalswhile midwifesor              curriculumand in manyrespectshas to deal with
a nurse practitioner will manage a health center            similar morbidity patterns and also develop
or work in hospitals. In addition there are 5               strong MCH and family planning support.
District Health Supervisors,4 Health Extension
Officers and 28 Nurse Practitioners (discussed              7.55 Nurse Practitioners/Health Extension
below) who have been largely drawn from the                 Officers are makinga significantcontributionin
nursing pool for training for these                         Vanuatu and have the capacity to play an even
responsibilities.                                           more importantrole in the future as efforts are
                                                            made to improve the efficiency with which
7.53 Thus, the health system relies heavily on              health services are delivered and how medical
nursesfor health servicedelivery. Historically,             officers are utilized. Nurse practitioners have
nurses were trained in curative medicinewith a              the capacity,particularlywith improvedtraining,
strong emphasis on hospital based medicine.                 to undertake even more of the activities
Since 1991, however, the Vanuatu Center for                 currently undertaken by doctors.          Nurse
Nurse Educationhas implementeda new 3-year                  Practitioners are trained after completing the
Diploma in Nursing program (with assistance                 nursing program, and gaining significantwork
from WHO and Save the Children Fund                         experience. They are able to undertakea range
Australia) which is more community health-                  of diagnostic and prescription functions, in
orientated, with a 50 percent split between                 addition to those carried out by staff nurses
theory and practical training.' Efforts are                 according to established treatment protocols.
ongoingto establishan improvedprimary health                They are thus suitable for health centers which
care focus in the training program. In                      cannot justify a doctor on case load
particular, there is a need to improve content              considerations and for outpatient sections of
relevant to public health nursing in rural areas.           hospitals.
A significant problem with curriculum review
has been the dependenceon expatriate advice                 7.56 There is a need to improve the
and a lack of ownership of the reviewed                     curriculum content of the Nurse Practitioner
curriculumby ni-Vanuatustaff. The Centeralso                program and develop a task-orientatedsyllabus
provides training in midwifery, and for Nurse               and specific training manuals. This should be
Practitioners,post basicnursingqualifications on            undertaken in tandem with other efforts in this
an alternate year basis. Attrition of nursing               area in the region, particularly with the Fiji
graduates from the work force has not been a                School of Medicine. It would be beneficial if
problem, as 61 of the 64 graduateswho entered               agreementcould be reached with the Fiji School
the programbetween 1984and 1988 continueto                  of Medicine on entry credits for Nurse
be employedas nurses.
                                                     - 281 -


Practitioners to their Primary Health Care                     secretly along family lines. Some methodsuse
Practitionerprogram.                                           herbs for healing whilst others use magical
                                                               powers. On the southern island of Tanna there
 7.57 Medical Officers including Specialists                   is a strong tradition of successful bone setting.
form the top of the medical staffing pyramid.                  Traditional healers are discouraged from
There are 15 doctorsprovidingmedicalservices                   attending to hospitalized patients by hospital
 in Governmenthospitals,the vast majorityin the                authorities. Cultural and older traditional
Port Vila hospital. There are however only five                practices are particularly strongly followed on
ni-Vanuatudoctors in the system, and there is                  Tanna. Payment to traditional healers is
little prospectfor significantlocalizationof the               primarily through gifts such as food, although
work force before 2000 unless there is a                       cash contributionsare believedto be formingan
concertedtrainingeffortand salariesare adjusted                increasing part of such payments for services.
to become competitivewith those in the broader                 It is not possible to ascertainhow much money
Pacific labormarket. Further, it is inappropriate              is channelled to traditional practitioners,
that Vanuatucontinueto maintainits dependence                  althoughit is thought to be relatively small.
on donor support for medical officers,
particularly given its stated aims of reducing                 7.59 Health         Spending:      Levels and
dependenceon expatriatesand aid. Optionsto                     Allocations. Government as the primary
attract more ni-Vanuatu to the medical                         supplierof health servicesin Vanuatuexpendsa
profession should be pursued, including raising                considerable proportion of its resources on
salaries and allowing private practice. The                    health. However, Government expenditureon
optionof using Nurse Practitionersto undertake                 health both as a proportion of total government
some of the functionscurrently undertaken by                   expenditure and as a share of GDP over the
doctors also exists. A significantproportion of                 1980shas declinedsignificantly. As a share of
ni-Vanuatudoctors who have trained in PNG                      the total budget, it has declined from a peak of
and elsewherehave not returned. Further there                   14.2 percent in 1982 to 10.1 percent in 1991,
have been occasions when well qualified                        while as a share of GDP it has declined from
nationals(includingpost graduate trained) have                 3.7 percent in 1982to 2.6 in 1990(Table 7.14).
returned to take over specific positions only to               Since 1982, real per capita Government
be redeployedto dutiesnot relateddirectlyto the                expenditureson health have declinedfrom 5,545
training undertaken.                                           Vatu per head to 3,138 Vatu (1992 prices), a
                                                               decline of 43 percent over the decade in real
7.58 Traditional Healing. There is an active                   terms. These trends clearly indicate that
practice of traditional healing which varies in                Governmenthas not been able to sustain past
type and popularity from area to area in the                   levels of expenditureon health. At best, it is
country. While the scope of traditional healing                possible that Government may be able to
is poorlydocumented,a significantproportionof                  stabilizeexpenditureson health in the 1990s,but
patients in government health institutions also                it is unlikelythat Govermnenthas the capacityto
consultstraditional healers, often as a first step             reverse recent trends and increase significantly
in the process. It is evident that patients use                the share of the budgetcurrentlygoing to health.
traditional healers to a widely varying extent                 By international  standards, the current allocation
dependingon traditionalcustom in each area of                  to health as a share of the budget is high.
the country and often in combination with                      Generallyonly high incomeEuropeanand North
government-supplied   health services, especially              Americancountriesallocatecomparableamounts
when the sicknessis slow to resolve. The older                 of resources to the health sector.
type of healer in the cultural context is called a
"kleva". Many of the practices associatedwith                  7.60 In addition to Government expenditures
the various styles of healing are passed on                    on health, contributions are made by other
                                                    - 282 -


ministries, local government, aid agencies and                because of the substantial real decline in
private individuals. While systematic data on                 governmentexpenditure(see below).
total resourceuse on health are not availablefor
recent years, it has been estimated that the                  7.61 Questions need to be raised about the
Ministryof Health accountedfor between56 and                  current allocationof Governmentexpenditureon
61 percent of health funding over the years,                  health, and whetherhealth spendingpatternsare
 1983-86,with the share consistentlyrising over               appropriateincludingallocationsto the recurrent
time. The second largest source of financing                  and the developmentbudgets (both domestically
was foreign aid which decreased from 25 to 21                 and donor financed). First, a very high
percent of total funding over the period. Direct              proportion of all Government recurrent
private payments were estimated at between 11                 expenditureon health is on referral and district
and 12 percent of the total,2' while local                    hospitals, which account for 51 percent of the
governmentand other ministries(includingrural                 health budget, while rural (district) health
water supplies)accountedfor about6 percent of                 servicesaccount for only 22 percent of the total.
the total.'    While it was anticipated in the                It is also notable that the two referral hospitals
early 1980s that local councils would expand                  account for 40 percent of the total budget, while
their role in the health sector (from about 1.7               the district hospitals account for a further
percent of the total), their importance has                   12 percent. The central medical store which is
probablydeclined due to financial weaknesses.                 responsible for purchasing and distributing all
The share of foreign assistance has increased,                drugs to health facilities in the public health
partly because of sustained support and partly                system accounts for further 10 percent of the


            Table 7.14: GOVERNMENTHEALTH EXPENDniUR                                 1982-92
                                                                         AND REVENUE,


                                                                             Nominal        Real      MOH
             Total        MOH         % MOH                   MOH Rev.       Per Cap.     Per Cap.   Expend.
Fiscal      Gov't         Rec.        Rec. of     MOH          as % of         Health     Health      as 9
Year       Expend.       Expend.       Total      Rev.        MOH Exp.        Expend.     Expend.     GDP


                                                (Vatu Million)
1982           2,486          353      14.2          9            2.5            3,080       5,545      Da
1983           2,565          367      14.3         12            3.3            3,113       5,385     3.7
1984           2,825          406      14.4         15            3.7            3,350       5,427     3.3
1985           3,316          436      13.1         17            3.9            3,496       5,524     3.5
1986           3,651          441      12.1        26             5.9            3,440        5,12     3.6
1987           3,638          408      11.2        25             6.1            3,093       3,960     3.0
1988           3,960          456      11.5        28             6.1            3,363       3,966     3.0
1989           4,051          424      10.5        27             6.4            2,957       3,343     2.6
1990           4,943          457       9.2         27            5.9            3,100       3,314     2.6
1991           4,693          472      10.1        23             4.9            3,115       3,138
1992 /a                       496                   10            2.0            3,184       3,184
1993 /a                       496                    6            1.2            3,097


Source: Ministry of Planning and Statistics and Mission estimates.

/a 1992 and 1993 figures are budget and Mission estimates.
                                                       - 283 -


budget. Preventative health, which includes                      7.63 The allocation of resources by cost
malaria, water supply and sanitationand health                   centers and budget line shows that health policy
educationreceivesless than 3 percent of the total                and expenditure planning remain divergent
recurrent allocation(Table 7.15).                                functionswithinthe sector. It would appearthat
                                                                 there will have to be significant budget
7.62 An analysis of recurrent expenditure                        rationalizationif the general policy objectives
trends by budget line (Table 7.16) indicatesthat                 outlined for health in the Third National
the largest budgetitems are salaries(68 percent)                 DevelopmentPlan are to be achieved. These
followed by Drugs and X-Rays (12 percent).                       objectivesinclude: (i) emphasison preventative
The recurrent budget is notable for its limited                  rather than curative health services; and (ii) an
provision for travel and subsistence(1 percent),                 equitableand regionallybalanceddistributionof
and for building maintenanceand minor works                      health services premised on sustainability,
(1 percent). Most field staff interviewedcited                   community control, and participation. The
lack of funds for travel and maintenanceas a                     present recurrent budget allocations do not
major cause of poor rural health extension                       reflect the proposed health policy objectives.
servicesand low staff morale.

                     Table 7.15: HEALTH EXPENDITUREBY COST CENTERS, 1989-92
                                            ('000 vatu)

                                                                                                         Average
                                                                                                          1989-92
Cost Center               1989     Percent    1990       Percent        1991 Percent     1992 Percent    Percent

National Health Office    25,235     6.5     26,114         6.2         30,065   6.8    27,963   6.3       6.5
Vila Central Hospital    105,429    27.0     108,718       26.0        119,354 27.0    114,366 25.9       26.2
N. District Hospital      59,818    15.3      60,561       14.5         64,399 14.6     64,069 14.5       14.5
Norsup Hospital           20,335     5.2      18,670        4.5         20,876   4.7    20,064   4.5       4.8
Lemakel Hospital          18,020     4.6      11,229        2.7         23,015   5.2    20,887   4.7       4.5
Lolowal Hospit            10,770     2.8      11,861        2.8         12,883   2.9    14,160   3.2       2.9
N. District
 Rural Health             19,046     4.9      18,943        4.5         20,619   4.7    20,991   4.7       5.3
Cent. Dist. II
 Rural Health             23,610     6.0     24,033         5.7         26,134   5.9    27,198   6.1       6.0
Cent. Dist. I
Rural Health              16,487     4.2      19,833        4.7         21,268 4.8      21,846   4.9       4.6
Sth. Dist.
 Rural Health             12,472     3.2      11,937        2.9         12,713   2.9    11,288   2.6       2.8
EastDist.
Rura Health               19,627     5.0     24,242         5.8         25,156 5.7      26,630 6.0         5.4
School of Nursing          8,458     2.2      7,215         1.7          8,228   1.9    12,152 2.7         2.1
Dental                    3,896       1.0     4,419         1.1          4,787 1.1       4,904 1.1         1.0
Central Medical Store    42,323     10.8     58,733        14.0         39,152   8.9    39,930   9.0      10.5
Preventive Section        5,473       1.4     11,590        2.8         12,895   2.9    15,930   3.6       2.7
  Total                  390,999 100.0       418,118     100.0        441,543100.0     442.409 100.0     100.0

Source: Ministry of Finance Budget papers, various years.
                                                               - 284 -


                  Table 7.16: ANALYSISOF RECURRENT  BUDGET BY LINE ITEM, 1989-93
                                           ('000 vatu)

                                                                                                                                Average
                                                                                                                                1989-92
Budget Line                     1989 Percent       1990 Percent       1991 Percent       1992      Percent    1993 Percent      Percent

Estab. Staff Salaries          230,627 55.9 233,193 52.2             257.551 54.3 291,188            61.1 291,738 58.7           56.3
Estab. Staff Overtime            1,884 0.5    2,254 0.5                2,053 0.4    2,153             0.5   2,153  0.4            0.5
Estab. Staff Allowances          1,796 0.4      919 0.2                  315 0.1    2,477             0.5   2,477  0.5            0.5
Daily rated labor               61,865 15.0 61,034 13.7               55,571 11.7 23,644              5.0 39,844 8.0             11.0
Total Personal
 Emoluments                    296,172     71.8   297,400     66.6   315,490     66.5   319,462      67.1    336,212     67.7    68.2

Travelling & subsistence          5,038     1.2     5,407      1.2       5,388    1.1     6,258       1.3      5,682      1.1      1.3
Telephone & Telex
 Charges                         5,989      1.5     8,456      1.9     9,587      2.0     7,414       1.6      8,873      1.8     1.7
Books & Stationery               4,488      1.1     6,046      1.4     4,508      0.9     4,730       1.0      5,257      1.1     1.1
Public Utility Charges          20,209      4.9    24,909      5.6    30,343      6.4    26,455       5.6     23,810      4.8     5.4
Consultant&OtherFees                426     0.1        436     0.1        480     0.1        592      0.1           0     0.0     0.1
Fuel for Vehicles & Vessels      3,605      0.9     4,783      1.1     3,534      0.7     4,820       1.0      3,836      0.8     1.0
Spare parts & plant maint.       1,795      0.4     1.572      0.4     2,154      0.5     3,762       0.8      3,386      0.7     0.5
H irecharges, vehic. & plant     7,779      1.9     8,177      1.8    12,561      2.6    10,806       2.3      8,729      1.8     2.1
Building maint. &
 minor works                     1,946      0.5     2,229      0.5     2,413      0.5     2,628       0.6     20,399      4.1     1.1
Other purchase& incid.           2,721      0.7     3,221      0.7     3,139      0.7     3,422       0.7      3,080      0.6     0.9
Rent of land & buildings            124     0.0        143     0.0        234     0.0        218      0.0         197     0.0     0.0
Drugs and X-rays                34,137      8.3    59,583     13.3    57,534     12.1    61,282      12.9     55,154     11.1    11.5
Specialist visits to Van              0     0.0          0     0.0          0     0.0        S00      0.1         300     0.1     0.0
Local treatment (transport)      3,405      0.8     3,778      0.8     6,204      1.3     4,132       0.9      3,859      0.8     0.8
Overseas treatment (Tsport)         146     0.0       278      0.1        573     0.1        729      0.2         658     0.1     0.1
Patients food                   14,596      3.5    14,436      3.2    15,463      3.3    15,038       3.2     13,634      2.7     3.2
M.V. Sanvinfana - Op Costs       1,318      0.3     1,434      0.3          0     0.0          0      0.0           0     0.0     0.1
M.V. Sanvinfana - Deprec.             0     0.0          0     0.0          0     0.0          0      0.0           0     0.0     0.1
Land surveys                          0     0.0          0     0.0          0     0.0          0      0.0      1,000      0.2     0.0
Distribution of drugs & med.     1,307      0.3       939      0.2     1,555      0.3     1,585       0.3      1,438      0.3     0.2
Cleaning & laundry               2,450      0.6     2,145      0.5     2,327      0.5     2,458       0.5      2,212      0.4     0.4

Total Operational              118,741     28.8   147,972     33.1   157,997     33.3   156,829      32.9    160,411     32.3    31.8

Total Recurrent                412,736    100.0   446,410    100.0   474,673 100.0      476,308     100.0    496,623    100.0   100.0


Source:   Ministry of Finance Budget Papers, various years.


The emphasis is on curative rather than                                  forward in health policy articulation and
preventative services. While it is difficult to                          planning in Vanuatu. However, health policy
allocate the health budget by region on a                                objectives must be reflected in an expenditure
consistent basis, it is clear there are marked                           plan.     To align strategic objectives with
regionaldisparitiesin resourceallocationsand as                          expenditure planning, the health policy,
demonstratedabove in Table 7.12 in access to                             planning, budgeting and aid management
health services. Further the decisionto provide                          functionsmust be more closely integrated. The
free outpatienthealth care has undermined the                            effectingof resourceshifts will not be easy, and
principles of community control, participation                           will not come without serious efforts to adjust
and self reliance.                                                       the existingrecurrent and aid budgets in support
                                                                         of agreed objectives.
7.64 The policy objectivesarticulatedfor the
health sector in the National Health                                     7.65 External Aid. Prior to independence,
Development Plan constitute a major step                                 France and Britain shared the major costs of the
                                                 - 285 -


health service, althoughmission agencies were              the health sector. These include the Australian
also involved extensivelyin service provision.             Save the Children Fund, Rotary and the
Following independence, Britain and France                 Foundationfor the People's of the SouthPacific.
indicated their intention to reduce their direct           One major issue from this rather extensiverange
support for the recurrent budget. By the mid               of donors active in the sector is that there is an
 1980s, the Vanuatu Government had assumed                 even more bewilderingarray of activeprojects.
primary responsibility for recurrent budget                It is estimatedthat the Departmenthas had more
support. The extent of recurrent budgetary                 than 300 projects since 1985, rangingfrom those
commitments provided little scope for                      involving a few thousand dollars, to relatively
maintenance additionalcapitalexpenditurein
             and                                           large initiatives of I million dollars or more.
health. This situationhas been exacerbatedby               There is little discriminationin procedures and
the Government's taking over full financial                allocationof managementtime between a small
responsibility for mission facilities. The                 and a large project under current administrative
Government and the Department have                         arrangements, which has had the effect of
increasinglysought donor interventionsin these             drawing management away from strategic
areas, and have effectively capitalized                    issues.6     Needless to say, there is no
maintenance generalequipment
             and                  replacement.             systematically  documentedanalysisof resources
                                                           from all donor sources available.

  Table 7.17: TOTALGOVERNMNTAND                            7.67 An analysis of major donor figures for
     DONOR RESOURCES ALLOCATED                             the period 1989-93 indicatesthe importance in
         TO HEALTH, 1989-93                                aggregateterms of donor financing(Table7.17).
                  (Vatu million)                           From 1989 to 1993, major donors allocated
                                                           resources equivalent to between 46 and 48
                                                           percent of total resources available. This
                                 Planned                   indicatesan extreme dependenceon aid, despite
                    19891990199119921993                   attempts to increase the level of self reliance.
                                                           __Given most technical assistanceis hospital-
                                                                 that
                                                           based, data indicate that the majority of
Total Recurrent     413 446 475 476 496                    resourcesare allocatedto hospital-basedservices
Total Donor         376 408 437 417 423                    and thus in aggregate terms support domestic
                                                           resource allocation priorities (Tables 7.18 and
  Total             789 854 912 893 919                    7.19). Over the period, direct allocationsof aid
                                                           to hospitals has ranged between 21 and 42
DonorFinanced 47.7 47.8 47.9 46.7 46.0                     percent of the total.    With the inclusion of
                                                           technical assistance support, which is mainly
                                                           hospital-based,more than 50 percent has been
Source:Tables 7.16 and 7.18.                               allocated to hospital support.
                                                           7.68 Availabledatado not enable recentdonor
7.66 A wide range of aid donors including                  resource allocations to be distributed between
WHO, UNICEF, Australia, the United                         capital and recurrent donor support.        27
Kingdom,Japan, New Zealandand Canadahave                   However, the list of projects supported by aid
been active in supporting recurrent and new                donors suggeststhat donors are responsible for
development  initiativesin the health sector since         meetinga significantproportionof the recurrent
                                     has
independence.French involvement declined                   expenses of the health system. Analysis of
significantly. A number of Non-Government                  donor support for capital and recurrent
Organizations(NGOs)have also been active in                expenditurein 1986 indicatedthat 57 percent of
                                                  - 286 -


           Table 7.18: ANALYSIS MAjOR DONORExPENDITuRES VANUATU,
                              OF                       IN      1989-93
                                        ($US)


                                                                                         Planned
Function                              1989           1990            1991        1992              1993


Administration                       98,000         89,000         105,000     100,000           100,000
Hospitals& Related                1,200,000      1,550,000       1,452,000     800,000           800,000
Staff Develop & Training            309,800        308,000         353,600     344,800           350,000
Water Supply & Sanitation           406,500        398,500         525,000     684,500           534,500
TechnicalAssistance/a             1,227,000      1,220,000       1,291,000   1,270,500         1,122,500
MedicalEvacuations                   31,400         29,800          27,100      81,900            81,900
OtherLb                             123,800        136,800         187,900     462,200           811,100

Total                            3,396,500       3,732,900       3,941,600   3,743,900         3,800,000


Source: Major donors includingNew Zealand, United Kingdom,Australia,WHO, UNICEFand UNFPA; the
        Departmentof Health and Mission Estimates.

/a The majorityof technicalassistanceis in fact hospitalbased.
Lb Not allocatableby function/category.



                                                      IN      1989-93
           Table 7.19: ANALYSIS MAJOR DONOREXPENDITURES VANUATU
                              OF
                                      (Percent)


                                                                                     Planned
Function                           1989           1990            1991        1992              1993


Administration                      2.9            2.4             2.7         2.7               2.6
Hospitals& Related                 35.3           41.5            36.8        21.4              21.1
Staff Develop& Training             9.1            8.3             9.0         9.2               9.2
Water Supply& Sanitation           12.0           10.7            13.3        18.3              14.1
TechnicalAssistance/a              36.1           32.7            32.8        33.9              29.5
MedicalEvacuations                  1.0            0.8             0.7         2.2               2.2
Other /b                            3.6            3.7             4.8        12.4              21.3

Total                               100            100             100         100               100


Source:    Major donorsincludingNew Zealand, United Kingdom,Australia, WHO, UNICEFand UNFPA;
           the Departmentof Health and Mission Estimates.

LaThe majorityof technicalassistanceis in fact hospitalbased.
lb Not allocatableby function/category.
                                                  -   287 -


 all aid was allocatedto recurrent expenditure.  2            input specification involving cost center
The 1986figures suggest that donors supported                 managers impedes physical and financial
 about 25 percent of combined governmentand                   monitoring, and evaluation of the recurrent
donor health expenditure. This would suggest                  health program and the scope for resource
that dependence aid is increasing,particularly
                  on                                          rationalization. It also inhibits the commitment
for recurrent support.            Mission field               of managers, responsible for program
observationsreveal that most cost centers rely                                 to
                                                              implementation, achievingobjectivesto which
heavily on donor support for operationalcosts.                they are not party to developing.
Withoutdonor supportfor travel and subsistence
and materials, most rural health extension                    7.71 The documentation of existing and
programs would cease to function. These                       proposed project activities in the new National
includekey functionssuch as MCH, Malariaand                   Health DevelopmentPlan by sector provides an
the Rural Water Supply and Sanitation and                     opportunity to develop a project planning
Health Education. Vanuatucannot assumethat                    capacitywithinthe Department. Each of the 14
donors will be willing to continue funding the                strategic activities specified in plan could be
health sector at this level and with this focus, or           developed into programs and projects with
that donor preferences will necessarily reflect               clearly defined physical and financial inputs to
domestic priorities over the 1990s. In                        facilitatemonitoringand the reviewof efficiency
particular, the global focus of donor assistance              and effectivenessconsiderations. However, the
seemsto have changedaway from immunization                    Health Plan proposes at least 167 projects and
and familyplanningtowardsAIDS. Further, the                   strategic activities preliminarily costed at Vatu
failure of Vanuatu to adequately address                       135 millionper annumover the period 1992-96
sustainabilityissues in water supply, sanitation,             (Table 7.20). While each project is linked to
and staffingmay result in a reluctanceof donors               one of the 14 strategic activities, this program
to continuepast funding levels in these areas.                comprisesfar too many initiatives. There is a
                                                              need to introduce a more strategic focus and to
7.69 Project and Program Planning                             set priorities within realistic budget constraints.
Capacity. Planning within the Departmentof                    The set of project proposals does not consider
Health has been largely restricted to project                 the many ongoing projects, including those
planning for the development budget. Aid                      funded by donors. Short courses in project
donors require varying levels of documentation                planning and budgeting seminars would be
in order to supportdevelopmentrequestsand, in                 useful mechanismsto achievean agreedstrategic
the case of larger projects, usuallyprovidetheir              focus once all the resource constraints and
own technical assistance inputs to design and                 ongoing projects had been documented.
manage projects. National staff within the
Departmenthave had limitedexposureto project                  7.72 User Fees. In fulfillment of its 1991
planning beyond the submissionof requests for                 election promise, the new Government has
funding through small grant schemes.                          abolishedoutpatientand dispensingfees. While
                                                              inpatientfees are still collected, the Department
7.70 Projector programplanningfor recurrent                   anticipatesthat its total revenue will decline to
health activitieshave not been attemptedby the                around 1.2 percent of total expenditurein 1993
Department. The planning cycle is budget-                     (Table 7.14). Departmental cost recovery was
driven, with the only program planning activity               steadily increased as a proportion of total
beingthe preparationof annualbudgets for each                 recurrent budget expenditure over the period
cost center. However, the preparationof these                 1982 to 1989 (in part because of increased
budgets seldom involves the cost center                       complianceand fees revised in 1986, and partly
managers at the nationalor at the district level.             due to a real decline in budget allocations)
The lack of objectivesetting, output activityand
                                                        - 288 -


                   Table 7.20: NATIONALHEALTH PLAN DEVELOPMENT PROGRAM,
                                         1992-1996La


                                                No of                            Proposed allocation Vatu Million
Program                                         Projects                     1992-96                      Annual


1. Health Education                                12                           13.2                             2.6
2. Family Health Services                          32                           59.2                            29.6
3. Food and Nutrition                              16                           19.6                             9.8
4. Expand Prog. of Immun.                          12                           10.4                             2.1
5. Tuberculosis & Leprosy                           7                           22.9                             4.6
6. Environmental Health                               Not Documented
7. Malaria and Vector Cont.                        14                           60.2                             12.0
8. STD/AIDS Programs                               15                             Not Costed
9. Health legislation                              10                            8.0                             1.6
10. Health Care Delivery /b                        10                          219.7                            43.9
11. Management of Health /c                         8                           33.2                             6.6
12. Health Workforce Devel.                        16                          150.4                            30.1
13 Upgrade of Referral Hosp.                       10                             Not costed
14. Urban Primary Hlth Care                         5                           73.3                             14.7

Currently costed Total                            167                          694.8                            134.4


Source: Draft National Health Development Plan 1992-1996.

/a   Does not include any on-going projects funded by aid donors at present.
Lb   Only 3 of 10 projects costed. Rehabilitation, maintenance and repair of health facilities is costed at vatu
     219.5 million.
/c   One project provides for Vatu 31.3 million for 'visits to rural areas'.    This is clearly a request for
     recurrent budget support.

peaking at 6.4 percent of total expenditurein                     for one or two months of operation a year if
1989.                                                             they have any at all) and other small items
                                                                  necessary for the effective running of health
7.73 Department of Finance regulations                            service delivery institutions. These funds are
required that 60 percent of revenuescollectedat                   crucialfor effectiveservice delivery, in view of
rural health facilitiesbe remittedback to general                 the lack of fundsfrom the centralbudget. These
centralfunds. The remaining40 percent of fees                     activities, particularly the outreach work, are
collected through outpatient and dispensing                       crucial in a countrywith both difficulttransport
services couldbe retainedby staff at the facility                 facilities and a dispersed population for
for the support of health service delivery. In                    preventativehealth, MCH and family planning
Dispensariesand Health Centers, support staff,                    activities and small maintenance activities.
such as cleaners and nurse aids, were typically                   There is clear evidencethat the better maintained
paid for from these retained fees. Revenues                       facilities attractedhigher usage.
from this source were also used to pay for
transportcosts for outreachprograms (currently                    7.74 The recent (1992) decisionto abolish all
manyfacilitieshave only enoughtransportfunds                      fees means this revenue source is no longer
                                                -   289 -


availableto health institutionsand no alternative           country medical staff. It is estimated that
support from the budget has been instituted.                resourcesdevotedto this relativelysmallnumber
Thus, Government health institutions are no                 of individuals (less than 100, with about 10
longer ableto deliver the samequalityof service             being evacuated each year) is the equivalentof
and maintaintheir infrastructureas before. One              5 percent of the national recurrent budget.
crucial impact has been that individuals are                Governmentauthoritieshave been informed by
refusing to pay Village Health Workers because              New Zealand that the current financial ceilings
the Governmenthas announcedhealth services                  for medical evacuationswill not be allowed to
are free, and in areas where transport is                   increasesignificantlyin the future.
availableto higherlevel facilities,individualsare
now gaining"free" health servicesby payingfor               7.77 As a result of the existence of
transport to get there. Field observations                  catastrophicillness coverage and given that the
strongly suggest the distribution of outpatient             Vanuatu Government effectively pays for the
visits is shifting significantlyin many areas to            health care servicesfor the publicupon demand,
higher level (more costly) facilities. With fees            any insurancescheme would only be viable if it
now abolished at rural health facilities, the               offered qualitativelydifferent medical services.
highest level of cost recovery is at the basic              The reintroduction of outpatient fees and
level of the system, the reverse of an optimal              revision of hospital fees would establish an
structureof cost recovery. It would appearthat              increasedpotentialmarket. However, it must be
the government's policy of free outpatient                  recognizedthat 80 percent of the populationis
services is in danger of undermining the                    based in rural areas with limited cash incomes.
community-based aid post system and                         In 1989, there were 65,000 people in the
overloading higher order health services with               Vanuatuwork'force, but it is estimatedthat only
minor ailments.                                              17,000 were in the monetized sector, a
                                                            significantproportionof whom would not be in
7.75 In its 1993 budget submission to the                   full-time formal sector employment. In 1991,
Department of Finance, the Department of                    the National Provident Fund had 19,641
Health noted that the government's new policy               members,of whom 17,741 were active. Health
of free outpatient treatment has led to an                  insurance is therefore unlikely to be viable
increaseof almost 40 percent in pharmaceutical              option for the vast majority of the population,
usage. This is importantgiven concernsabout                 but it may be feasible for formal sector
over-usage of drugs and the fact that drugs                 employees who are largely urban-based and
constitute a significant share of the health                currently enjoying the significant benefits
budget, about7 percent.                                     relative to rural populations. The WHO has
                                                            recommendedthat employee insurancethrough
7.76 Health Insurance. There is no general                  private employer organizations warrants
health insurance scheme available in Vanuatu                investigation.' Recent offers of assistanceby
althoughpublic servants are entitledto some fee             donors to further study possibilities of
remissionfor health chargesunder their general              introducing medical insurance through either
terms and conditionsof employment. Provision                private or public sector mechanisms have not
is made in the New Zealand aid budget                       been taken up by the Government.
(NZ$150,000 in 1993 increased from
NZ$50,000 in earlier years) for evacuationand               7.78 Private Sector. There is a small private
treatment in New Zealand for catastrophic                   sector which largely serves the local expatriate
illness. In addition a number of visiting                   community, although more urban based ni-
specialist medical teams funded by major aid                Vanuatuin well paid employmentare beginning
donors and Non-Government Organizations                     to use private medical practitioners and
addressa significantrange of catastrophicillness            pharmacistsin increasingnumbers. The sector
problems which can not be handled by in-                    did not grow significantly during the 1980s,
                                                      - 290 -


                       Table 7.21: TOrAL, WEEKLY AND DAILY ATrENDANCES;
                                   ALL HEALTH FACILITIEs, 1990


                                             Total                OPD/          OPD/          IPD/        IPD/
Facility Type /a                   OPD               IPD          Week          Day           Week        Day


Hospitals
Port Vila                           33,200           22,268           639          91           428           61
Santo                               15,955           19,216           307          44           370           53
Lolowai                              6,029            4,040           116          17            78           11
Norsup                                 700            3,266            13           2            63            9
Lentel                              15,252           10,496           293          42           202           29

Total Hospitals                     71,136           59,286         1,368         195           162       1,140
Total Health Centers               166,990           10,463         3,211         458           201          29
Total Dispensaries                 105,330                 -        2,026         289              -             -


Total All Facilities               343,456           69,749         6,605         941         1,341          191

Mean Hospitals                      (No.5)                            274          39           228           32
Mean Health Centers                (No.49)                             66           9             4            1
Mean Dispensaries                  (No.48)                             42           6              -             -




Source:     Ministry of Health Planning Division, Field Visits and Mission Estimates based on earlier year
            figures for missing data for 1990.

/a   All rural institutions rated with a bed capacity have been classified as a health center in this Table and
     those without beds as dispensaries. There is considerable confusion in definitions of facilities and numbers
     over time in official statistics. The National Health Development Plan for instance indicates that there are
     19 health centers and 64 dispensaries (83 rural institutions in total) while the Draft 1990 Health Report
     indicates there are 97 institutions. The latter has been used as the basis for this Table. OPD = Outpatient
     Days. IPD = Inpatient Days.

partly a reflectionof the fact the numberof non-                7.79 The primary method of payment is fee
citizens has fallen since independence in                       for service with consultations,averaging about
1980.2 There are five doctors and two                           US$10-15 per visit, although most private
pharmacies in the private sector, all based in                  practitionershave a different (lower)scheduleof
Port Vila. Loganville-the second urban area,                    fees for ni-Vanuatupatients. While increasing
had the servicesof a private medicalpractitioner                numbersof ni-Vanuatufrom the formalsector of
until the mid 1980s, and there is a licensed                    the economy attend private practitioners, most
"druggist"supplying a range of medicinesover                    clients are from the expatriatecommunity. The
the counter. Recently, a ni-Vanuatu Health                      Health Extension Officer's practice is expected
ExtensionOfficer has left the public sector, and                to be based on ni-Vanuatuclients.
established a private practice in Port Vila." 3
Health authoritiesare now trying to formalize                   7.80 Patients requiring either specialist or
and clarify the legal position of such a move.                  inpatienttreatment are referred to Government
There are no private laboratory or radiology                    hospitals(usuallythe Port Vila referral hospital).
services in Vanuatu.                                            There seems to be a good informal relationship
                                                  - 291 -


between private practitioners and the port Vila             respectively, and even the national referral
hospital, although formalizing the relationship             hospitalin Port Vila has a bed occupancyrate of
and encouraginguse of expertise in the private              only 47.3 percent. The average numberof beds
sector in the public health system has the                  in health centers is only 5.9 with many only
potential to be beneficial for both sectors. At             havingone or two beds. Despitethis small scale
present, there is no formalized provision to                and dispersed capacity, the bed occupancy rate
contractin private sector doctors on a sessional            for health centers is only 9.9 percent (Table
basis.                                                      7.22). This low occupancy rate is very
                                                            widespreadwith only 11 facilitieshaving a bed
7.81 Utilization, Roles and Skills. In                      occupancyrate greater than 10 percent. Onehas
aggregate terms, the utilization of Vanuatu                 achievedan occupancyrate just over 50 percent
health facilities is at relativelyhigh levels, with         and anotherjust over 25 percent.
total outpatientvisits per capita to Ministry of
Health facilities being 2.3 per annum. The3                   Table 7.22: BED OCCUPANCY RATES AT
averagedaily outpatientattendancesat hospitals,                  HoSPrrALs AND HEALTH CENTERS,
health centers and dispensariesare presented in                                  1990
Table 7.21. The figures clearly show the
problemsof providing facilities to areas with a
small population,and suggeststronglythat there                                         Total Bed Occup.
are some inefficiencies in the use of health                Facility Type    Beds    Inpatients Rate %
facilities and staff. The five hospitals account
for 21 percent of total outpatient attendance,
while the 49 health centers and 48 dispensaries             Hospitals
account for 49 percent and 30 percent of all out            PortVila          373         22,268     47.3
patient attendances, respectively. Mean daily               Lolowai            33          4,040     33.5
and weekly outpatientvisits show considerable               Norgup             58          3,266     15.4
variability in use. The average outpatient                  Lenakel            36         10,496     79.9
attendanceat hospitalsis 39 visits per day, but
two smaller hospitalshave relatively low usage              TotalHospitals    374         59,286     43.4
more comparableto health centers with 17 and
2 visits per day, respectively. The mean                    Total(49)
outpatientvisits to health centersis only nineper           HealthCenters     289          10,463     9.9
day and to dispensaries is only six. Further
these averages hide a relatively skewed                       Total           663         69,749     28.2
distributionaround the mean. Thus, of the 49
health centers, 19 (39 percent) have 6 or less
outpatient visits per day, while for the 48                                 of
                                                            Source: Ministry HealthPlanningDivision
dispensaries, 34 (71 percent) have less than 6                      andInstitutionReturns.
visits per day.
                                                            7.83 It must also be acknowledgedthat health
7.82 There is also relatively low utilizationof             staff also conduct outreach activities and MCH
inpatient capacity of public health facilities.             clinics. Overall, however, staff at rural health
Overall, there are 663 public beds in Vanuatu               facilitiesonly spent 28 days per facility in 1990
with 374 (56 percent) in the five hospitals, and            on outreach activities (which is less than 20
289 (44 percent) in the 49 rural facilities. The            percent of one staff members working year per
hospital sector has an aggregatebed occupancy               facility), and MCH visits would only add an
rate of only 43.4 percent. Two hospitals,                   additional 11 percent to rural facility patient
Lolowai and Norsup have extremely low bed                   loads.
occupancy rates of 33.5 and 15.4 percent
                                                - 292 -


7.84 The efficiencyof providingtrained health             7.86 Family health education rather than
workersto see such small numbersof outpatients            family planningeducationis the current focusof
and service extremely small numbers of                    efforts in this area, largely because of the
inpatients (on average there is one inpatient             damage done to the image of family planning in
every day within each health center) suggests             an emotional public debate about injectable
that the role of many rural facilities should be          contraceptivesearly last decade.
carefullyconsidered. While manyrural facilities
have only one staff member, there is scope to             7.87 The Health Education Section of the
ensure that staffing of other rural facilities is         Department has few staff or facilities, but is
based on work load. A locationalmapping of                active in its program using leaflets, brochures
facilities and population catchments would                and radio programs, albeit largely donor
determine the extent of rationalizationfeasible,          financed.'     Presently the half hour radio
including the numbers which could be closed               program per week is broadcast at no chargeby
and those down graded. A mapping exercise                 Radio Vanuatu. Health Education in the
would also determinethe areas not well served             peripheral areas is generally done through face
at present. Rationalization would have the                to face health education by nursing staff
potentialfor cost saving which couldbe devoted            operating out of Government health facilities
to achievingbetter accessto those not served at           with some efforts conducted as a vertical
present or increasing the recurrent budget of             programfrom the center. Peripheralhealth staff
existing facilities.                                      are inadequatelytrained in this area, and not
                                                          equipped for adequate health education and
7.85 Health Awareness and Health                          health awareness activities. At present, the
Education. There is a fair awarenessof sound              health education staff at headquarters have
sanitarypracticesand the general health benefits          extremely limited resources and are unable to
of clean water suppliesby ni-Vanuatu. Villages            travel. They currently lack an aid-funded
are kept clean and toilets, particularly family           project to give them resources for mobility in
owned ones, are utilized where available. The             the absenceof domestic financing.
primary school syllabus includes basic health
principles and sanitation, and there are some             7.88 The active Primary Health Care
limited ongoing efforts to further revise and             motivationprogramwhich initiatedthe desire for
improve the curriculum. There is no family                Aid Posts in rural communities and also
planning or education about sexual matters in             improvedenvironmentalknowledgeand habits,
primary schools and AIDS education is only                has lost momentum over recent years. The
givenin grade nine of high schoolswhich means             activeparticipationin health service delivery by
that a significantproportion of children do not           the communitythrough the impositionof levies
receive any exposure to this as many do not go            by community-basedcommittees on services,
to schooland only a smallproportionof children            allowed for the employmentof extra staff and
go to high school. The lack of family health              money for travel and patrols at health centers
and sex educationin schools puts many young               and dispensaries. This communityparticipation
peopleat a disadvantage at greater risk from
                        and                               program built up with considerableeffort over
contractingdisease. A recent survey conducted             the last decade has now effectively ceased with
from the unit associated with the AIDS                    the goverrunent's recent decision to abolish
prevention program found that the age of first            outpatient fees-this undermined the domestic
sexualencounter was 15.2 years, and there was             revenuebase for thesecrucialoutreachactivities.
a minimumof 2.4 sexual partners per person.
The number of teenage pregnancies is also a
cause for alarm with some 10 percent having
children by age 17, and 35 percent by age 19
(Table 7.23).
                                                    -   293 -


          Table 7.23: AGE AT FIRSr CEaLDBEARING 1989, CUMULATIVE
                                              IN               PERCENTAGE


Local Government                                          Age (years)
Region                15       16       17              18      19         20       21       22       23    24


Banks/Torres           0        4        9          14            40       55       61       68       92    92
Santo/Malo             6       12       14          26            43       53       61       76       76    84
Ambae/Maevo            1        4       13          20            33       40       54       66       70    81
Pentecost              3        7        4           7            26       35       37       53       60    68
Malekula               9       13       11          22            36       45       62       62       76    81
Ambrym                 3        7        5          10            21       52       56       59       76    92
Paama                  0        0       14          22            32        8       73       63       43    64
Epi                    3        9       10           0            36       30       30       60       64    77
Sheperds               3       17       22          30            31       57       59       83       59    81
Efate (rural)         14        7       12          20            42       51       64       74       81    88
Tafea                  2        6       12           9            30       45       49       70       75    75

Loganville             0        3       12           9            30       45       49       70      75     75
Port Vila              2        7        7          21            30       40       52       68      65     75

Total                  4        6       10          19            35       46       56       67      73     81


Source: PlanningDivisionof Ministryof Health.


        EI. PROSPECTSAND OPITONS                                skin diseases and endemic malaria. A number
                                                                of other communicable diseases also present
7.89 As demonstrated above, the current                         health authoritieswith challengesover the 1990s
health scene in Vanuatu is significantlybetter                  includingdenguefever and gonorrhoea/STDs.
than the pattern of morbidity and mortalitythat
prevailed in the early 1970s. The infant                        7.91 While non-Communicablediseases are
mortality rate, which serves as a useful broad                  not major causes of morbidity or mortality at
gauge indicator of past achievementshas been                    present, it will become increasinglyappropriate
reduced from more than 100 per thousand live                    for health authoritiesto monitor their trends in
births in the mid 1970s to 45 per thousand in                   order to plan for low cost interventionswhich
 1989. Life expectancyhas risen from 55 years                                          3
                                                                impact on their spread.'
to 63 years over the sameperiod.
                                                             7.92 The continuedrapid rate of growth of the
7.90 Despite these gains, Vanuatu faces a                    population also presents a major challenge to
number of specific disease challengesover the                health authorities. With the populationgrowing
next decade which will need to be addressed in               at 2.8 percent per annum, down from the 3.4
order for further significanthealth gains to be              percent per annum growth in the 1970s, the
made. The still relatively high infant mortality             Total Fertility Rate remains high at 5.3,
rate is indicative of the continuing significance            presenting specific problems for the health of
of infectious and communicable diseases in                   both women and children associated with too
overall morbidity patterns. Morbiditypatterns                frequent births inadequately spaced. It also
thus continue to be dominated by pneumonia                   presents a strategic constraint to sustained per
(includingmoderateand severeARI), diarrhoea,                 capita economicgrowth.
                                                - 294 -


7.93 The Ministry of Health is, however,                  urban and rural services which can be utilized
faced with conflictingdemandsfor improvement              by the relevant implementing authorities for
in the curativehealth system (includingdemands            capital and maintenance costs, there is little
for sophisticated hospital equipment), the                prospectof developinga sustainableapproachto
extensionof accessto health servicesthroughthe            the provision of urban and rural water supply
provisionof furtherhealth infrastructurein rural          and sanitationservices. It is important that
areas while also extending and improving the              institutionaland policy issuespertainingto water
quality and effectiveness of its preventative             supplies and sanitation/waste disposal be
health program. There is also a major need to             resolved in order to address these financingand
develop human resources in the sector and                 sustainability issues.        The Government
reduce the extremely high dependence on                   recognizesopportunitiesfor interventionin both
expatriatemedicalofficersand otherprofessional            urban and rural areas.
and technicalstaff. This in a contextwhere the
budget for the Ministry of Health has been                7.96 The populations of Port Vila and
declining significantlyin real per capita terms           Loganville are expected to double in 8 and 14
(by 51 percent between 1982 and 1992) and                 years respectively. The existing urban water
dependenceon aid donors has increaseddespite              supply, sanitation and waste disposal systems
national political objectives of improving self           cannotmeet existingneeds let alonecater for the
reliance.                                                 anticipatedpopulation increase. In recognition
                                                          of these problems, the government of Vanuatu
7.94 Thus the choiceswhich must be made in                has developed a set of policy statements,
the health sector over the next decade will be            objectives and strategies for urban water,
within very severe budget constraints. While              sanitationand waste disposal for inclusionin the
there is a capacity to significantlyimprove the           1992-97developmentplan.
efficiency of the existing deployment of
resources (human and financial) in the sector,            7.97 With respect to water, the strategies
there is also a crucialneed to generateadditional         include: establishment of a Water Unit to
resources domesticallyfor health. A numberof              operate a revolving account to ensure adequate
options to improve the current situation are              replacement and maintenance of the existing
canvassed. Particular attention is focussed on            system; developing a long term plan for Port
the capacity to reduce dependence of the                  Vila and Loganville water resources; and
responsibilityfor health financing, particularly                           of
                                                          commencement a hydro-geologicalsurvey of
curativehealth, on the public fisc. While there           these cities' water resources. For sanitation,the
is a need for Government to significantly                 strategies include: adoption of measures to
strengthen its support of preventative health             reduce discharges from septic tanks and cruise
activities, a primary objective must be to                ships into Port Vila harbor; a standard system
encourage individuals to take on more                     for on-site sewerage treatment for new
responsibility for their own health. The                                 and
                                                          developments the design and constructionof
followingparagraphslist steps and options that            a reticulatedsewage system for the capital. For
might form the basis for a mediumterm strategy            waste disposal, the strategies proposed include;
to increase the degrees of freedom of policy              relocation of the present solid and hazardous
makers to improve the health status of the                waste disposal site in Port Vila; training of
population.                                               council personnel in waste management and a
                                                          public awareness campaign on waste disposal
7.95 Water and Sanitation. The key issue                  and its environmentalconsequences. A range of
concerningthe developmentof sustainablerural              studieshave been conductedon the relocationof
and urban water supply and sanitationprograms             the existing waste disposal site in Port Vila.
in Vanuatuis that of capital investmentand cost
recovery. Withouta regime of user chargesfor
                                               -   295 -


7.98 Authorities, however, need to carefully               7.100 The strategic issues which need to be
consider the financial viability of the                    addressedin this sector in both urban and rural
development of urban water supply and                      areas are well documented and understood.
sanitationsystems. On publichealth grounds, it             Progress towards resolving these issues is once
is essential that appropriate services are                 again linked to preparing an investment,human
developed in urban areas and peri-urban                    resource developmentand managementstrategy
settlements. The two large cities, particularly            for the sector which is affordable, and
the capital, are approachingcritical sizes where           environmentallyand economically sustainable.
an overall water and waste control systems                 There is a specific need for the Ministry of
under the controlof a single authorityshouldbe             Health to promote technical, social and
established. This should be approachedwithin               financially sustainable systems rather than
the context of a physical planning scheme                              the              of
                                                           emphasizing achievement physicaltargets.
designedto ensure all basic urban infrastructure           While the governmentshouldstrive to maximize
services can be provided optimally on a least              coverage, greater long term benefits will accrue
cost basis with cost recoveries.                           to a strategy which emphasizes sustainable
                                                           development through increased community
7.99 The rural water supply and sanitation                 involvement in the design, management and
program has been focussed on a strategy based              financing of rural water supply and sanitation
on the principlesof community  participationand            services.
management. While good progress has been
made in the installationof water supplies and to           7.101 In the development of its strategy the
a lesser extent with sanitation facilities,                Ministry also needs to examine the issue of
communityparticipationand managementhave                   servicing other rural sites. It is suggested that
been uneven, particularly in the area of                   the emphasisplaced on communitymanagement
maintenanceof water supplies. To address this              and financing of village water and sanitation
issue, the Ministry has formed a Maintenance               services may require some modification when
and AdvisoryTrainingTeam to educatevillages                planning services for schools, dispensariesand
on maintenanceissues and to train village and              health centers. Communitygroups are unlikely
local governmentcouncil plumbers/sanitarians.              to be able to bear the capital costs of financing
A study on maintenance issues has also                     and managing water and sanitationfacilities at
               a
recommended community-controlled       approach            these centers. It is also important that rural
accordingto which, communitieswould needto                 systems are not 'overloaded' by adding in
indicatethat they viewedwater as a development             institutionalneeds without carefully considering
priority and would undertake greater                       the capacity of the existing system. The
responsibility for management before they                  Ministry should investigatethe need and scope
receivedassistance. They should also indicatea             for a strategywhich deals specificallywith rural
willingnessto financeoperatingand maintenance              institutionalwater supply and sanitationneeds.
costs. The 1992-96Development     Plan for rural           It should also exercise care to ensure that funds
water supply and sanitation anticipates an                 previously designated for village water supply
extensionof coverageto 90 percent of Vanuatu's             and sanitation schemes are not diverted to its
rural populationby 1997. The Departmentplans               own institutionalneeds. It is also crucial for the
to provide 65 percent of rural householdswith              development of an effective health education
improvedtoilets by the end of 1996. This is to             strategy that these non-villageinstitutionshave
be achieved by: extending the present                      good systems in place for public health
Vanuatu-UNICEF Rural Sanitation Project;                   demonstrations as well as general cleanliness.
supportingthe functions of village sanitarians;            Promoting sound public health behavior in
and standardizing technologies to facilitate               schools and health facilities is clearly a sensible
village education, training, construction and              health educationstratagem.
maintenance.
                                                - 296 -


7.102 Health Education.           A significant           7.104 Attention also needs to be paid to the
proportionof the major health problems facing             school health educationsyllabus at both primary
Vanuatu are preventable through behavioral                and secondarylevel. While efforts to improve
change, albeitoften in associationwith physical           the current situation are ongoing there is little
investments such as waterand sanitationservices           effective communication between education
and other health service infrastructure. Vanuatu          authoritiesand health educatorsor commitment
has an understaffedand poorly resourcedhealth             to review the present health syllabus in schools.
education unit which is highly dependant on               A new emphasis needs to be placed on healthy
expatriate input to support inadequatelytrained           behavior, focussingon family and interpersonal
ni-Vanuatu staff.5        Currently without a             relationships, including sexual, diet, exercise,
significant aid-financed project, the unit is             road and occupationalsafety insteadof focussing
unableto plan and mountmajor health education             only on environmentalhealth.
campaigns. A strong commitment by the
Ministry through domestic financing of health             7.105 The high populationgrowth rate, and the
educationactivitiescould be an extremelycost-             relatively low prevalence of contraceptiveuse
effectivemethodof improvinghealth outcomes.               require special attention. The damage done by
Historicallythe Health EducationProgram has               the emotional debate over injectable
been very successful in obtaining community               contraceptivesa decade ago has to be addressed
participationin health delivery at the periphery.         squarely and rectified. A social marketing
Similar success is being seen with the                    programfor family planningwouldhelp resolve
distribution and use of insecticide impregnated           the problems.
mosquitonets for the control of malaria.6 In
addition recent social marketing programs in              7.106 Concernhas been expressedby clinicians
AIDS preventionand control seem to have been              in Port Vila that there is an apparent increase in
successful. The success of these programs has             the number of lung cancer cases presenting.
been largely because of external input. Thus,             The high prevalenceof tobaccouse indicatesthat
their sustainability and extension to other               more attentioncouldbe paid for health education
domestic health education priorities will be              programs in this area throughoutschools and the
dependent on the commitment of domestic                   whole community.
resources, financialand staff.
                                                          7.107 Health Services. In areas where road
7.103 It is importantthat all health cadresmake           and transportation are good, many peripheral
a sustained contribution to health education              health services are being bypassed, and patients
activities as an integral component of their              are presenting themselves at higher level
professional activities, and that these be                facilities including out-patientsat the hospitals.
supportedby the central health educationunit.             This has been clearly exacerbated by the
The use of social marketingtechniquescoupled              abolitionof user charges at Governmentowned
with a more effective use of peripheral health            health facilities. The perceivedbetter care to be
workers, supported by regular visits from the             obtained at higher level facilities (Nurse
health educators, could greatly improve the               Practitionersat health centers and better access
current situation. Traditional healers, after             to Medical Officers at hospitals) contributes to
appropriatetraining, could be of assistance in            this. These trends are having the effect of
many areas of the country, as a significant               overcrowding at some outpatient clinics and
proportion of the population attend these                 reducingthe cost-effectiveness other facilities
                                                                                          of
practitioners before making contact with the              due to reducedutilization.
formal health sector. Further many traditional
practitioners are also influential in traditional         7.108 In the climateof relativelylow case loads
villagestructures.                                        and incapacity to effectively conduct outreach
                                                          activities, many staff have lost their motivation
                                                   -   297 -


and do not remain at work for the completeday.                 of current proposals will be wastage of scarce
Administrative problems getting pays also                      resources,lack of coordinationbetweenstaff and
contribute to absenteeism. Both low staff                      programs and confusion over the roles and
morale and low case loads affect quality of                    function of service providers. Managementat
service. One major consequenceof low case                      districthealth servicelevel should not be split as
loads is that it contributes to a significantde-               proposed, as this will lead to conflictingsignals
skilling of health staff over time. Reasonable                 to staff at health institutions,addedcoordination
case loads and high morale can make a major                    problems and most importantly a requirement
contributionto service quality. The supply of                  for additional health managers not directly
qualityreferencebooks and manualsof standard                   contributing to service delivery. This would
or commontreatmentsfor all health cadres can                   come at a time when there are not only financial
also be an extremelysound support mechanism                    but also major human resourceconstraintsin the
for staff working without access to second                     system. Proposals to increase the number of
opinionsand other support.                                     districts from 5 to 13 would only magnifythese
                                                               problems, and would have the potential to
7.109 Of particular concern are proposals to                   completely undermine cost-effective health
establish 13 health districts to correspond with               delivery in Vanuatu and be a retrograde step.
local governmentareas. The centralpurpose of
the departnental headquartersoperationsshould                  7.111 The decentralizationof the social and
be to support the efficient and effectiverunning               economic functions of government is still,
of hospitalsand most importantlythe peripheral                 however, a relevant development issue.
health services. The central departmentshould                  Decentralizationof service functions does not
not be attemptingto manage directly individual                 have to be tied to the creation of a new
service delivery units; the core role of central               administrative system which absorbs the
health professionals should be to provide                      functions of the line agencies. Assuming
technical and policy support to field managers.                ministerial support, there is nothing to stop the
Where vertical programs are necessary, they                    Department of Health from deconcentrating
should be well coordinated with district                       selectedfunctionsand responsibilityfor revenue
managers. There should be deconcentrationof                    and expenditurecontrol to its line officers at the
management responsibilities within the                         district level.
Department. Hospital and health district
managers should be given responsibility for                    7.112 Once the transferred functionshad been
managingstaff and resourcesunder their control,                identified, a base-year financial allocation for
and should be accountable to the center for                    services couldbe calculatedfor each district or
generalperformance and health outcomes.                        health planning region.          This base-year
                                                               allocation would form the basis of an annual
7.110 It must be accepted that health                          grant for the operationof the service. The base-
professionalsat the sharp end of servicedelivery               year grant should be adjustedeach year by the
in dispensariesand health centershavedual roles                nationalgovernmentto keep pace with inflation
in terms of preventionand curativehealth. The                  and population increase. However, any
core of the primary health care approach                       significant expansion of the service would
advocatesthis, and it is not possible for these                requirejustificationwithinthe frameworkof the
roles to be separated in terms of staffingat the               national health expenditure plan and
peripheral health facility level. While it has                 district/healthregion priorities.
been stated that the reason for dividing the
current Departmentof Health into two separate                  7.113 If cost recoveryis to be encouragedas an
entities (with a number of concurrent functions                option for supportingand expandingtransferred
yet to be defined)was in order to emphasizethe                 health functions,a substantialproportion (if not
importanceof preventativemedicine, the result                  all) of the revenue collected should be retained
                                                 - 298 -


by the district health service. The Department             the coverage of family planning within the
of Financewouldneedto agree to revise current              country. Family planning should become a
provisions according to which most revenue                 strategicfocus of health care professionalsin all
generatedfrom governmentservices is directed               their activities. This will require a strong
towards consolidatedrevenue. Decentralization              emphasison family planning in the curriculum
of health functions in this manner provides an             of health care professionals and in training
excellent opportunity for national and district            programs for those already in the work force.
health personnel to review national health                 The profile of family planning should be
priorities against district health needs. A                increased in the health educationprogram.
commitmentto decentralizationof basic health
care serviceswould require nationalplannersto              7.116 Injectable contraceptives popular in
liaise with district health personnel on local             nearbycountriesand formerlyvery popularwith
priorities, service and budgetaryconsiderations.           rural women in Vanuatu are presently not
This interactionwould provide the basis for the            available in the country because of government
development of more informed district health               policy. The recent approval of Depro-Provera
plans within the context of national health                by the Federal Drug Administrationfor use in
planning objectives.                                       the United States may provide the basis for a
                                                           change in policy in this area by national
7.114 Maternal Healthand FamilyPlanning.                   authorities.
 One quarter of deliveriesstill take place outside
the supervisionof trained health workers. It is            7.117 Despite the lack of refrigerationin over
importantto improvethe coverage of the health              half of health institutions, the immunization
system in this respect. Specificallythere is a             coverage achieved is impressive given the
need to improve both the number of ante-natal              difficulties of terrain and dispersion of the
visits by pregnant women 37and the proportion              population. However,strong attemptsshould be
of women who attend post-natal medical                     made to extend coverage. Also of concern is
examinations. There is also a need to increase             whetherpast achievementsare sustainable. The
the proportion of women who have tetanus                   effectivedecrease in moneyfor transportationin
toxoidvaccinations. This could be achievedby               peripheral areas associatedwith the removal of
nurses checking records of patients and taking             fees for servicehas already seen problemsbegin
                   3
appropriate action, ' and by encouraging more              to occur in the capacity of health workers in
expectantmothers to present at health facilities           rural areas to undertake outreach activities. As
through a more active educationprogram and                 discussedabovethe proportionof time spent out
outreach activities. Some traditional midwives             on such activities is already relatively low, and
have been trained to support efforts in this               it is highly probable that those not currently
regard and to give improvedassistanceat births.            covered need to be reached in this manner.
However, there is not a strong traditional                 Further, whilegas refrigeratorshave been found
midwife system in many parts of the country.               to work better and require less maintenance  than
Traditionally women in labor are assisted by               kerosene-basedmachines, some difficulties are
their close relatives. Maternal anaemia is also            being experiencedwith getting gas to the health
prevalent and coupled with close spacing of                centers and dispensaries. As the stock of
children can have more severe consequenceson               equipment ages, maintenance can expect to
both the health of mothers and their new born              become more of a problem. In this respect, it
children.                                                  may be desirable to assess the performance of
                                                           solar refrigerators in Vanuatu, given they have
7.115 The high total fertility rates are clearly           been found to be successful in neighboring
affectingthe health statusof womenand children             countries.
and present a significanthealth problem to be
addressed. There is an urgent need to increase
                                                   -   299   -




7.118 Human Resource Issues. The cost and                        costs of training doctors in the Pacific 'rim'
effectivenessof any health system are highly                     countries, many of whom do not remain in
dependenton the levels, skillsand distributionof                 service, is significantly more expensive than
health workers. The tiered structure of the                      training in either Papua New Guineaor Fiji."'
health system and health staffing in Vanuatu
have taken this into account. However, recent                    7.122 Several ni-Vanuatu students have
developments are threatening the system's                        undergonetraining as Health ExtensionOfficers
effectiveness.                                                   in Papua New Guinea and are now working in
                                                                 the Vanuatu health system. One such graduate
7.119 There is a heavy dependence on                             has entered private practice in Port Vila. The
expatriate medical officers in Vanuatu, with a                   Health ExtensionOfficer qualificationis akin to
large amount of donor funding being allocated                    than of the degree in Primary Health Care
for this purpose.       The development and                      Practice as issued from the Fiji School of
distribution of standard treatment manuals will                  Medicine. This cadre together with the locally
lead to some conformityin the medicalpractices                   trained nurse practitioner play an importantrole
of these medical officers coming from differing                                     the
                                                                 in complementing work of medicalofficers.
backgrounds.        However, these differing                     Some have already had specialisttraining in the
backgroundslead to differing concepts in both                    specialistarea of anesthetics. A major effort to
clinical and preventative practices, which                       further improve the quality and number of this
become especially important when the officers                    cadreof health worker couldhave a large impact
have a role in supervising and teaching other                    on the quality of service provided and provide
cadresof health workers in the system.                           back up and even substitutefor medicalofficers
                                                                 in some areas.
7.120 In order to attract more ni-Vanuatu
school leavers to undertake training as medical                  7.123 The general nurse course has been
officers and to retain the graduates in the                      recentlyrevised so as to improvethe community
system, the paymentof allowancesfor overtime                     health orientation, as well as the clinical,
and "on call" periods worked should be                           diagnostic and treatment skills covered in the
investigated. The potential of "after hours"                     program. This is in part possible given the
rights of private practice could also be                         improved quality and numbers of secondary
considered. A number of specific postings of                     school graduates available for entry to the
returned ni-Vanuatu doctors (including those                     program. It is hoped to increase intake so as to
with post graduate training) have been                           graduate 15 students each year from the course.
inappropriate.' The bonding of students sent                     It is importantto develop a strong commitment
                         and
both for undergraduate postgraduatetraining                      to a primary health care approach to nursing
should be instituted. It may also be possible to                 educationin Vanuatuthat gives highestpriority
reach agreementwith neighbors(e.g., PNG and                      to developing skills relevant to public health
Fiji)that they will not recruit ni-Vanuatudoctors                nursing in rural areas.
trained in thesetwo countries,at least until they
have fulfilledtheir bond.40                                      7.124 As part of the Primary Health Care
                                                                 Program, the Aid Post became the front line
7.121 The government is now planning to                          provider of health services in Vanuatu and the
concentrate medical officer training at the Fiji                 Village Health Worker was highly sought after
School of Medicine, and to utilize the                           by most village communities. The Nurse
intermediatequalificationof the Primary Health                   Education Center is also responsible for the
Care PractitionerDegree to improvethe quality                    training course for the Village Health Workers
of the nurse practitionercadre. This is strongly                 who staff the Aid Posts. Discussions are
supported,both on relevanceto health problems                    underway to improve the quality and relevance
of Vanuatu and on cost-effectivegrounds. The                     of training and extend the program from 8
                                                - 300 -


weeks to 12 weeks. Particular attentionshould             vehicle to discourage unsafe or inappropriate
be paid to growth monitoring, immunization,               traditional practiceswhere these exist. In many
first aid, basic midwifery, family planning and           areas, traditional healers could be harnessed to
health educationtogether with options to reduce           treat and prevent disease and to encourage
the costs of current training programs and make           patients to present early.
them more community based.       42  While not
coveredin the past, they should also be seen as           7.127 Village Organizations and Local
agents for change and encouragementof water               Government Councils. While there have been
supply/sanitationprograms and their optimal               significant efforts in the past to develop
use.43                                                    women's committees and other village-based
                                                          organizations, most have not been effectively
7.125 There have been manyproblemswith the                sustained. This in part results from the rapid
paymentof these workersby their communities,              changestaking place in many village structures
especially after the government decided to                and reduced cohesion resulting from increased
abolishfees at higher level health facilities. If         mobilityand socialchange. There has also been
the Aid Post system is to survive efforts to              a lack of support from centralauthorities. Thus,
improve training of the Village Health Worker             women's committees are not very strong and
must be sustained and the fee structure in the            together with Primary Health Care Support
health service reinstated. There is little doubt          Committeesare decreasingin importance. This
that in dispersed and isolated Vanuatu                    is also due to changes in fee collection.
communities, a system of Village Health                   Leadership and commitment to community
Workers has the potential to provide crucial              participation must come from the central
health services that cannot otherwise be cost-            government level if these changes are to be
effectively delivered. Experience from other              reversed.
countrieshowever indicatesthat reliance on the
communityto pay peripheral health workers is              7.128 The abolishmentof the head tax, the key
fraughtwith uncertainty,unless there are strong           revenue source under the control of local
village-based management systems. Bringing                councils, and the lack of central government
such workers into the governmentpayroll, as is            support has resulted in an inability to provide
the case in some neighboring countries would              many services in rural areas. Many sanitarians
add an extra burden on already strained                   have now been put out of work as a
resources. The possibility of granting small              consequence. This has the potentialto threaten
subsidies could be investigated as could the              the sustainability of the water supply and
possibilityof havingthese workerschargingfees             sanitation program without action by the
for their service.                                        Ministry of Health to find other mechanismsfor
                                                          their financing. It is unlikely that local
7.126 Traditional Healing. Many people in                 governmentwill be in the position to materially
Vanuatuuse traditional healers to complement              support the Village Health Worker scheme.
the treatment they receive from the government
health services. In some areas, traditional               7.129 Health Financing. The health system in
healers are consulted in preference to their              Vanuatu faces significant resource constraints
government counterparts. Because traditional              and is highly dependent on donor financing in
practice varies so much from healer to healer             both curative and preventive services. In the
and from area to area, the governmenthas had              1980s, revenuesfrom the sector covered only 6
difficultyintegratingthe two groupsof practices.          percent of recurrent expenditurebut even this
There is, however, scope to encourage health              has been undermined by the abolition of most
workers to work cooperativelywith traditional             fees for attendance at outpatient clinics, with
healers in their local communities. This could            revenues now only representing 1 percent of
significantlyimprovehealth care, and provide a            expenditures. The government has relied very
                                                 - 301   -



heavilyon donor supportfor the developmentof                 both financial and human. These are discussed
health infrastructure and its maintenance.                   below.'
Donors have also been responsible for most
initiativesin strategicallyimportantpreventative             7.131 ExternalAid, HealthPlanningand the
health programs. Further, Vanuatu is also                    Need for a Public Investment Plan. The past
allocatinga significantproportionof the budget               lack of a strategicplan for the health sector has
to health, and funding requirements for the                   alloweddonorsconsiderablepiecemealinfluence
sector will continue to increase because of the              on health directions and meant that domestic
followingreasons. First, the existingsystem is               resources have not been strategicallyfocussed.
experiencingrecurrent budget and maintenance                 The recent preparation of a National Health
underfunding relative to needs to ensure                     DevelopmentPlan is a useful first step and will
sustainability. Second, there is a need to further           providea basis for a policydialogue with donors
develop access to health services through                    and with the Ministriesof Planningand Finance.
infrastructuredevelopmentin rural areas. This                There is, however, a need to further improve
will also add to recurrent budget needs of the               and develop the planning capacity within the
sector. Third, the growth of chronic diseases                health sector. The current unit is inadequately
will increase the resource requirementsof the                staffed and highly dependent on expatriate
curativehospital system. Fourth, Vanuatuwill                 support. Further it is not fully integrated into
need to become increasingly responsible for                  the budgeting and policy making frameworkof
funding of existing efforts. This includes the               the Department. The recent decision to create
curativesystem, whichreceivessignificantdonor                two Departmentsleaves planningand budgeting
support through infrastructure and staffing                  as a concurrent function, with very confused
assistance, and preventativeprograms.                        lines of communication, management and
                                                             coordinationwithin the Ministry.
7.130 The challenge facing the Ministry is to
maintainthe existingsystem, improve its quality              7.132 The coordination and planning of new
 and extend basic health services to less well               projects and programs and the establishmentof
 served areas of the country, while also taking              strategic policy and program options and
 increased responsibility for recurrent costs                priorities for the Ministry should reside in the
 currently financed by donors. For these                     PlanningDivision whetherdonor funded or not.
reasons, Vanuatuwill need to explore financing               Fundamentally, there is a need to establish a
options open to it. As discussed, there is now               three to five year public investmentplan for the
little cost recovery in the system currently as a            sector which takes account of the recurrent
consequence of the recent decision on fees.                  budget resource constraintsand which can form
Vanuatuhas gone from one of the highestlevels                the basis for joint financing by donors and the
of cost recovery in World BankPacific Member                 Government. The success of such a process is
Countries to one of the lowest."             The             cruciallydependenton the strategic involvement
reinstatement of fees clearly provides a                     of health program and district managers in the
significant option for increasing the resources              process."
available to health. Other financing options
should also be considered. These include                     7.133 The health plan and public investment
improved use of external financing, targeted                 program shouldestablishhealth sectorpriorities,
import levies, promotion of private sector                   programobjectivesand outputs and be based on
development,includingthe explorationof health                a rigorous analysis of morbidity and mortality
insurance options, partial reinstatementof Non               patterns, their trends, technical options for
GovernmentInstitutions (particularlymissions)                             and                      in
                                                             interventions their cost-effectiveness order
in the running and managementof health service               to justify the strategy adopted. An integral
facilitiesand improveduse of existingresources,              component of this process would entail the
                                                             putting in place the management and human
                                                 - 302 -


resource development implications of the                   appropriateto charge for immunization other
                                                                                                    or
                                          within
strategyas well as the capital implications                preventative activities since the benefits from
the contexiof an expenditure    plan which aligns          such services accrue to individuals only, often
recurrent and developmentexpendituresto the                over a long period of time. In many cases, the
plan. This is currently lacking in the Health              benefits of these programs accrue to the
Plan, partly becauseof the lack of integrationof           community and individuals only if everyone
the planning, budgeting and policy making                  participatesin the program. One cannot charge
functions within the Ministry. Thus while the              the full price for "public goods" where the
recent planning effort represents a significant            benefits "spill-over" to other individuals. On
step forward, the Ministry still lacks a                   thesegrounds, it is thus appropriateto subsidize,
framework to guide the development of an                   for example, some fees for sanitationservices
 investment program which targets priority                 because immediate benefits accrue to the
programs and provides the basis for the                    individual but the full benefits to society only
formulation of coherent management, human                  derive if the whole communityparticipates.
resource and recurrent budget support of the
departmentallyagreed priorities.                           7.136 The level of charges should be set with
                                                           clear objectivesin mind. A principalobjective,
7.134 Cost Recovery.             An increasing             in the Vanuatu context, is to raise additional
proportionof the economically   activepopulation           revenue to sustain and extend the level of
are now participating significantly in the                 servicesprovided. Second, fees signalthat real
monetized sector of the economy. Thus most                 resources are being used to provide services.
householdshave access to cash incomesand are               Individualswill carefully consider the need for
in a positionto makesome contributionto health             a service (e.g., drugs) just as they purchase
revenues. Tle reintroduction of reasonable                 other items for consumption. On the other
patient fees, payments for drugs and other user            hand, payment of fees raises consumer
charges is feasible on equity, efficiency and              expectations about the quality of service they
affordability grounds. The population has                  will require from providers. A fee collecting
historically accepteduser changes in the social            health service has to respond to the needs of the
sectors in Vanuatuwith familiesand individuals             consumersrather than to the convenienceof the
paying significant fees for both educationand              supplierof the service. The motivationof health
health services. In the health sector, payments            staff can be significantlyimproved at the local
(gifts) have always been given to traditional              level if revenues are collected and (at least in
healers and birth attendants. A significant                part) used at the point of collection to provide
proportionof expectantmothers have continued               additional resources for staff to supply quality
to pay for hospitalizationfor births in order to           health services. Clients of health facilities
have access to quality care, a clear indication            (particularly if there are community groups
that there is an effective demand for quality              involved together with the health staff in the
services. Further, it is difficultto see how the           managementand operation of peripheral health
Ministryof Health can progress towardsa more               facilities) can also see how the resources are
sustainable health program without the                     being used in their interest.' Fees can also be
reinstatement user fees for out-patientservices
               of                                          used to improve the efficiency of service
and drugs.                                                 deliveryby encouraging   better referral practices.
                                                           Thus an important option available to health
7.135 A key questionis what should be priced               authoritieswould be to charge a premium for
and how should charges be determined? From                 individualsbypassingtheir designateddispensary
first principles, it is appropriateto collect fees         or health clinic without an appropriate referral
for goods and services(e.g., medicines,sutures             from their local health worker.'
and surgery) which yield a direct and immediate
therapeutic benefit to the individual. It is not
                                                  -   303 -


7.137 Discussions with dispensary and health                  reintroduction of fees according to 1986 fee
clinic staff suggest a fee of Vatu 30 - 40 for                schedulecould thus be expectedto generatethis
basic medicineswould be consideredfair. 9 It                  as additionalrevenue. If the level of exemption
may be appropriate to charge lower fees in                    was reduced to 20 percent total additional
remote and/or less developed areas. Further,                  revenues could be of the order of Vatu 52
local communities and health staff have the                   million with the reintroduction of fees. Any
ability to establish fee remissions for the                   increase in the fees to account for inflation
indigent. It is importantthat charges for drugs               would result in further revenues. It should be
shouldbe on the basis of the required course of               possible to generate at least Vatu 80 million in
drugs and not on a daily or per tabletbasis as it             current prices which would represent about 15
is crucial that treatments are completed on                   percent of the 1993budget allocation.
medicalgrounds and that health servicesdo not
get a reputation for treatment failures resulting             7.140 Import Levies. As a policy option,
from non-completionof drug therapies. This is                 import taxes and duties or excises on sugar,
particularly important for antibiotics where                  tobacco and alcohol related products provide a
resistance can be encouraged through non-                     potential basis for raising additional revenues
completionof drug courses.                                    and curtailing consumption in the interests of
                                                              both the health status of the population and the
7.138 For in-patientcare at hospitals,dailybed                productivity of the work force. For a given
 chargescouldbe indicatively at Vatu 600 per
                              set                             level of income, increasing the price through
night for adults (children Vatu 200 and infants               higher duties may result in a reduction in the
Vatu 100) in general wards, with specific                     amount consumed.          Further, since price
charges for food, laboratory tests,                           elasticitiesare generally less than one for the
pharmaceuticals,  X-rayfilmsand surgicaltheater               commoditiesunder consideration,revenue from
services. Outpatientfees could be set in the                  import duties will rise, without a concomitant
range of Vatu 100to Vatu 150dependingon the                   drop in the amount consumed. Thus, in effect,
location of the facility. These suggested                     the country would be raising additionalrevenue
indicativefees wouldonly be marginalincreases                 from those most likely to fall ill from the
relative to the fee schedule establishedin 1986               additionalconsumption. This actslike a specific
(and abolished in 1992) although the implied                  "health tax" even though the tax may not be
exemptions are significantly less than those                  directly earmarked for the health sectorper se.
embodied in the 1986 fee schedule which
effectively exempted 50 percent of the                        7.141 In the context of a country without
population, i.e., children under 14 years and                 income taxes, it is difficult to make direct
those over 60 years. It is recommendedthat the                comparisonsof duty rates on these items with
modifiedfees be reinstated,and that provision is              other countries. In 1990, revenue raised from
made to adjustfees on a regular (annual)basis in              import duties and excises on sugar and related
a mannerthat ensuresmodestreal increasesover                  products, alcohol beverages, and tobacco was
the decade.                                                   about Vatu 735.7 million. If the current duty
                                                              rates were increased 10 percent additional
7.139 Total health receipts are calculated on                 revenues of Vatu 79.1 million would be raised
potentialinpatientand outpatientrevenuesusing                 for the Governmentbudget (Table 7.25).
the 1990 patient loads (Table 7.24). Based on
the standard fee established for these services               7.142 More generally, government should
(without exemptions), the total potential                     consideradjustingthe relative structure of duties
recoverable revenue amounted to Vatu 64.9                     and chargesto encouragebetter (nutritious)food
milliongivenrecordedusage rates. With the 50                  consumptionpatterns within the population. It
percent fee exemption, the amount collected                   is also important to develop appropriate
should been about Vatu 32.5 million. The                      incentives to encourage diversified domestic
                                                   - 304 -


                  Table 7.24: INPATIENTAND OUTPATIENTPoTENTIAL REVENuE, 1990


                                                                                                     1990
                         No. of      Bed        Unit             Potential       With 50%           Actual
RevenueSource            Patients    Days      Rev./a            Receipts        Exempts. lb      Receipts /c


Inpatients
Vila                       3,669      22,268        600           13,360,800         6,680,400
Santo                      2,899      19,216        600           11,529,600         5,764,800
Other Hospital/
Clinic                     5,344      28,445         200           5,689,000         2,844,500

Total Inpatients          11,912      69,749                      20,579,400        15,289,700

Outpatients
Vila                      33,200                     100           3,320,000         1,660,000
Santo                     15,955                     100           1,595,500           797,750
Other Hospital/
 Clinic                  294,301                     100          29,430,100        14,715,050

Tota] Outpatients        343,456                                  64,925,000        32,462,500     26,703,602


Source: Ministryof Health and Mission estimates.

/a   User Chargesbased on 1986average estimates.
/b   Assumes50% exemptions(includeschildrenunder 14 years (45%) and adults over 60 years (5%).
/c   Actual revenueis total includingrevenue from X-rays, Dental, Laboratoryand Drugs.



production and marketing of food crops for                   of the proposed insuranceplan and the level of
domestic consumption, particularly in urban                  premiums which must be collected from the
areas such as Port Vila and Loganville.                      potential beneficiaries. The scope of services to
                                                             be covered, at least initially, should be
7.143 Health Insurance.        This is a health              consistent with the basic insurance principle of
financingoption which could be consideredfor                 coveringexpensiveinfrequenteventsand limited
furtherdevelopment. Optionsexistto encourage                 to inpatient secondary and tertiary care. This
private insurance for catastrophic illness                   type of insurance coverage would be relatively
requiring medical evacuation as well as                      easy to implement (relative to payment for
hospitalizationwithin Vanuatu and should be                  ambulatorycare at private doctors and drugs and
offered to those in the formal sector of the                 for Government services that are charged for)
economy. A possible approachwouldentail the                  since it would not involve the processing of a
Governmentundertakingthe following. First, a                 large number claims. It would be a mistake to
cost findingstudy is neededin order to establish             attempt to cover low cost and frequent events
the fee structure which allows for full cost                 such as outpatientvisits. This would be better
reimbursement of services provided by the                    handled by appropriate user charges.           The
Ministry of Health facilities and staff. Second,             National Provident Fund         would be        an
there would be a need to determine the benefits              appropriate vehicle to act as a collection agency
                                                       -   305 -


                         Table 7125: ESTIMATEDANNUALGOVERNmENTREVENUE
                     FROMIMPORTDurIEs AND EXCISE FROMSUGAR, ALCOHOLAND
                            TOBACCO-RELATED PRODUCTS(1990 DATA)


                                                                          Implied/         Total         Additional
                       Value of                            Duty/          Average       Revenues          Revenues
                       Imports         Quantity            Excise          Duty          Collected       From 10%
Item                  (Vt. '000)      of Imports           Rate /a        Rate %        (Vt. '000)       Increase /b


Sugar & Related
Products               110,376                     -        50%                            55,188            11,038

AlcoholProd.
Imports                248,721         1,290,536 It     Vt220/lt           114           283,918             28,392
Domestic Beer                            814,100 It     Vt 60/lt           n.a.           48,846              4,885

Tobacco & Rel.
Products                76,590          42,664 kg      Vt8,150 kg          454           347,712             34,771

     Total             435,784                                                           735,664             79,086


Source: National Planning and Statistics Office, Ministry of Ffinance and Mission Estimates.

/a     Includes import duty rate and service charge of 5 percent. It = liter; kg = kilogram.
lb     Specified as 10 percent increase in the specific duty/excise rate. Results in 10.75 percent increae in total
       revenues.



for a health insurance scheme as it currently                      to the health care of the population. The
collectsfundsfrom all employeesin the country.                     reintroduction of user fees (advocated above)
Efforts could be made to explore collection                        may encourage more consumers (and
vehicles such as local government councils for                     practitioners) to enter the market for medical
those in rural areas, but the primary focuswould                   services and stimulate development of private
be the formal sector of the economyinitially.                      insurance.

7.144 Private Sector. The scope for the                            7.145 Considerationof the role and functionof
private sectorto expandin the future will in part                  the private sector is often limited to the role of
be related to the nature of services able to be                    medicalofficers,dentistsandpharmacists. This,
effectively provided by the public sector, the                     however, is a very restrictive perspective and
direct costs of publicly provided medical                          does not seem appropriate in the context of a
services and the niche market (or specialty)                       health system which is almost completely
within which individual practitioners operate.                     dependenton other professionalcadres-nurses,
There do not seem to be any significantbarriers                    nurse practitioners,health extensionofficersand
to entry of medicalofficersto the private sector.                  village health workers-who currently work
There is, however, a need for the recognitionby                    without the direct supervision of medical
the Ministry of Health of the positive                             officers. With a clear delineationof the range
contributionan activeprivate sector couldmake                      of medical problemswhich can be addressedby
                                                 - 306 -


the different cadres and the establishment of              responsibility in a number of multi-staffed
standardtreatment protocols,there is no reason             facilities between outpatient and MCH services
not to encourageall cadres to enter the private            has resulted in inefficientstaff utilization. This
sector. In Vanuatu, the Village Health Worker              may have implications for training of staff
is alreadyeffectivelyin the private health sector,         postedto rural facilities, e.g., ensuringthat they
providing a crucial service which the public               have skills in nursing and MCH as well as
sector is unable to effectivelyundertake. It may           diagnosticskills. There may also be a need for
be that if other health professionals were                 health professionalsin some areas to be female
encouraged to enter private practice in an                 in order for MCH servicesto be acceptable.
innovative manner, they would be able to
address the supply of services in some areas not           7.148 Third, significant cost savings could be
currently serviced and indeed may be able to               achievedby reducingthe capacityof the hospital
take over responsibility for health service                system. Occupancy rates at all hospitals are
deliveryin areascurrentlyservicedby inefficient            significantlybelow capacity and it is probable
public sector facilities. Such an approachwould            that current staffing patterns are larger than
require registration procedures to be codified             required in a more efficient cost-effective
and other potential barriers to entry to the               structure of facilities. At least two of the
private sector to be addressedby the Ministryof            hospitals, Lolowai and Norsup, should be
Health. The Ministry would also need to                    downgraded to health center status.' It is
develop appropriate inspectorate/quality                   probable that careful review of cost-effective
assurance programs for both the public and                 options would conclude that with the
private sector.                                            establishment of emergency evacuation
                                                           procedures (which are basically in place now),
7.146 While there is not likely to be a rapid              all three district hospitalscould be managed by
changein the compositionof healthcare delivery             Health ExtensionOfficers/NursePractitioners.
between the private and public sector, a clear
signal for its developmentwould possibly both              7.149 Finally, reintroduction of charges for
reduce the burden of health care to the public             drugs would reduce consumption, both in
fisc and improve access to health services                 hospitals and rural health facilities, without
throughoutthe wholecountry. Anotherpotential               affecting the quality of treatrnent of patients.
role for the private sectorwouldbe for specialist          Increases in drug use in 1992 by as much as 50
medical officers (particularly ni-Vanuatu                  percent in rural facilities and 30 percent in Port
specialists)to be encouragedto enter the private           Vila hospital following the removal of fees
sector and employedon a sessionalbasis in the              points to sustainabilityissues (the drug budget
public system when their skills are required.              was Vatu 35 million in 1992) and waste/
This may enable ni-Vanuatuspecialistincomes                inappropriateuse of drugs." It is also crucial
to be increased while guaranteeing specialist              on health groundsthat drug use does not become
skills for the public sector.                              too high as this can contributeto the emergence
                                                           of drug-resistantillnesses.
7.147 Improved Efficiency of Existing
Resource Use. The Ministry of Health has a                 7.150 Health Planning and Information
numberof options to realize cost savings. First,           Systems.      The planning, evaluation and
a careful mapping of existing facilities with              establishmentof priorities and the subsequent
catchment areas is likely to reveal that some              monitoringof the health situationdepend on the
rural institutionscan either be downgraded or              availabilityof relevant and timely information.
closedwhilestill maintainingsatisfactoryservice            Timely information is also crucial for public
levels. Second, a significantnumber of rural               health managers to direct field operations in
health facilities are over-staffed relative to             responseto specificdiseaseout breaks. There is
current work loads. The current division of                an absence of useful summary informationfor
                                                 - 307 -


decisionmakers. At the facilitylevel, little use           Departments and Finance and within the
is made of informationgeneratedto effectively              Departments. Although the new Health Plan
influence local programs and there is no                   states that preventativeprograms should receive
feedback of informationfrom the nationallevel               a high proportion of expenditure, this is not
to the periphery. The quality of the information           taken into account in the budgetary allocations.
collected is suspect partly because all health             Health policy decisionshave been made without
workers know that under current arrangements               first considering the ramifications, and health
very little is done with the data. There is also a         service delivery and communityattitudes have
differencein the type of informationcollectedat            been adversely affected. Although Districts
the hospitals and that at the health centers and           receive allocations on an annual basis and are
dispensaries, with the two systems of data not             generally in charge of their expenditures, they
being comparable. The Aid Post is outsidethe               havevery little inputinto budgetaryformulations
reporting system. There is a need to review                and allocations. There is a need to integratethe
what is necessaryto be reported and how best to            recurrent budget and the donor financed
collect this information.          The District            development budget. The coordination of
Supervisorsshould be brought into the analysis             budgetary procedures is going to be more
of the reports so that they can take immediate             difficultif the proposed "two department"health
action on problems in their area.                          structure is continued with.          Qualitative
                                                           improvementsin the information,planning and
7.151 Athigherlevels, currentbudgetprocesses               budgetaryprocess at each level, will be crucial
lack a policy base, both between the                       to the long term successof any health strategies.
                                               - 308 -


                                              Endnotes


1.    The latest census was in 1989, when the enumerationwas 139,475.

2.    Groups of localitiesin areas of dispersedsettlementusuallybased on group affiliations.

3.    Inter-sectoralinfrastructureplanningis neededin Vanuatuto encouragethe developmentof larger
      rural settlementswhich in turn enablesome economiesof scale and thus relativelyefficientdelivery
      strategiesto be developedover time.

4.    At independence,adult literacy was estimatedat 13 percent, and there were only 10 ni-Vanuatu
      universitygraduates.

5.    Vanuatu has a Public Services Commission charged with recruitment, posting and staff
      development responsibilities, but it operates with significantly less autonomy than similar
      organizationselsewherein the Pacific.

6.    The 1986 Urban Population Census indicatedan infant mortality rate of 20 per thousand for the
      combinedpopulationof Loganvilleand Port Vila.

7.    Reportedannual deaths accountedfor about 40 percent of estimatedtotal deaths in the late 1980s.
      It is highly probable that there is a higher level of neonatal deaths among those not born under
      medical supervisionand thus reported.

8.    Data on disease rates for Vanuatuare available using two separate disease classificationsystems
      which also have differing coverage. The key data on morbidity patterns from each data base are
      presented in Tables 6.4 and 6.5.

9.    A further 9 percent was accountedfor by injuries.

10.   The transfer of patients internationallyconsumesa considerablelevel of resources, particularlyof
      the aid budget.

11.   There has been speculationthat at least some of the rheumaticfever has its origin associatedwith
      infectionof the skin rather than the throat. Experience in other Pacific Islands strongly suggest
      that this disease may become more prevalent.

12.   Sarda, WHO (1989).

13.   Maker et al, WHO (1991).

14.   Wong, WHO (1991).

15.   Mimeo,WHO/SPC (1985).

16.   Missioncommunicationwith chief public health physician 1992.

17.   Wallis, WHO (1992).
                                               -   309 -


18.   Following independencein 1980, the Government passed the 'Decentralization Act" which
      establishedthe Departmentof Local Governmentand eleven local governmentcouncils. The role
      of these councilswas to enhancelocal level administration,facilitatelocal participationin decision
      making and to promote social and economicdevelopmentrelevantto local needs. While the Act
      was a significant step forward in encouraging a regional approach to development planning,
      councilshave only limited powers to generatepolicies, raise revenue and enact laws and do not
      have the capacityto undertakethe rangeof responsibilities
                                                              they were originallyenvisionedto have.

19.   A typical aid post has one room for treatmentand a cupboardto store Government-supplied
                                                                                            drug
      supplies.

20.   A British aid project is currently assisting a number of facilities in this regard, and major
      developments in telecommunicationsover the next few years are expected to improve
      communication  options for a significantnumberof health institutions.

21.   Prior to independence,limiteddental serviceswereprovidedby missionsand visitingdental teams.

22.   Health ExtensionOfficers have been trained in Papua New Guinea.

23.   Pre-requisitesfor entry to the programs are completionof Form 5 with better than average grades
      in Mathematics,Science and English or French, and a minimumage of 18 years.

24.   This estimate includes fees paid to private medical and dental practitioners and out of pocket
      purchasesfrom the populationin privatepharmacies,but excludestraditionalhealers and expenses
      associatedwith travel to and from medicalcare centers.

25.   National Study of Health Sector Expenditureand Financing and National Financial Master Plan
      for Health 1987-1991,E.P. Mack and O.R. Small, WHO, 1987.

26.   This problem is endemicin Vanuatuand in neighboringcountries. During the last development
      plan period, the 72 expenditureunits within Governmenthad 2,500 projects with more than 600
      remainingactive.

27.   Administratively all donor assistance is included in the development program. However
      functionallya significantproportionof the funds are of a recurrentnature and will eventuallyneed
      to be absorbed into the government'soperating budget.

28.   March, WHO (1987).

29.   Yadrav, WHO (1991).

30.   The expatriate communityhas access to the Port Vila Central Hospital which generally had a
      relativelygood servicefor out-patientand in-patientservices. They generallypay a premiumover
      the ni-Vanuatuscheduleof fees but they do not cover the full costs to the Ministry of Health of
      providing services.

31.   The Health Extension Officer was trained in Papua New Guinea where such graduates are now
      permittedto establishprivate practice.
                                                -   310-

32.   The visits per capita to seek outpatienthealth services would be considerablyhigher than this, if
      all visits to village-ownedhealth posts and private sector practitioners were also included.
      Unfortunately,there is no data availableto documentthis, but if every VillageHealth Worker was
      seeing only two patients per day (one-thirdof the average for a dispensary)then the number of
      visits per capitaper annumwould be more than 3.1.

33.   For example,the poster and leaflet program is funded by the South Pacific Commission.

34.   For example, it should be noted that heart valvular damage (believedto be causedby rheumatic
      fever) is the main reason for patienttransfers overseas (a significanthealth expense, albeit funded
      by donors). Preventativeprograms are technicallyfeasible at significantlyless expense.

35.   The head of the unit is scheduledfor overseas training in 1993 which means that near term ni-
      Vanuatucapacityto manage the program is extremelylimited.

36.   The impregnated malaria net program is currently being trialed with encouraging preliminary
      results. The program, however, will be crucially dependent on changingni-Vanuatubehavior,
      though health educationcampaignshave the potential to make a significant contributionin this
      regard.

37.   The Departmentof Health currently recommendsthat there be 15 ante-natalvisits per pregnancy.
      In 1988, it was estimatedthat there was an average of four visits per pregnancy.

38.   Dependingon the numberof doses (if any) previouslyadministered.

39.   Includingthe deploymentof a trained public health specialistto treat outpatientsat a hospital.

40.   Those studying under scholarshipsfrom major bilateral donors have to return to Vanuatu upon
      graduation. However, graduates can then apply to migrate to a numberof countries.

41.   It costs 3-4 times more to train doctors in Australiaand New Zealandcomparedto training in Fiji.
      Tlhus, for the required budget of SUS 1 million to train five doctors in rim countries, enough
      doctors to localize all medicalofficer positions in Vanuatu at present could be trained in Fiji.

42.   For example,traineescurrently receiveper diems far in excess of paymentsthey can expect while
      working.

43.   The new task-orientatedsyllabusfor CommunityHealth Workers as taught in Papua New Guinea
      may provide a useful model.

44.   On the other hand this study argues on equity and efficiencygrounds that the levels of cost
      recovery in the Pacific should be increased.
                                                -   311 -


45.   Health financingin Vanuatuhas been the subjectof three detailed reviews by WHO (Mach 1987,
      Ro 1990, Yadav 1991). The Mach report detailed a series of revenue and expenditureplanning
      initiativesto improvethe status of health planning and financingincludingthe potentialto involve
      the private sector; encouragemissionarygroups to take back nationalizedhealth services; expand
      the role of Local GovernmentCouncilsin the provision of health services; improvemanagement
      of revenuecollection. On the expenditureside, recommendations   were made to periodicallyreview
      the cost effectiveness individualhealth serviceswithin each cost center to facilitatecomparison
                            of
      of service delivery and apply the findings of the cost effectivenessreviews to effect changes in
      personneland operationalcost utilization;introducecost accountingand improvedrecord keeping
      for cost effectivemanagement;and improvehuman resource management.

46.   Yadav (WHO, 1991) identifiedthe lack of involvementof cost center staff at the district and
      national level in the budget cycle as a major impedimentto the improvementof health planning
      and budgeting. He also recommendedthat programperformance budgetingshould be introduced
      to each of the cost centers. It is noteworthythat the 1993budgethas been prepared with minimum
      consultationwith cost center staff at the district and national level as well as virtually no
      involvementof those producing the Health Plan. Furthermore, the Department of Finance's
      instructionsto reduce operationalexpenditureby 10 percent were applied across all cost centers
      with no attempt to prioritize the cuts.

47.   Vanuatuhad a revenue sharing arrangementat the health facility level. Field visits suggestedthat
      the communitiesappreciatedthe benefitsof retainedrevenuesand clearlyunderstoodservicelevels
      had declinedwith the abolitionof fees.

48.   At hospitals,Health ExtensionOfficersor Nurse Practitionersshouldscreen those patients coming
      to outpatient clinics without referral. Significantpremiums should be charged for the right to
      bypassthis level of health professionalto a Medical Officer, as the current opportunity cost of a
      15 minute consultation with a MedicalOfficeris of the order of Vatu 700 to 900 for salariesalone.

49.   During field visits, the vast majorityof health staff indicateda strong belief that fees should be
      charged with some concern expressed at the wastageof drugs since fees were abolished. There
      was also clear evidencefrom the field that many individualswere spending considerablemoney
      to bypassVillageHealth Workersand aid posts to unnecessarilyattenddispensaries,health centers
      and hospital out-patientsin order to now take advantageof the "free" health service.

50.   A decision was taken in the last developmentplan period to downgradethese facilities, but as a
      consequenceof an electionpromisethe new Governmentreinstatedthem to hospital status.
51.   There had been no indicationthat past charges for drugs were precluding access to appropriate
      treatment.
- 312 -

				
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