This presentation reviews useful concepts and frameworks for health system strengthening and to be able to achieve UHC and health related SDGs with regard to the Pacific. Given the important role of essential package of health services, the presntation addresses how PEN implementation can be well integrated into health strategy and planning processes to be able to help achieve NCD and health service related SDGs such as 3.4.1 / 3.5.2 / 3.8.1.

1. Role of Health Systems
Strengthening in the
Implementation of PEN
Interventions
30 Sep 2019
Changgyo Yoon,
technical officer for integrated health service delivery,
Division of Pacific Technical Support

2. Table of Contents
 Health systems perspective on achieving universal health coverage in
the Pacific
 Looking at PEN implementation at health system strengthening level
 Good examples in integrating PEN implementation (NCD
management) in diagonal approach
 Take home messages

3. 0
50
100
150
200
250
300
1995 2000 2005 2010
LMIC PNG Solomon Islands Kiribati Vanuatu Fiji Tonga Samoa
3
Current health expenditure per capita in
selected PICs 1995 - 2014
Note: in USD (average exchange rate)

4. Data source: WHO, The first 20 years of the journey towards the vision of Healthy Islands in the Pacific, 2015

5. The Vision of Healthy Islands
 It has been addressed in 1995
 Healthy Islands should be places
where:
– Children are nurtured in body and mind
– Environments invite learning and
leisure
– People work and age with dignity
– Ecological balance is a source of pride
– The ocean which sustains us is
protected
 Yanuca Island Declaration that
reconfirms the vision has been
endorsed at 11th PHMM in 2015
 WHO provides support Ministries to
achieve the vision such as Healthy
Islands monitoring framework and etc.

6. Universal Health Coverage Box
 UHC is based on the principle that all
individuals and communities should
receive the quality health services they
need without suffering financial
hardship
 UHC has classically included three
components
a) the population covered
b) the health services covered
c) the extent of financial protection given to the
population
 More recent descriptions of UHC
attempt to equal emphasis on equity,
quality, efficiency, resilience and
accountability

7. WPRO. Universal Health Coverage: Moving Towards Better Health. Action Framework for the Western Pacific Region. 2016

9. National Health Plans guiding health programmes &
linking health system components
WHO. Update on the regional analysis of role delineation policy. 6th Heads of Health Meeting. 2018

10. Role Delineation Policy
a health service planning tool to integrate PEN
• RDP is a planning tool to
define health services to
meet the health demand of
the population
• Defines the scope of
essential health services
(what services) with regard
to the proposed level of care
(at which level will the
service be provided), with
regard to the required
human resources (by
whom, doctor or nurse for
example), the available
equipment, drugs and
infrastructure (equipped
with)

11. Domain Health facility 2017 RDP 2004 RDP
Health
service
Aid post
Basic care; health promotion;
communicable disease control;
environmental health; STI/HIV
control; maternal and child health;
NCD management; essential
medicine provision; and referral
service.
Basic acute clinical treatment and
referral service; condom distribution;
immunization; public sanitation;
supervisory role for community
activities
Dispensary
Along with services provided by
aid post, dispensary will provide
services such as: IV fluid treatment;
outpatient service; malaria and TB
management; IUD insertion;
emergency contraception; STI and
HIV chemoprevention; and injury
care.
Plus to the functions of aid post:
Normal delivery; minor suturing;
maternal and child health;
supervisory role for village health
workers and traditional birth
attendants;
Remote dispensary
Same services done by dispensary
plus high risk delivery service and
intrauterine device insertion.
Health centre
Along with services provided by
dispensary, health centre will
provide services such as: inpatient
service; specialised care; risky
pregnancy management; post-
partum care; and mental illness
management.
Plus to the functions of health
centre:
Inpatient service; minor surgery;
dental services; assisting visiting
medical team; and supervisory role
for dispensary and aid post
RDP that evolves to integrate NCD management:
Vanuatu

12. Marshall Islands
- Dual health burden due to NCD
and Tb
- Residents of Ebeye and Majuro
island have been screened for
diabetes / hypertension and TB
- Found high rate of people with
increased blood pressure and
glucose and helped refer patients
to further treatment
Samoa
- Rapidly increasing NCDs
are main health
- To revitalize PHC and
community engagement,
MOH has implemented
PEN Fa’a Samoa
- Helped achieve high level
of population screened for
NCDs with support of the
Women’s group
Kiribati
- Triple health burden due to
CD, NCD, climate change
- WHO and JICA have pilot
tested NCD screening in two
villages in South Tarawa
with community
involvement

13. NCD screening programme combined with
Tb screening in Ebeye and Majuro in RMI
 Marshall Islands has one of the highest Tb prevalence in the
world
– Being diabetic is a important risk factor of Tb infection
– NCD prevalence is very high in RMI due to lack of physical
activity, poor nutrition, and poor health seeking behaviours
 A “diagonal” approach model to effectively respond to high
rate of CD and NCD
 Challenges
– framed as disease specific screening programme using existing
service delivery system. There is a need to review how to adopt
the implication into health systems
– A review on competing priorities that health workers at village /
district level have to provide: Tb/DM vs. other disease categories
in terms of working hour
– Supported by local health workers and external agencies (WHO /
US CDC / PIHOA). To be able to sustainable, strengthening local
/ central health systems with community engagement is required.
– To ensrue that screening leads to proper treatment, availability of
essential drugs for NCD management and providing adequate
treatment and counselling for lifestyle correction need a review
and support

14. PEN Fa’a Samoa
 Women’s groups (Komiti Tumama) have historically played
a vital role in the delivery of public health
 PEN package contextualized was introduced through
Komiti Tumama to provide better detection and
management of NCD risk factors for their communities.
 The implementation has catalyzed change in health
system transformation towards bringing primary health
care closer to the heart of the community
 Challenges
– Weak linkages with existing service delivery esp. at district
health facilities
– A need to look into the availability of essential medicine at
district health facilities
– Lack of monitoring indicator to track progress with this
approach that can be shared with other countries

15. Strengthening NCD screening and outreach services
for patient in South Tarawa, Kiribati

16. WPRO. Universal Health Coverage: Moving Towards Better Health. Action Framework for the Western Pacific Region. 2016
One billion more
people enjoying
better health and
well-being
SDG 3.4.1
Mortality rate
attributed to
cardiovascular
disease, cancer,
diabetes or chronic
respiratory disease
SDG 3.5.2
Harmful use of
alcohol, defined
according to the
national context as
alcohol per capita
consumption
SDG 3.8.1
Coverage of essential
health services that
includes NCD
management
Co-benefits of
full integration
of PEN into
health systems

17. Lessons from TB to Control NCDs: DOTS
 Political commitment – Sustained government commitment to health-systems
strengthening should include a national plan for NCDs.
 Case finding among people attending primary-care services – PHC is uniquely placed to
identify people at high risk and deliver prevention and care interventions.
 Standardised diagnostic and treatment protocols – Use of simple standardised protocols
for diagnosis, treatment, follow-up and referral, when necessary, are essential
components of quality care for NCDs.
 Regular supply of essential medicines – Uninterrupted supply of essential quality-
assured medicines is an integral part of continuity care for chronic conditions. However,
adherence to treatment, even when the medicines are available, is a particular issue for
patients with chronic NCDs, especially for asymptomatic conditions.
 Systematic monitoring and evaluation – An efficient health-information system for data
collection and management is essential for the evaluation of patients’ progress and the
burden of chronic NCDs, as well as the effectiveness of health-system interventions.

18. Take home messages
 PEN well adapted to the context of the Pacific island countries and areas
– Many countries have considered PEN protocol in national health plans / NCD plans and health
service plans e.g. Role Delineation Policy (KIR, SOL, VUT) and Essential Package of Health
Services (TON)
– However, there are existing challenges at implementation level such as health workforce,
finance, equipment and etc.
 Given its rapidly increasing trend and health burden, health system
strengthening can generate co-benefit in better implementing PEN for effective
and efficient service delivery
– A number of Pacific countries demonstrate good models of care that use communities (WSM,
KIR) or blend with infectious disease control (RMI)
 HSS is also important in tracking progress in managing NCD patients and
reducing population exposed to the risk factors of NCD
 HSS fully integrating PEN can accelerate achieving NCD-related SDGs (3.4.1,
3.5.2, 3.8.1) which are key to “One billion goal for better health and well-being”

19. Primary health care as a starting point
Quality
Efficiency
Equity
Accountability
Resilience and
sustainability
Islands settings
Tax-based public-provided health services
Contextual differences by islands countries
Double/Triple burdens
Low GDP per capita
Universal Health Coverage
Compass for
the journey
towards Healthy
Islands
Strong wind for the
Pacific health
systems to
disembark on the
healthy Islands

20. Thank you!