A fraying lifeline: chronically under-funded and lacking resources

Pacific islands health care faces the crisis of a lifetime

The COVID-19 pandemic hasn’t just highlighted the Pacific’s fragile health systems.  It’s amplified the central role that public health plays in all aspects of our personal and public lives; from education to culture, travel to trade.

Pacific health leaders have been prompted to question our level of investment in health systems, how it’s been spent in the past, and what needs to be built for the future.

Health spending as a % of GDP (2019)

Health spending

A paper by the Global Burden of Disease 2020 Health Financing Collaborator Network in the Lancet medical journal stated, “The context in which COVID-19 has spread globally is one of grave inequality in access to health services.” Its authors found that in 2019, before the pandemic struck, national health spending ranged from $7 (in Somalia) to $11 345 per person in the United States, and that government health spending ranged from $2 to $6578 per person. Pacific island states and territories, which bestride multiple income categories, generally spend less per capita than the World Health Organisation recommends. In some jurisdictions though, figures are distorted by the high cost of sending citizens off-shore for treatment.

In 2019, “development assistance for health to low-income and middle-income countries was $40·4 billion, or 0·5% of total global health spending,” the paper states. “However, in 2020, total development assistance for health (including development assistance for health for COVID-19) amounted to $54·8 billion, a $14·0 billion (34·6%) increase from 2019.”

This assistance has been varied. Partner governments and international organisations have supplied vaccines, oxygen, personal protection equipment (PPE), training, ventilators, surge capacity, field hospitals, transport and even paid for health workers’ lunches as the need has arisen.

In the Pacific, over 80% of health expenditure is publicly funded by governments, through domestic revenue and high levels of donor/partner funding. The remaining 20% comes from out-of-budget donor assistance and private spending on health services.

A recent Pacific Heads of Health meeting heard anecdotal evidence suggesting that budget allocations for health will hold up in 2022, but:The impact of COVID-19 on health financing in Pacific countries depends not only on the extent, duration, and severity of the economic contraction, but also on general domestic revenues, on government borrowing and external financing, as well as on health’s share of public expenditure, and how well that share is managed.”

Dr Ian Anderson, an Associate at the Development Policy Centre with over 25 years of experience in development work for the Australian Government, says government spending on health tends to increase in scale and as a share of GDP as countries ‘develop’. Similarly, as life expectancy lengthens and the aged population grows, the diseases requiring treatment and the cost of that treatment also grows.

“The counterargument is politics,” he says. “The amount of public expenditure on public health is essentially a political decision. It really tells you how serious is any government about public health.”

“Without donor assistance,  health systems in the Pacific will not be able to cope,” says Pacific Community (SPC) Deputy Director-General, Dr Paula Vivili. A medical professional who has worked in Tonga and New Zealand, Dr Vivili previously led the SPC’s Public Health Division, which has been critical to regional efforts to address the COVID-19 pandemic.

“[Donors] provide a lot of support for the public health component of the work. Because the country’s own budgets, generally speaking, fund the curative, the hospital component, the clinical component,” he continues.

“Of course, everywhere you go, there’s always discussion that we are always under-funding the public health aspect, the preventative component…That’s always easy for people from the outside to say, until you work in the system, and realise that you still have to look after the people that are sick.”

Dr Vivili remarks that “there’s a lot of talk about sustainability”, but “personally, my view is that the donor support is here to stay, and it’s about how people can use this best to build their own systems and progress that way.”

He notes that for some Pacific states, the challenge is actually spending the money, due to limited resources. “We saw that to some extent with COVID, as well. Some countries were able to spend the money quicker than others. And it’s all about absorptive capacity.”

Dr Vivili and others acknowledge the role of development aid in equipping hospitals, providing vaccines and supporting surge capability in Pacific nations. But the tendency of these efforts to steamroll past domestic responders has been castigated by some.

PNG’s COVID controller and Police Commissioner, David Manning, says the international aid sector needs to shoulder some of the blame for the crisis in Papua New Guinea, where the COVID response has exposed deep inadequacies in the health system, and vaccination rates are extremely low.

“At the national level the Department of Health has become little more than a shell that is controlled by a cabal of multilateral agencies and international NGOs,” Manning claims.

“They undermined our data systems, they disobeyed my orders and set up parallel systems and advised a struggling disease surveillance team accordingly,” he continued.

Pacific islands health care: Testing positive

Third or fourth wave notwithstanding, health leaders are now looking at what we’ve learnt through COVID, and how these lessons can be applied in the longer term.

In January 2020 a Joint Incident Management Team was set up by the World Health Organisation and partners to coordinate the pandemic response across agencies.

Dr Vivili applauds the bringing together of more than 20 partners through the team, saying it eased coordination and delineation of responsibilities.

He feels that countries are as prepared as they can be to deal with COVID, but admits that some countries remain untested by community transmission.

“The big question, of course, is how sustainable this all is for the countries. Because, you know, we got a lot of money from partners to support the COVID response… the countries certainly got a whole lot of money. And depending on how much countries spend on building their systems, then some of it will be long lasting, perhaps some not so long lasting,” he says.

Improvements to laboratory testing also worked “really well.” Prior to the pandemic, only French Polynesia, Fiji, Guam, New Caledonia, and Papua New Guinea could test for COVID. Since then, nine more countries are performing their own testing, with another four on the way. “The reason why this is a great move is that people will now be able to test for other things, like Zika, Chikunga, measles,” he says. “Prior to COVID, you had to send your test for these things to New Zealand, Australia, or Fiji, or New Caledonia. And by and large, the results came back two or three weeks later, so patients [were] either home or dead.

“So it’s a good example of where the COVID response has enabled countries to be able to do a lot more than what they would normally.”

For Fiji’s most senior government medical officer, Dr James Fong, one of the biggest lessons has been the need for ‘line list management’ across the sector, so that people are better connected to the health care they need and don’t get “cut and paste” care.

Line list management involves collection of what types of people are getting the disease, when they became symptomatic and where they may have been exposed.

Dr Fong says applying these principles  will ensure access to health care is meaningfully improved. “You can’t just build a health centre somewhere and then expect things just to flow in. You have to have a plan of actively seeking out and making [sure] people have access to care.”

Reflecting on the year that Fiji was largely COVID-free, he said while “Most of us were caught up in the old traditional way of medical practice, where you passively wait for things to happen.

“And I think one of the one of the biggest lessons that I take away from this, and a lesson that I need to inculcate in the system is that one of the strongest [ways] of being proactive is to have a line list, [because] people started finding new ways of doing things, they were able to categorise risk, they were able to know who’s low risk, what to do for them, who’s a medium risk, who’s high risk. And the care plans evolved naturally.”

In Papua New Guinea, Oro province Governor, Gary Juffa suggests the crisis has provided an opportunity for PNG to “review our defunct national department of health, which has deteriorated  and has been decimated by corruption for so many years that basically,[it’s] not a responsible functioning entity.”

His first step would be to look at public accounts committee reports from recent years, which he says exposed corrupt dealings in Health’s procurement committee. He believes an emergency task force should be set up.

Senior Research Fellow, National Centre for Epidemiology and Population Health, Australian National University, Meru Sheel listed her lessons from the pandemic at the recent Pacific Update online symposium:

  1. Border controls work
  2. Masks use is practical
  3. Health systems can be easily overwhelmed.

She sees a need to monitor what she calls “events” related to vaccines, and suggests integrating information about them into vaccination drives. She rattles off a list of policy concerns: mixing and matching vaccines, viral variants, cold chain logistics, vaccine safety, boosters, and child vaccination.

Like most health experts, she believed at some point, the Delta strain will arrive in most countries, even those with few if any COVID cases. She fears that pressures from local outbreaks will cause disruptions to routine health services.

Former Fiji Minister of Health Dr Neil Sharma agreed, adding that Fiji’s health facilities are extremely fragile: “Urgent healthcare strengthening of facilities is needed, our supply chain of medication and consumables is important. Our Technology is in need of upgrades and servicing, and our human resource needs to be optimised. We have focused very firmly on  COVID, and we’ve left things loose on NCDs, which is the largest killer. And additionally, if we look at health literacy, I don’t think our general Pacific literacy levels are high enough for people to understand health literacy as such. [And] there’s a need to address the microeconomic issues, while still factoring in the macroeconomic issues; food security, well-being are all affected.”

Pacific islands health care and non communicable diseases

While the world has been consumed by the COVID- response, the Pacific’s other pandemic continues unabated. Three-quarters of deaths in the Pacific are related to non-communicable diseases (NCDs) according to World Bank data. For Fiji, 84% of deaths are NCD-related, the highest figure in the world. Three diabetes-related amputations are performed daily in Fiji.

“This continuous rise in cases and impact is happening, despite the very significant investment made in this area,” says Simona Achitei of the Pacific Food Revolution.

In Fiji, Dr James Fong says COVID has also demonstrated the “miserable” failure of health promotion initiatives over the year, and that future primary health care programs will need to move beyond lip service.

The world’s four most obese nations are found in the Pacific (Cook Islands, Tonga, Samoa and Kiribati) , and obesity and other NCDs are believed to not only increase the risk factor for contracting COVID-19, but also increase the likelihood of being hospitalised. Papua New Guinea and Solomon Islands have the high double burden of malnutrition and obesity.

Ian Anderson says the interconnectedness of different diseases has been highlighted by COVID. “What they’re finding in Australia, and I guess this would be true in Fiji as well, is the people with diabetes, people with obesity, people who smoke, they are much more likely to have a severe response to COVID.

“It’s a good reminder that things like smoking just have no health benefits. None whatsoever. They have nothing but disadvantages. So I think it is very important to sort of use this COVID situation as a reminder to governments and society, tobacco is a killer.”

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