6apo tongahealthsystemreview-190927052833
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The document provides a review of Tonga's health system. It summarizes that Tonga has a decentralized health system managed through 4 districts, with the majority of primary care and 90% of hospital services provided by the public sector. Key achievements include control of infectious diseases, high immunization coverage, and prioritization of non-communicable diseases. However, challenges remain such as high rates of non-communicable diseases and their risk factors. The health workforce faces issues of limited education opportunities and brain drain overseas. Infrastructure and medical equipment also require significant upgrades.
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6apo tongahealthsystemreview-190927052833
- 1. Health Systems in Transition Kingdom of Tonga Health System Review
- 2. Health Systems in Transition: Kingdom of Tonga Health System Review 2 Authors: Editors: Maxine Whittaker Anna Rodney Anna Rodney Sione Hufunga Viliami Ika Sela Sausini Paasi Paula Vivili Tu’akoi ‘Ahoi Mafi Hufanga Suggested citation: Rodny A, Huanga S, Ika V, Passi SS, Vivlli P, Ahio Ta, et al. The Kingdom of Tonga Health System Review. Vol.5 No.6. Manila: World Health Organization, Regional Office for the Western Pacific, 2015.
- 3. Tonga: Socio-demographic profile Overview of health system Service delivery network Governance and administration Health financing Infrastructure Human Resources Major reforms Main findings Progress made Remaining challenges Future prospects 3 Presentation outline: This map is an approximation of actual country borders Source: https://www.who.int/countries/ton/en/ Location of Tonga. Source: By TUBS (This vector image includes elements that have been taken or adapted from this: Polynesian triangle.svg (by Gringer)., CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=15127566
- 4. 4 Socio-demographic profile Area 649.38 sq. km* 170 islands and islets Population • 103252 (2011) • 76.5% Rural population • 4.1 TFR (2012) Life expectancy at birth m/f 65/69 (2011) GDP per capita: USD $4,332 (PPP, 2012) HDI 95 Expenditure on health % GDP 5 (2011) Source: Tonga Department of Statistics and Tonga Ministry of Health et al., 2014 Tonga population pyramid 2012
- 5. 5 Decentralized, donor supported 1.1. Decentralized. Managed geographically through 4 districts (corresponding to main island groups) 2.2. Small private sector, largely informal traditional healers 3.3. Government provides majority of primary care (RCH clinics): 4. a. rural & remote populations often bypass primary care 5. b. 90% hospital-based service delivery (89% services at public hospitals) 6. c. community health section for outreach and education programmes 7.4. Public sector and donor fund 85% of health system financing 8. a. User fees for inpatient care introduced in 2008/09 9.5. Free healthcare to all citizens mandated constitutionally 10.6. MoH control and regulation Overview: Health system
- 6. Overview: Service delivery Service delivery overview: Decentralized 6 divisions responsible for service delivery Patient pathways: Patients may bypass primary care and access tertiary care services directly Access to overseas referral treatment (NZ and Aus) Outpatient /inpatient care: Low outpatient contact rate (1-2 consultations/year) Anecdotal evidence highlight draw attention to the limited capacity and lack of equipment of outer health centre doctors Basic medical equipment not always available at lower level health centres Surgical teams from overseas visit to provide surgical care unavailable in Tonga normally 6 A nurse takes vital signs after registration at the reception desk in a clinic in Nukuʻalofa. ©WHO/Yoshi Shimizu
- 7. 7 • MOH – administration, curative and preventive health services • Administration and delivery of preventive and curative public health services Central • Health services decentralized, managed geographically through 4 health districts Local (Districts) • Professional Associations: Tonga Medical Association, Tonga Dental Association and Tongan Nurses Association – regulate public and private health workers • Limited private sector; churches and NGOs provide a limited number of health services Other Overview: Governance and Administration
- 8. 8 Overview: Health Financing • Public financing 48% | Donor /development partner funding 38% | OOPE 10% a. User fees for inpatient care introduced in 2008/09 • Government spending at 16% of total budget one of the highest in the East Asia and Pacific region • Rising levels of government expenditure have seen a corresponding decrease in OOP payments Source: WHO, 2014; Somanathan and Hafez, 2009; MoFNP, 2011a, 2010b, 2009 Trends in health expenditure
- 9. Number of Health Facilities Overview: Infrastructure Source: MOH, 2013b 2.9 beds per 1000 population (higher than East Asia and Pacific region) Low occupancy rate ALOS 4.9 days higher for NCD care at 9. 2 days (2003) Limited medical equipment available (example: no MRI machine, or equipment for renal dialysis)
- 10. Overview: Human resources for Health Source: WHO and UNSW HRH Hub, 2014 Staff employed by the Ministry of Health, density per 1000 population • 3.54 health workers per 1000 population – high workforce density compared to other LMICs • 809 staff within the MoH • 50.4% of the workforce: nurses, midwives and student nurses • 6.8% of MoH positions doctors (55 medical doctors); 20 specialists • ~ 70% of MOH workers are women (half of all generalist medical practitioners) • 23% of the workforce is expected to reach retirement age in the next ten years • Migration of skilled health workers a challenge
- 11. Overview: Major reforms SPSRP • Economic and Public Sector Reform Programme 1999-2001 THSPMP • Tonga Health Sector Planning and Management Project 1999- 2007 HSSP • Health Sector Support Project 2003-2007 THSSP • Tonga Health Systems Support Program 2009-2013 TSDF • Tonga Strategic Development Framework 2011-2014 11
- 12. 12 Achievements and progress made: Health Status One of the best overall levels of health in Pacific Control and eradication of common infectious diseases Safe drinking water and adequate sanitation Maternal and child health Health workers attend an in-patient at a hospital in Tonga. ©WHO/Yoshi Shimizu
- 13. 13 Achievements and progress made: MCH Source: MOH, 2010b; Tonga Department of Statistics and Tonga Ministry of Health et al., 2014 Maternal and child indicators • 99.3% coverage for antenatal care in 2012 • All pregnant women, even on remote islands have access to skilled birth attendants • Immunization coverage mandatory by law, overall coverage of 99.8% surpassing many industrialized nations • Tonga now has no polio, measles or neonatal tetanus
- 14. Finance National Health Accounts (introduced 2001/2002) Budget execution 90% Policy & planning Key policy recommendations: Integrating traditional healers, NCD focus and re-alignment Corporate plan: linking strategies, KPIs and the budget framework Key performance appraisals for staff – accountability, monitoring and reporting 14 Achievements & progress: Integrated policy, planning and finances
- 15. 15 Achievements & progress: NCD control and prevention Key achievements: • Strategic prioritization of NCDs in Tonga Strategic Development Framework 2011-2014 • TongaHealth: better definition, distribution of funding sources for NCD activities, website for health promotion • Health Promoting Church partnership: Facilitate health messages and interventions via the Church 1st Pacific nation to develop NCD strategy TSDF inclusion: Prioritized national strategy Tonga Health Promotion Foundation Government- church partnership
- 16. 16 Source: WHO, 2014 Achievements & progress: Low OOPE Regional comparison of OOPs as a percentage of total health expenditure
- 17. 17 Achievements & progress: Health Information Systems HIS introduction Broadband capability Better data collection • Updated data collection processes for health centres and outer islands • THIS introduction: • Minimized cost, access in all hospitals and outlying health centres • Improved communicable disease surveillance • Increased data reliability and accuracy, including data bank creation • Real-time advice received from international specialists overseas • Strong international influence in HIS development recognition
- 18. 18 Achievements & progress: Intersectoral collaboration & emergency preparedness Pandemic preparedness, e.g. influenza Water and sanitation MDG taskforce National NCD Committee • Tonga vulnerable to natural disasters including cyclones, earthquakes and tsunamis • National Committees made to plan and standardize emergency response processes • Efforts led by MOH: Pandemic preparedness, water and sanitation and the National NCD Committee
- 19. 19 NCDs • 99.9% of the adult population estimated to be at moderate to high risk of developing NCD • Epidemiological transition: NCDs cause 74% of deaths • Leading causes of NCD mortality: Cancers, CVDs, respiratory diseases, diabetes • Diabetes prevalence doubled to 34.4% by 2012 Risk factors • 3rd most overweight country in the world • Tobacco: 7% male and 8% female deaths Remaining challenges: NCDs and risk factors Source: 2004 STEPS survey (MoH and WHO, 2012), 2011/2012 STEPS survey (MoH and WPRO, 2013) Risk factors influencing health status
- 20. 20 Remaining challenges: • Donors provide 38% of health system funding • Significant infrastructure upgrades: Vaiola Hospital, 54% of equipment and lab costs • Funding visiting overseas medical specialists, overseas treatment of patients, education of majority of medical workforce • Assistance with development of MOH leadership • Implementing THSPMP: public sector management and budgeting Leadership Management Funding Infrastructure Workforce, treatment
- 21. 21 Remaining challenges: Health workforce • Limited medical education: Only nursing and ad-hoc programs offered in-country • Low salaries and better conditions overseas leads to health worker brain drain • Reliance on DFAT to fill in key vacancies, e.g. surgeons. • Staff with advanced skills almost exclusively based on the main island • Retirement: 23% of the workforce to retire in the next ten years Limited in- country education Brain drain Challenge of an ageing workforce Specialised staff centrally located
- 22. 22 Remaining challenges: Medical equipment Hardware challenges • A significant portion of medical equipment is non-operational • There are no MRIs, PETs or renal dialysis machines • Outer island facilities have even less access to basic, functional equipment Workforce • Doctors require newer equipment to ensure they can practice their skills learnt overseas and maintain their clinical currency • Limited access to equipment also common reason for out-migration of health professionals • Medical imaging and therapeutic equipment technicians have decreased from 11 to 7 Impact on health outcomes • Decreased quality of treatment and diagnosis • Overseas travel for costly procedures – diagnosis and procedures cases most commonly cardiac surgery and cancer
- 23. 23 Remaining challenges: Quality of Care • Customer service • Improvements made towards better customer service, lack of follow-up hinders understanding of progress • Vaiola Hospital centric service provision • 73% of population reside in Tongatapu, 80% of health workers including hi-tech equipment and operating staff • Socioeconomic status • Lowest income quintile less likely to access services than highest • Neonatal mortality 6 times higher and under-5 mortality 2 times higher in lowest quintile compared to highest • Limitations in Overseas Treatment Scheme • May not cover some treatments, e.g. radiotherapy, limiting treatments to those who can find alternative financing • Mental health • Mental health on outer islands delivered by staff with no formal training
- 24. 24 Remaining challenges: Budget allocation Source: NHA, 2008-2012;Ahio et al., 2010 Ministry of Health recurrent expenditure by service input over time (selected) • Input-based method of budget allocation: does little to improve efficiency/quality of care • 22% of MoH budget spent on NCD curative care (local and overseas) • 60% of NCD-related spending is on pharmaceuticals • Spending for psychiatric services very low at 1% of MOH expenditure with no information on allocation
- 25. 25 Remaining challenges: Health data •Lack of disaggregation of data demographics, e.g. gender to understand health outcome inequities Health outcomes •Poor reporting prior to 2011 led to overestimation of life expectancy by 5 years for males, 3 years for females. Inefficient mortality reporting •Missing private sector data: not routinely reported including traditional healers who are often first line of treatment for many. Private sector •Impact of user fees unclear: social health insurance vetoed Lack of research
- 26. 26 Future prospects: Tonga 2nd National Strategy to Prevent and Control NCDs (2010-2015) Shift towards customer service, output-based system Public and Financial Reform Roadmap (2013-2018) Major new projects Ongoing Strategies Key actions to take: • Budget allocations to focus on preventive health • Shift primary care system to address NCDs • Ensure quality primary-care services can be maintained in remote areas • Retention of workforce • Provision and maintenance of health equipment and infrastructure
- 27. 27 Based on the Health Systems in Transition The Kingdom of Tonga Health System Review, 2015