Problem: Health services are inadequate for people in rural areas. 80% of the population lives in rural areas and islands with weak health infrastructure; 73 out of 86 doctors are based at the National Referral Hospital; public perceptions of service quality results in large numbers of people travelling long distances to the national hospital for primary health services. This skews optimum allocation of the hospital’s resources including staff time.
Solution: To achieve effective coverage of services, Role Delineation Policy (RDP) was developed following extensive consultation. The RDP defines service delivery packages for six levels of health facilities: rural health centres, area and urban health centres, general hospitals and the national referral hospital; successful advocacy led to inclusion of Universal Health Coverage in the National Development Plan, and to Role Delineation being the central unifying feature of the National Health Strategic Plan, 2016-2020, based on initial implementation experiences, the RDP was revised and will be sequentially will be implemented in rural provinces commencing in 2017.
Description of practice
The Solomon Islands’ 670,000 people rely on a nurse-run provincial primary care system, which addresses communicable and non-communicable diseases. However, while 80% live in rural areas, resources and health staff are too heavily focused in the capital city of Honiara. Of only 86 doctors, 73 are at the National Referral Hospital.
Many Rural Health Centres are run down, with up to 70% requiring upgrade, repair or renovation. There are no consistent standards for health facilities. Some new facilities are being built for political reasons or from private donations, and are not integrated with national services or priorities. Large numbers of people travel long distances to the national hospital for primary health services, including 6,000 deliveries per year (40% of all births). This limits that hospital’s ability to provide specialised referral services.
While around 100 doctors have been trained in Cuba and will return in the coming years, they will require to undergo an internship period on return. Their placement in rural areas will require additional resources for equipment, laboratory staff and medical supplies. Poorly defined governance and priorities for provinces means it is unclear how universal health coverage or equity across provinces can be achieved.
In consultation with senior policy makers, the draft Role Delineation Policy and Service Delivery Packages was developed in 2011. The policy defines the range and services to be delivered at different levels, to ensure better access to primary health care throughout the Solomon Islands.
The Service Delivery Packages were refined and simplified in 2016, based on the experiences from the early piloting. The new packages were developed through an iterative, consultative process. They outline what will be provided at six levels: Rural Health Centres (abolishing the previous category of Nurse Aide Posts), Area Health Centres levels 1 and 2, Urban Health Centres, and General Hospitals. Services to be provided at the National Referral Hospital will be defined later.
These Service Delivery Packages include what is required at each level: staffing, infrastructure, equipment, essential registers, manuals, guidelines and forms, and essential medicines. They will be used by policy makers to guide resource allocation, by provincial health planners to guide changes, and by local communities to identify what range of services they can expect, and by local staff to assess what services they should be delivering.
Successful advocacy has now resulted in strong political commitment, with alignment of the National Development Plan, the National Health Strategic Plan and the Role Delineation Policy. The National Development Strategy 2016-2030 specifies that all Solomon Islanders should have access to quality health and education. The National Health Strategic Plan 2016-2020 places the Role Delineation Policy as central to achieving the highest level goal, which is Universal Health Coverage, to support the vision of “Happy healthy productive people”.
Implementation of practice
What stage is the practice currently in?
Who was/is responsible for the implementation of the practice?
The Role Delineation Policy was initiated by national program directors and staff, not by external donors. Peer review of Service Delivery Packages was conducted by local and international experts. Final consultations were held with Provincial Health Directors, Program Officers and Clinical Staff at all levels.
The outputs are the Role Delineation Policy (a concise policy brief will be prepared in 2017); defined Service Delivery Packages; a National Development Plan that specifies, “Access to quality health care is a universal aim of all Solomon Islanders”; and a National Health Strategy includes healthy happy productive people as the vision, Universal Health Coverage as the goal, and Role Delineation Policy as the central driver of required changes.
The outcomes are strong national political commitment, support from Provincial Health Departments and Provincial Governments, and readiness to conduct new piloting of Role Delineation Policy in priority provinces in 2017.
The impact is not yet realised, but will result from further piloting in 2017 and scaling up during the period of the National Health Strategic Plan to 2020.
Strong and ongoing advocacy was integral to developing political and health sector commitment to the Role Delineation Policy, as evidenced by the alignment of the National Development Plan and the National Health Strategic Plan with Universal Health Coverage.
- Indrajit Hazarika
- WHO Western Pacific Regional Office