Report of the Ministry of Health - Seychelles
Ministry of Health
Annual Report
2014
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Acknowledgements
This report was compiled by the Chief Medical Officer, Dr Bernard Valentin, for the Ministry of Health (June 2015).
A number of Programme Leaders and Section Directors contributed both raw and processed information for the compilation of the report.
Extracts from the Annual Epidemiological Report, 2014 and the NCD Survey Report 2013-2014 also feature in the report.
Other sources were also consulted and are acknowledged in the report.
Table of Contents
|List of acronyms |4 |
|List of Tables |5 |
|List of Figures |6 |
|Introduction |6 |
|Implementation of the Recommendations of the 2013 Health Task Force Report |8 |
|The Evolving Health Landscape |12 |
|Functions of the Parent Ministry of Health |15 |
|Addressing Health System Priorities in 2014 |19 |
|Governance |19 |
|Human Resource for Health |22 |
|Health Service Delivery |27 |
|Vaccine, Pharmaceuticals and Technology |31 |
|Health Information Systerm |45 |
|Health Financing |46 |
|Partnerships for Health |47 |
|Double Burden of Diseases |40 |
|Health Diplomacy |49 |
|Overseas Treatment |58 |
|Projects and Procurement |62 |
|Miscellaneous Topics |65 |
|Conclusion |69 |
|References |71 |
List of Acronyms
|NIHSS |National Institute of Health and Social Studies |
|WHO |World Health Organization |
|MOH |Ministry of Health |
|GDP |Gross Domestic Product |
|CEO |Chief Executive Officer |
|PSM | |
|NCD |Non-Communicable Diseaes |
|MOU |Memorandum of Understanding |
|MIOT |Madras Institute of Orthopaedics and Traumatology |
|MDG |Millennium Development Goals |
|SADC |Southern Africa Development Community |
List of Tables
|Table 1 |Health Sector Agencies and their responsibilities |8 |
|Table 2 |Distribution of Private Conventional Health Care Facilities |13/14 |
|Table 3 |Composition of the Modernization Secretariat in 2014 |15 |
|Table 4 |Vaccine coverage in 2014 |31 |
|Table 5 |Donations to MOH in 2014 and their monetary values |55/56 |
|Table 6 |Distribution of patients according to selected overseas facilities |58 |
|Table 7 |Distribution of expenditure per overseas treatment facilties in 2014 |60 |
|Table 8 |Projects undertaken in 2014 and their costs |61/62 |
|Table 9 |Outsourced services and contractors | |
|Table 10 |Breakdown to the Health Minister in the National Assembly in 2014 | |
List of Figures
|Figure 1 |Institutional Structure of the Ministry of Health |9 |
|Figure 2 |Health Sector Periscope |11 |
|Figure 3 |Millennium Development Goals |28 |
|Figure 4 |Infant Mortality rate from 1990 to 2014 |30 |
|Figure 5 |Teenage deliveries for the past five years |32 |
|Figure 6 |Contraceptive prevalence for the past five year |33 |
|Figure 7 |Number of pap smears during the past ten years |34 |
|Figure 8 |Abortions by type and age group in 2014 |35 |
|Figure 9 |Incidence of Female Cancers of the Reproductive Tract |35 |
|Figure 10 |Occurrence of breast cancer in women during the past ten years |36 |
|Figure 11 |Occurrence of prostate cance in men during the past 10 years |37 |
|Figure 12 |Population pyramid of Seychelles, 2014 |38 |
|Figure 13 |Main causes of death |39 |
|Figure 14 | | |
|Figure 15 | | |
|Figure 16 | | |
Introduction
Modern health thinking, both in Seychelles and elsewhere, perceives a nation’s pursuit of health not as an onerous expenditure but as a highly desirable investment.
Any action or omission in relation to health protection, promotion or restoration has major consequences on the productivity of individuals, families and entire communities. Therefore, the impact of health actions or omissions on the human development efforts of a country, is enormous.
In his 2014 budget speech to the National Assembly, the Seychelles Minister of Finance recognized this verity.
He stated: “We believe firmly that….a healthy nation is a prerequisite to a prosperous nation.”
Further in the same budget speech, the Finance Minister implied that like education, free access to quality health care will remain one of the cornerstones of Seychelles government’s strategy “to promote growth and economic prosperity.”
The Ministry of Health warmly welcomed these comments and the accompanying commitment of SR 535.4 million that were allocated to it and its key agencies in 2014 out of a total government budget of SR 5.4 billion.
The budget allocation to the Ministry of Health represented 9.9% of the total government budget for that year. Budget allocation as a percentage of the 2013 Gross Domestic Product was around 4.9% at exchange rate of 1US dollar for 13 rupees. The GDP in 2013 was 1.4 billion dollars. (World Macroeconomic Research 1970-2013 by Ivan Kushmir).
Worthy of note is the fact that, additionally, in October 2014, the National Assembly approved a supplementary budget of almost 27 million rupees (SR 26, 994,338.74) for the Ministry of Health out of a total supplementary budget of SR224 million for various other functions of government. (MoH received, therefore, 12% of that supplementary budget).
Modern health promotion strategies strongly advocate that key aspects of the national health agenda feature prominently in the policies and programmes of all “non-health” sectors, both public and private. This approach acknowledges the significance of the socio-economic determinants on a nation’s health.
Since the late 1970s, Seychelles has espoused the “health for all” and “health by all” approach to health, which formed part of the Alma Ata philosophy of primary health care. It is now incumbent upon the country to also adopt the health in all principle, a principle aimed at preparing the ground, sowing the seeds and engineering appropriate actions for meaningful partnerships in health, to germinate, flourish and bear fruits.
The campaign “My health, my responsibility” which the Ministry of Health proudly launched in 2014, is geared, precisely, at the short-term, medium-term and long-term objectives of achieving a health promoting society in Seychelles. It seeks to do this through nationwide mobilization and purposeful and concerted efforts to improve the nation’s health.
With this background, the 2014 Annual Report of the Ministry of Health seeks to illustrate how the Parent Ministry of Health has utilized the finite resources accorded to it in 2014, to strengthen its own internal structures and processes and to strengthen the health system as a whole, so as to achieve the best health outcomes and impact possible, for the country.
In particular, the report reflects
1) The implementation of the reform and modernization processes contained in the recommendations of the Health Task Force Report and approved by the Government in June 2013 (a key national road map).
2) The continuing efforts undertaken by Seychelles in 2014 to achieve the United Nations Millennium Development Goals (a prime international road map).
In so doing, the Report highlights achievements, challenges, constraints and trials and tribulations in the pursuit of better health for all, through the implementations of these road maps.
Implementation of the Recommendations of the 2013
Health Task Force Report
The first phase of the reorganization and modernization of the Ministry of Health which were finalized in 2014 formed part of a series of rock-hard recommendations made to the Government by the HEALTH TASK FORCE.
These recommendations are contained in the seminal HEALTH TASK FORCE REPORT 2013.
The main recommendations consisted of reorganizing the Ministry of Health into separate entities working at arm’s length from the parent Ministry.
Following the first phase of the structural reorganization and modernization, the five main government-funded health sector entities that emerged are:
|1 |The “Parent” Ministry of Health (MOH) |Responsible for planning and oversight of the sector, |
| | |formulation of policies and broad strategies, legislation, |
| | |resource mobilization and allocation |
|2 |The Health Care Agency (HCA) |Responsible for Health Service delivery in primary, secondary |
| | |and tertiary care institutions of government |
|3 |The Public Health Authority (PHA) |Responsible for public health and safety across the nation |
|4 |The National AIDS Council (NAC) |Responsible for coordinating, evaluation and resource |
| | |mobilization of the national response against HIV and AIDS |
|5 |The National Institute of Health and Social Studies |Responsible for the basic training and development of the |
| |(NIHSS) |nursing, midwifery, public health, laboratory, dental therapy |
| | |and social services personnel |
Table 1: Health Sector Agencies and their responsibilities
The first four of these entities were created through laws enacted in the National Assembly, in the last quarter of 2013. The entities began their operations as semi-autonomous agencies early in 2014, with the appointments or reappointment of their respective Chief Executive Officers and their Governing Boards.
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Figure 1: Institutional Structure of the new Ministry of Health
The National Institute of Health and Social Studies is yet to become a full-fledged Professional Centre according to the Tertiary Education Act. Steps were undertaken in that direction in 2014. A first draft of the Charter of the Institute was submitted to the Chambers of the Attorney General for legal oversight and approval.
Apart from the above entities, there existed in 2014, three other, often forgotten, subsidiary statutory entities, which receive partial or complete funding from the state budget.
These are the:
1. Seychelles Medical and Dental Council
2. Seychelles Nurses and Midwives Council
3. Health Professionals Council
The role of these subsidiary entities is to protect the public by registering the health professionals, regulating their professional practices and receiving and investigating complaints made against them.
In 2014, all three subsidiary entities started to operate under new leadership and new attitudes. The Ministry of Health hailed the election of the new leaderships of the three Councils, given that their programmes appeared to be consonant with the overall reorganization and modernization efforts taking place in the wider public health sector.
In 2014, the regulatory councils have been active, ensuring that all health professionals are registered according to the law, that they undertake Continuous Professional Development activities and also that the laws regulating health professional practice in Seychelles are modernized according to best international standards. Committees with varying levels of appointments, (including appointment by the Health Minister for the Seychelles Medical and Dental Council) were set up to review the regulatory framework of all three Councils.
The oversight of the Ministry of Health does not stop at the perimeter of the public health sector. As guardian of the health of the nation, the Ministry of Health must always be mindful of what is taking place in the entire health sector. The diagram below illustrates the different lenses of the periscope of the Ministry of Health.
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Figure 2: Health Sector Periscope
The Evolving Health Landscape
Seychelles Accession to the World Trade Organization
International trade in health services is growing in many areas and Seychelles is no exception. Health professionals are moving from country to country, on temporary or permanent basis, usually in search of higher wages and better working or living conditions.
Seychelles’ accession to the World Trade Organization is likely to have a major impact on the health landscape.
But even without WTO, there was an overwhelming number of foreign health professionals (up to 60% and especially doctors), working in Seychelles. On the other hand, many trained Seychellois professionals have not returned home to practice.
Like elsewhere, even in Seychelles, there are notable increases in foreign investment by health care operators. In 2014, Nawaloka of Sri Lanka and MIOT of India showed interest.
Seychelles completed its accession negotiations to join the World Trade Organization on 17 October 2014, when the Working Party adopted the accession package. The General Council approved the accession on 10 December 2014.
Since this 2014 Annual Report of the Ministry of Health is being written in June 2015, it must be noted that Seychelles completed the ratification process of its Accession Protocol in March 2015. On 26 April 2015, the WTO welcomed Seychelles as its 161st Member.
Seychelles’ Accession Working Party Report contains 40 specific commitment paragraphs. From the date of accession, Seychelles has committed to fully apply all WTO provisions with recourse to transitional periods only for sanitary and phytosanitary measures (food safety and animal and plant health), technical barriers to trade (product standards and certification) and transparency. Seychelles will initiate negotiations to accede to the Government Procurement Agreement within 12 months of its accession, a WTO multi-lateral agreement covering the procurement of goods, services and capital infrastructure by Governments and other public authorities.
The private Health Sector
The conventional private sector in Seychelles is characterized by ever increasing numbers of private medical and paramedical services. The increase is consistent with government policy, which is to offer “choice” to the population in their health seeking behavior.
In 2014 private health care facilities were distributed as follows:
|Clinics offering |Number |Description |
|General primary care services |10 |Dr Marie (Hope and Trust Private Clinic), Eureka, |
| | |Euromedical (2 clinics – Eden Island and Providence), |
| | |DR Jivan, |
| | |Dr Albert, |
| | |Dr Chetty, |
| | |Dr Felix, |
| | |Dr Cruise-Wilkins, |
| | |Dr Annia Rousseau |
|Specialized medical care |5 |Eureka (established in 2014) |
| | |Eureka Medical, |
| | |Panafricare (established in 2014) |
| | |Dr Seth, |
| | |Nawaloka (established in 2014) |
|General dental care | |Dr Silvana Bisogni, |
| | |Dr Dereck Samsoodin, |
| | |PSM, |
| | |Dr Marlene Konate |
|Specialized dental Care | |Medent |
|Opticians | |Micock, |
| | |VisionCare, |
|Pharmacies | |Health World Pharmacy (Mont Fleuri) |
| | |Behram Pharmacy (Victoria) |
| | |D’Offay Pharmacy (Beau Vallon) (established in 2014) |
| | |Lailam Pharmacy (Victoria) |
| | |Central Point Pharmacy (Victoria) |
| | |Medix Pharmacy (Victoria) |
| | |In addition, most of the Private Clinics have a dispensary attached |
| | |to their clinics |
Table 2: Distribution of Private Conventional Health Care Facilities
As a result of increasing competition between these private care givers and also between the public sector care givers and the private care givers, the following phenomena are being observed or are being alleged to be taking place.
1. Increasing number of print media and broadcast media advertisement for medical services.
2. Certain (although few) private care givers tend to attract patients with gimmicks such as over-prescription of sick leave certificates. Other gimmicks include over prescription of drugs or diagnostic services or even follow up visits.
3. Certain private facilities are poaching crowd-pulling health care professionals to moonlight at their facilities.
4. There are allegations that clinical supplies are finding their way fraudulently from the public health facilities to the private facilities.
5. Pressure on the public health service to allow health care professionals employed by government to also work part-time at private health care facilities.
In 2014, the Ministry of Health began to explore the pros and cons of allowing the professionals in its employ to work part-time at private health care facilities. The results of that study is still pending.
Functions of the Parent Ministry of Health
Planning and oversight of the public health sector, formulation of policies and broad strategies, legislation, resource mobilization and allocation of finite resources are now the prime functions of the “parent” Ministry of Health.
In 2014, the Ministry of Health undertook these functions primarily through the “Modernization Secretariat” led by the Principal Secretary for Health.
The Modernization Secretariat has been institutionalized as the main policy cluster of the Ministry of Health and the main body advising the Minister of Health on key aspects of public health sector planning, implementation, monitoring and evaluation.
In 2014 the Modernization Secretariat consisted of the following members:
|Principal Secretary |Mrs Peggy Vidot |
|Public Health Commissioner, Public Health Authority |Dr Jude Gedeon |
|Deputy Chief Executive Office, Health Care Agency |Dr Danny Louange |
|Chief Executive Officer, Health Care Agency |DR Suresh Menon |
| |Dr Menon did not attend most of the Meetings in 2014 |
|Chief Policy Adviser |Dr Conrad Shamlaye |
|Chief Medical Officer |Dr Bernard Valentin |
|Chief Nursing Officer |Mrs Beryl Camille |
|Chief Allied Health Officer |Mrs Patricia Rene |
|Senior Policy Analyst |Mrs Bella Henderson |
|Independent Consultant |Mrs Daniella Larue |
Table 3: Composition of the Modernization Secretariat in 2014
During 2014, the Secretariat met regularly (every week) for long hours on end, to strategize, assess the pros and cons (possible impacts) of new policies and national initiatives and made significant evidence-based recommendations to the Minister of Health, to assist the Office of the Minister to formulate the national health agenda for the year.
The Modernization Secretariat also steered the implementation of the Recommendations of the Health Task Force Report and Seychelles’ Progress towards attainment of the Millennium Development Goals.
Among many other key tangible outputs, the Modernization Secretariat was responsible for
1. Launch of the campaign “My Health, My Responsibility!” (February 2014)
2. Crafting of the first Ministerial Declaration in the National on the State of the Nation’s Health (April 2014)
3. Conduct of the first Health of our Nation Conference and accompanying exhibition (April 2014)
4. Drafting of the accompanying Health of Our Nation Report (April 2014) and the subsequent Report of the Health of Our Nation Conference (December 2014)
5. Through the Health of Our Nation (HOON) Initiative, the Youth Health Conference (September 2014) and the subsequent Report of the Youth Health Conference (December 2014).
6. Review of implementation of health sector investment plans
Immediate Impact
As a result of the work of the Modernization Secretariat, both in the foreground and the background, the public image of the Ministry of Health is improving considerably. More and more people are consciously jumping on the bandwagon and adopting the attitude that their health is, first and foremost, their own responsibility and not that of anybody else’s. The impact of this shift in attitude on the overall health care landscape in Seychelles is yet to be fully evaluated.
Handling the strategic cross-cutting functions of the health sector
Partly by default and partly by design, in 2014, the parent Ministry of Health continued to take charge of the cross-cutting health sector functions such as procurement of drugs and other critical supplies and implementation of major new construction or remodeling projects.
Additionally, the roles of international cooperation as well as planning, training and continuous professional development of the human resources for health have all remained under the charge of the parent Ministry.
However, the parent Ministry of Health is not supposed, anymore, to attend to operational issues related to health service delivery. These roles are now bequeathed to the health sector agencies, operating with their relative autonomies, within the confines of their statutory instruments. However, it is still within the mandate of the Ministry to drawn the attention of the Minister to major dysfunctions in any area of the government-funded health care institutions and to advise the Minister on the appropriate course of action.
Devolution of responsibilities to the Statutory Agencies
Appointment of CEOs and Board Members of the different Entities
Following the enactment of the Health Care Agency Bill, the Public Health Authority Bill and the National AIDS Council Bill late in 2013, the Government appointed the Boards and Chief Executive Officers of the Health Care Agency (Dr. Suresh Menon), the Public Health Authority (Dr. Jude Gedeon) and the National AIDS Council (Dr. Anne Gabriel) early in 2014. The Ministry of Health also appointed an Acting Director of the National Institute of Health and Social Studies (Mrs. Marylyn Lucas).
The Governing Boards of the Health Care Agency, the Public Health Authority, and the National AIDS Council are functioning as expected and providing guidance to their different entities.
At the end of 2014, an advisory Board was yet to be appointed to steer the National Institute of Health and Social Studies.
Brief evaluation of devolution, during 2014
The Public Health Authority has a slightly longer experience with relative autonomy (it has been practically autonomous since 2009). Hence it appears to be functioning better than the Health Care Agency in the new context. Its structures and processes are more clearly defined, both in theory and in practice. It must be said however, that the Public Health Authority may also have slightly fewer health service challenges to grapple with.
On assessment at the end of 2014, the Health Care Agency still has some way to go to for example finalize and publicize 1) its organizational structures 2) its key priorities and 3) its key resource gaps and also to put in place key processes that matter to people. For example – the complaints management procedure that was a key recommendation of the Health Task Force Report, is yet to be clearly outlined and communicated.
Addressing Health Sector Priorities in 2014 and how they were addressed.
Health Sector Governance
Principles
It is well-understood from the different statutory and policy instruments of the Government that the mandates for direction and oversight given to the “Parent” Ministry Of Health also include the key functions of:
1. Setting-up of national standards and targets for the nation’s health and for health service delivery
2. Setting-up of accountability structures and processes for the whole health sector
3. Resource mobilization and advocacy
4. Proposal of legislations and regulations
5. Policy development
6. Monitoring and evaluation
The roles of the Parent Ministry of Health in these pursuits were not always understood by the Agencies in 2014. There were instances of conflict where certain agencies wanted more autonomy that their statutes had granted them.
The role of the Ministry, through the hand of the Minister, is to continue to clearly and firmly re-align the different entities to their statutory roles or to re-assess these roles and change the statutes, if the public health sector is to function smoothly.
Senior Health Executive Forum (SHEF)
Principle
The Health Task Force recommended a coordination mechanism to harmonize and rationalize the work of the Ministry and the public bodies under its purview.
The recommendations provided for these meetings to be held 4 to 6 times a year. It envisioned that these meetings would involve the participation of Senior Managers in the Ministry, the Public Health Authority, the Health Care Agency, the National AIDS Council and the NIHSS. These meetings were to focus on new policies to be developed or implemented, introduction of new programmes, reviewing performance, policy evaluation and on cross-cutting issues such as information sharing, research, etc.
Specifically the Senior Health Executives Forum was to:
Act as a Forum for escalation, risk and decision making which cuts across the public bodies but not for decisions about the specific organisation set-up.
Provide a Forum where the interconnectivity between programmes can be discussed.
Provide oversight and assurance over strategic, financial and people decisions required for implementing the new structure, ensuring the right resources are retained and deployed within the system.
Ensure that there are proper plans in place and these plans are aligned and deliver successfully.
The Minister of Health was to chair the Senior Health Executives Forum.
Actions
On two occasions during 2014, Senior Executive Forum met as prescribed by the SHEF Terms of Reference.
Whilst the Forum was originally conceptualized as a mechanism for the key actors at the level of senior management to share their experiences in the implementation of the different programmes and projects of the overall public health sector, the Forum has not, necessarily, lived up to the expectations of being the “dynamo” for the entire public health sector.
A re-assessment of the role of the forum was underway at the close of 2014.
Development of new National Health Policy, Strategic Plan and Monitoring and Evaluation Framework.
Principle
In 2013, the Health Task Force noted that although a strong Health Policy Declaration Of The Government had been documented in 1989 and although, over the years, there had been many other policy documents relating to specific health programme areas, including the ubiquitous National Health Strategic Framework 2006-2016, Seychelles did not have a National Health Policy document in the format recommended by the World Health Organization.
The Health Task Force acknowledged that a robust, evidence-based National Health Policy document, would not only guide national strategic planning, monitoring and evaluation but also, become a strong advocacy tool for the health sector, nationally, regionally and internationally.
The Health Task Force therefore presented an initial draft of the new policy and decided to seek assistance from the World Health Organization to finalize the document.
Actions
In 2014, the Ministry of Health requested assistance from the World Health Organization and the World Bank for this exercise.
The World Health Organization agreed to assist and indicated that assistance for this project would be forthcoming in 2015.
In 2014, the World Bank team in Seychelles listed the completion of the National Health Policy Document as one of the deliverables in 2015 for its continued assistance to the Seychelles Government in the health sector.
Human Resource for Health
Principles
1. Human resource has been declared as the most important asset of the Ministry of Health
2. The national goal of Localization of all health sector posts remained the goal of the Ministry of Health in 2014. However, major gaps continued to exist in achieving this goal.
The table below shows the number of human resource by type for the years 2008 to 2013. Figures for 2014 were not available at the time of compiling the report but the 2014 figures are not significantly different from the 2013 figures, due to resignations, retirement end of contract and freeze on recruitment imposed by the Department of Public Administration for some categories of workers.
|Health Personnel |2008 |2009 |2010 |2011 |2012 |2013 |
| | | | | | | |
|General Practitioners (GP)/ |70 |103 |100 |107 |93 |120 |
|Registrars | | | | | | |
| | | | | | | |
|Consultants |15 |14 |16 |18 |15 |14 |
| | | | | | | |
|Dental Consultants | |2 |1 |1 |1 |1 |
| | | | | | | |
|Dentists |12 |14 |18 |17 |13 |20 |
| | | | | | | |
|Pharmacists |4 |4 |4 |5 |4 |4 |
| | | | | | | |
|Other Professionals (1) |265 |157 |215 |187 |144 |216 |
| | | | | | | |
|Para- Medicals |439 |373 |328 |323 |253 |267 |
| | | | | | | |
|Nurses |407 |436 |412 |490 |419 |416 |
| | | | | | | |
|Student Nurses |82 |54 |44 |87 |97 |75 |
| | | | | | | |
|Other Health Ancillaries |491 |452 |285 |227 |558 |263 |
| |
|Source : Epidemiology and Statistics Section / Division of Health Surveillance and Response, Public Health Department |
a) The current pool of human resource for health is still grossly inadequate, both in terms of quality and quantity, to provide the quality of health care expected by the public and the national leadership.
b) Around 60% of medical practitioners and dentists posts continued to be occupied by expatriates
c) A large number of Seychellois medical practitioners and dentists sent for training by the government had still not returned in 2014 (at the count in 2014, there were around 30 qualified Seychellois doctors who were sent on training by the Government in New Zealand over several years who had not returned and were working in Australia or New Zealand. There were countless others in other countries)
d) Returning medical practitioners and dentists from the University of Mannipal in Malaysia were having great difficulties to gain placement in overseas institutions for their post graduate training. They had returned to Seychelles from Malaysia without doing their internship there. The reason for not doing their internship there was because the Government of Malaysia had discouraged foreigners to undertake internship in Malaysia due to the large number of Malaysian graduates waiting for internship placements in their own country.
e) The number of nurses and midwives necessary to provide the quality of care expected by the public and the working conditions expected by the nurses and midwives, was felt inadequate. The nurses coming out of the National Institute of Health and Social Studies did not necessarily meet the expected work ethos need for the health. They were also lower than needed in absolute numbers.
f) At the supreme policy-making, monitoring and evaluation levels of the Ministry there is a shortage of health planners, of financial analysts, of legal analysts of statisticians to undertake the monitoring and evaluation functions or to undertake operational research activities, worthy of a sector so large as the health sector.
g) There is a lack of staff adequately qualified in administration and human resources management and development.
h) There is a lack of adequately qualified procurement personnel and medical stores personnel. The result is that the procurement functions and the stores functions which manage millions of rupees every month find themselves functioning continually below expectations. It is not unusual for expensive medical supplies to expire through poor stocks management.
A combination of more and better trained personnel, together with a robust health information system will begin to address the deficiencies in the procurement and storage functions. The Government (Department of Public Administration) must not dither in allowing the recruitment of the requisite personnel to man these critical functions.
i) There remains major deficiencies in the paramedical personnel.
j) There is a shortage of qualified laboratory technologists.
k) There is a shortage of radiographers.
l) There is a shortage of nurses and of midwifes.
m) The biomedical engineering sector was still overwhelmingly manned by foreign expertise.
n) The Ministry of Health could not undertake many aspects of the approved modernization programme because of restrictions on recruitment imposed by the Department of public Administration together with lack of funding for the posts.
o) The Ministry of Health was unable to recruit a number of key staff it needs to carry out its oversight functions over the health sector. For example, it has not been able to recruit a human resource for health strategist. As human resource is the main asset of the Ministry, human resource planning, forecasting, management and development is essential. A person trained in this field needs to be recruited as a matter of urgency.
Actions
a) The Ministry of Health advocated to Cabinet to engage with the doctors and dentists in Oceania to assess to what extent they were prepared to contribute to the health development of the country despite working in Australia and New Zealand.
b) The Ministry of Health advocated to Cabinet that the doctors and dentists studying in Malaysia complete their internships there before coming to Seychelles
c) The Ministry of Health and the Seychelles Medical and Dental Council undertook serious efforts to structure the internship programme for those doctors who had returned to Seychelles.
d) The Ministry of Health actively sought placements for the returning medical and dental graduates in the following countries – Sri Lanka, South Africa, France (Reunion Island), India (MIOT group of Hospitals). These efforts were still underway at the end of 2014.
Nurses, Midwives and others trained at NIHSS
A reassessment of the National Institute of Health and Social Studies was undertaken and completed in 2014.
Early in 2014, the Health Minister appointed a Health Sector Commission to review all aspects of the work of the National Institute of Health and Social Studies. The Work of that Commission was informed by previous evaluations of that Institute such as “the report produced by the Seychelles Qualifications Authority in 2012, at the conclusion of an evaluation exercise carried out for the purpose of assessing the institute’s readiness for accreditation and a report produced by the Commonwealth of Learning prior to the accreditation visit, which helped the NIHSS to conduct its own self-evaluation, in preparation for the accreditation visit” (Report of the NIHSS Commission).
a) The Report of the Commission has been published and the Ministry of Health is implementing the Recommendations.
b) A draft charter for the NIHSS has been produced and sent to the AG’s Office for comments. The AG’s Office has recommended certain changes. The NIHSS is all set to function according to the Tertiary Education Act.
c) The National Institute of Health and Social Studies has started training in Midwifery, with the recruitment of a highly qualified trainer. Training in midwifery fills a long-standing need and will contribute immensely in improving reproductive, maternal and child health.
d) Graduates from NIHSS in 2014 were :
• 15 nurses
• 10 Public Health Officers,
• 3 Pharmacy dispensers
• 9 Dental Hygienist
• 7 Physiotherapy Technicians.
Health Service Delivery
Addressing the persisting gaps in the training, development and management of human resources for health is consonant with the national effort to improve health service delivery at all levels of the health system. Improvement of health service delivery involves improvement of both the quantity and the quality of health services nationwide.
Users of health services continued to point to the following weaknesses of the health service in 2014
Absence of patient-centered care with
1) Weaknesses in communication with patient (the problem continued to be compounded in 2014 by the large number of expatriate medical practitioners who cannot speak the national languages well enough.
2) poor involvement of patients and relatives in health care decision making,
3) long waiting times before getting the opportunity to see a specialist,
4) poor quality of the care environment in many cases etc.,
5) Inadequate mechanisms to address patient concerns and complaints.
It is now the remit of the Health Care Agency to put in place the necessary structures and processes to improve outcomes and impacts relating to health service delivery.
Access to health care services
Universal health coverage, has been practically achieved at primary health care level and citizens of Seychelles continue to enjoy full access to high-quality services for prevention and treatment and benefit from protection from financial risks as a result of illness. Seychelles proudly wears that badge of honour.
In 2014, there were 320,119 consultations at district health centres compared to 301, 364 in 2013. This represented an increase of 18,775 consultations (6, 2%).
With a population of around 100,000 people (including expatriates and tourists), this volume of medical consultations indicate that on average, every per person in Seychelles visit the doctor at least three times a year.
Nevertheless, realities on the ground continued to indicate that certain segments of the population might be under-utilizing certain health care services. It is clear from the statistics that certain key populations were not accessing health services as much as they should in 2014, although these services were, in theory, freely available to them. This is a long-standing trend in health service delivery which needs to be addressed. In the following sections, the report will cast a look on this issue and link it to the attempts undertaken by Seychelles in 2014 to achieve the ubiquitous millennium development goals
Millennium Development Goals
Since the turn of the new millennium, all countries, including Seychelles have been hard at work trying to achieve the Millennium Development Goals (MDG). Three of these Goals are directly linked to the health sector (Goals 4, 5 and 6).
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Figure 3: Millennium Development Goals
Child survival (Goal 4) is of particular importance to Seychelles given the, seemingly good performance of Seychelles in relation to infant mortality coupled with the re-energized nationwide movement and increased investment to further improve, since the World Conference on Early Childhood Care and Education in 2010, early childhood care and education.
In spite of all the efforts undertaken, in 2014, under-five mortality rate was not yet in line with the country’s target of six deaths per 1,000 live births, as defined by Millennium Development Goal 4 (MDG 4) (see graph below)
Indeed, early in 2014, the Ministry of Health was utterly taken-aback by the unexpected rise in infant mortality during 2013. In 2013, 30 babies aged less than one year died. Additionally, there were 20 still births. The tally for 2013 terminated in an infant mortality rate of 18.3 per one thousand live births. This was the highest rate recorded for over two decades.
The Ministry of Health immediately called together the different key actors in the management of pregnant mothers and newborns in the Health Care Agency and across the Ministry with a view to devise short term, medium term and long term strategies to reverse the trend.
A Commission of Inquiry was set up by the Minister for Health to investigate the quality of care being given to mothers and babies before pregnancy, during pregnancy, during labour and delivery and after delivery.
The Ministry of Health also directed that all infant deaths be investigated and a complete report with recommendations be produced each time. Following in-depth examination of the circumstances surrounding the 30 infant deaths and the environment of care, the Commission of Inquiry produced a report with more than 50 recommendations for the different entities of the Ministry to implement on a short term, medium term and long-term basis.
The Ministry of Health is happy to report that its efforts to reverse the trend paid off.
In 2014, Seychelles recorded the lowest infant mortality rate recorded for the past twenty-four years.
A study of this case alone clearly demonstrates that the new parent Ministry of Health must continue to exercise strong authority in the monitoring and evaluation of the different Health Sector entities and programmes and where necessary, it must take decisive, corrective actions to achieve the stated objectives of Government.
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Figure 4: Infant Mortality rate from 1990 to 2014
Graph supplied by the Statistics Unit, Ministry of Health
Vaccine coverage
Coverage for the vaccine preventable illnesses continued to remain high in 2014. The report below presents the percentage coverage for the main vaccine preventable diseases.
|Vaccine/Supplement |Official coverage estimates |
| |(percentage coverage) |
|BCG |98 |
|DTP1 |99 |
|DTP3 |100 |
|DTP4, 1st booster |94 |
|Polio3 |100 |
|HepB3 |100 |
|Hib3 |100 |
|Measles-containing vaccine, 1st dose (MCV1) |100 |
|Rubella 1 (rubella-containing vaccine) |100 |
|Measles-containing vaccine, 2nd dose (MCV2) |98 |
|Yellow fever vaccine |100 |
|Tetanus toxoid-containing vaccine (TT2+/Td2+) for pregnant women |97 |
Table 4: Vaccine coverage in 2014
Seychelles should only be entirely satisfied with its vaccine coverage if it is brought to and kept at 100% for all vaccine preventable illnesses.
Youth
Teenage pregnancy appears to be decreasing slowly in the 17-, 18- and 19- year old categories but they seem to be on the increase in the 14-, 15-, and 16- year old categories. This calls for better sexual and reproductive health education among girls and boys starting as earlier as possible. The Health Care Agency runs a School Health Programme which takes care of the in-school population of minors while the Youth Health Centre caters for all youth up to the age of 30 years. A holistic adolescent and youth health programme is yet to be developed.
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Figure 5: Teenage deliveries for the past five years
Graph provided by the Directorate of Programmes, Ministry of Health
Women’s Reproductive Health
In general, less than half of the women aged 18 t0 65 years visit health centres for pap smears and other women services.
In 2014, the percentage of Pap smear compared to 2013 decreased by 24.5%. The fraction of women of child-bearing age who use family planning services was relatively small during 2014. The new acceptors for contraceptives (617) decreased by 5% of an already low percentage of the total number of eligible women. Current users (24,338) also decreased by around 4%, denoting that women are not utilizing services that are available to them.
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Figure 6: Contraceptive prevalence for the past five year
Graph provided by the Directorate of Programmes, Ministry of Health
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Figure 7: Number of pap smears during the past ten years
Graph provided by the Directorate of Programmes, Ministry of Health
Figures for abortions and unwanted pregnancies were high in 2014. Referrals for termination of pregnancy increased by over 16% (79 referrals in total). At the final tally, there were 90 cases of TOP out of which 28 cases (31%) were in women less than 20 years.
The good news, in 2014, is that most women accessed prenatal care services. There were 1589 ANC bookings representing a 7.9% increase over 2013.
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Figure 8: Abortions by type and age group in 2014
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Figure 9: Incidence of Female Cancers of the Reproductive Tract
Graph provided by the Directorate of Programmes, Ministry of Health
In 2014, the HPV vaccine was introduced for girls at the age of puberty, (11-12 years). The target was to vaccinate 70% of those girls by the end of 2014. Most parents accepted for their daughters to receive the vaccine. However despite massive media campaigns there was a certain degree of resistance from some parents. 76% of girls have successfully received the vaccine. 22% have not since their parents have not consented whilst 2% did not return with the consent form.
Given the figures for cervical cancer, a combination of HPV vaccination, health education and promotion of Pap smear will contribute to reduce the incidence of this cancer.
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Figure 10: Occurrence of breast cancer in women during the past ten years
Graph provided by the Directorate of Programmes, Ministry of Health
Men
The gap in life expectancy between men and women continued to remain high. Although this gap is multifactorial, it is important to seriously study the health seeking behaviours of men and address potential gaps in the quantity and quality of health service available to them.
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Figure 11: Occurrence of prostate cance in men during the past 10 years
Graph provided by the Directorate of Programmes, Ministry of Health
Elderly
Life expectancy at birth in men is at 68 years and in women it is at 77 years. It is striking that on average men are living 11 years less than women. Given, the current life expectancy, the population pyramid indicates that the population of men and women over 60 and 70 years old will, most likely, continue to increase in the future.
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Figure 12: Population pyramid of Seychelles, 2014
It is government policy to to encourage individuals, families and communities to take care of their elderly and for government to lead by example and implement elderly friendly services. It is also the policy of government to encourage active aging. Many associations of Senior Citizens have been formed to encourage active aging and public transport is elderly friendly with reserved seats and free tickets for the elderly.
A health promotion programme designed specifically for the needs of the elderly is yet to be developped. The Ministry of Health will have to work closely with the Health Care Agency to ensure that elderly-friendly services are developed as per stated government policies, including a Home-Based Elderly Care Programme.
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Figure 13: Main causes of death
In 2014,725 deaths were reported compared to 717 in 2013. Diseases of the circulatory system contributed to 28% (202) of the total deaths. In that category, 58 deaths (29%) were due to hypertensive heart diseases followed by 46 deaths (23%) due to other heart diseases. Neoplasms contributed to 17% (125) of the total deaths, with 24 (19%) due to malignancy of colon/rectum and malignancy of prostate with 15 (12%) deaths. Diseases of the respiratory system was third with 104 (14%) of the total deaths, with 65 (62.5%) deaths due to pneumonia (inclusive of infant and child).
From the Annual Statistical Report of the Ministry of Health .
Double Burden Of Diseases
National Survey of Non-communicable Diseases in Seychelles 2013-2014 From Bovet et al
Main findings and global recommendations
a) The prevalence of tobacco use decreased between 1989-and 2013, reflecting strong tobacco control programs and policy in the interval. Data also show that the general public largely supports the tobacco control legislation implemented a few years ago in Seychelles.
• Tobacco control needs to be strengthened including strict enforcement of current legislation and need to address new issues, e.g. electronic cigarettes, shisha, measures targeting smoking among youth, etc.
b) Blood pressure (BP) has tended to decrease over time, consistent with improved awareness, treatment and control rates between 1989 and 2013. Favorable trends likely reflect socio-economic development, increasingly diverse nutrition, and improved medical care.
However, the level of control of BP among persons with HBP and knowledge on hypertension is far from optimal.
• There is a need to improve health care for patient with HBP, including updated guidelines for detection and treatment of hypertension, training of health professionals, extended use of home BP monitoring, etc.
• There is also a need to improve population-based interventions, including awareness campaigns (“know your number”, “reduce your salt”, etc.) and structural measures in all sectors to improve choices for healthy products and regular physical activity (e.g. reduction of salt in locally made or imported manufactured foods).
c) The prevalence of overweight/obesity and diabetes has markedly increased between 1989 and 2013, consistent with worldwide upward trends and increasingly globalized food markets. The survey provides information on dietary patterns in the population, which is useful to guide individual-based and population-based interventions.
• There is a need to develop structural interventions in all sectors to improve the availability of, and access to, healthy foods for all people and in different settings (schools, workplaces, etc.), including adequate food labeling, ban on advertising of unhealthy foods in mass media, subsidies/taxes on healthy/unhealthy foods, food labeling, etc. Interventions in all sectors are also needed to promote physical activity in different settings. Health education programs are helpful to raise awareness on healthy lifestyles and should target all population sub-groups. The school setting is particularly important to empower healthy choices at a young age and specific measures include water fountains in all schools, healthy food menus in canteens, compulsory 2 or 3 hours of physical activity per week, etc.
d) Knowledge on NCDs is fairly good in the population, reflecting the impact of continued health education programs in the mass media in Seychelles and through other avenues over the past 2-3 decades. Yet several areas of knowledge about NCDs should be improved. The survey also provides information on how people are exposed to different mass media in Seychelles and how people use electronic communication devices: this provides useful information on how these mass media and new technologies could be used to strengthen new NCD awareness campaigns.
• Need to brainstorm ways to enhance health education programs, including through targeted use of mass media and new communication technologies.
e) Many people report less than optimal exposure to advice on healthy lifestyle and nutrition by health professionals at the level of health care.
• Need to brainstorm efficient and innovative mechanisms to provide health education at the level of health care services (to target patients) and through other channels (to target the general public).
f) The survey provides information on frequency of screening for several priority cancers.
• Need to brainstorm the design, implementation and monitoring of screening programs for priority cancers in Seychelles.
g) Several characteristics related to NCDs (health behaviors, risk factors, knowledge, exposure to information, use of health care services, etc.) were less favorable among lower socio-economic groups.
• Need to brainstorm these results and consider social factors when designing interventions to address the prevention and control of NCDs.
The WHO 2014 NCD Status Report (available on www-who.int) provides lists of most cost-effective population wide and high risk interventions to reduce the burden of NCDs.
Global targets for NCD prevention and control
All WHO member states, including the Seychelles, agreed at the World Health Assembly in 2014 on 9 targets to be achieved by 2025 (compared to baseline in 2010):.
1) 25% reduction of NCD
2) 10% reduction in alcohol use
3) 10% reduction in prevalence of insufficient physical activity
4) 30% reduction in mean population salt intake
5) 30% reduction in the prevalence of tobacco use
6) 25% reduction in the prevalence of raised blood pressure
7) 0% increase in obesity and diabetes
8) At least 50% of eligible people receiving drug therapy and counseling to prevent heart attack and stroke (this includes hypertension and diabetes treatment)
9) At least 80% availability of the affordable technologies and essential medicines, including generics, required to treat major NCDs on both public and private facilities
Next national NCD surveys & WHO Global Status Reports
The WHO 2014 Global Status Report on NCDs provides population levels of selected indicators related to the 9 targets in 2010 and 2014 for all countries, based on actual data or estimated using statistical models. For Seychelles, levels of risk factors of NCDs appearing in the WHO Global Status Report 2014 on NCDs come from the 2013 survey.
Within the WHO Global Monitoring Framework and the WHO Global Plan of Action for the Prevention and Control of NCDs endorsed by all countries in 2013 and 2014, all countries are expected to report population levels of these 25 NCD indicators and updated national data will be published in updated versions of the Global Status Report on NCDs in 2020 and 2025.
This implies that each country should perform national surveys of NCD risk factors, similar to the 2013 Survey. On these premises, a next survey in Seychelles could be organized in 2018-2019 and, in all cases, in 2023-2024 in order to assess achievement of the 9 priority targets.
Communicable Diseases
HIV and AIDS
Although the 2013 KAP Study showed a low prevalence rate of HIV infection of just about .08 per cent in the general population, in 2014, the highest number of new cases of HIV since 1987 was reported, with 91(55M/36F) cases, an increase of 94% compared to 2013. The age of the patients ranged from 1 month old to 71 years old. Both extremes were females.
The 2014 Annual Epidemiological Report asserts that out of the 441 (246M/195F) cases living with HIV, 64 (40M,24F) cases did not access the service for over six months representing 15% of loss to follow-‐up (LTFU).
A cumulative of 231 (125M/106F) cases was on Highly Active Antiretroviral Therapy (HAART) by the end of 2014 representing 52% of people living with HIV.
55(28M/27F) cases representing 19% of cases eligible for treatment as per WHO guidelines defaulted treatment for more than three months in 2014.
Hepatitis C
A cumulative of 486 cases of Hepatitis C was reported from 2002 to 2014 representing 399 (82%) males and 87(18%) females. Out of the 486 cases, there 56 (43M/13F) HIV and Hepatitis C co-infections.
For the year 2014, 93 new cases of Hepatitis C were reported representing a reduction of 4% in new reported cases compared to 2013.
The youngest patient was 15 years old and the eldest was 52 year old. Both were of the male gender. The age group most affected was the 20 to 34 years, representing 76% of the total cases reported for 2014.
There were 28 (24M/4F) new cases of HIV and Hepatitis C co-infection and 18 (11M/7F) Hepatitis C related deaths. There were also 12(8M/4F) Hepatitis C related deaths and 4 Hepatitis C pregnancies reported. Three amongst the 12 Hepatitis C related deaths in 2014 were newly diagnosed cases of Hepatitis C for the year.
All these figures are grave causes for concern and appropriate strategies must be devised to reverse the trend. The Ministry of Health will work with its partner agencies to achieve the reversal.
Leptospirosis
A total of 672 suspected cases of leptospirosis were reported in 2014. Of these 50 (49M/1F) were confirmed. This represents an increase of 78% in confirmed cases compared to 2013 (28 cases). Out of the 50 confirmed cases, there were 11 deaths, representing a fatality of 22% for the year 2014 and an increase of 120% in the number of deaths confirmed to be from leptospirosis in 2014 compared to 5 such deaths in 2013. All fatal cases in 2014 were males, aged from 14 to 65 years old.
Health Information System
Principle
A modern national Health Information System (HIS) plays an important role in ensuring the production, analysis, dissemination and use of reliable, timely information on health determinants, health system performance, and health status. Reliable and timely health information is essential for strategic and operational decision making at all levels of the health system.
In 2013, the Health Task Force recommended that Government funds the purchase of an appropriate electronic health Information package (as a matter of urgency) and that all necessary steps be taken to ensure that once implemented the package delivers the intended benefits for health decision-making and improvement.
Action
In 2014, the Ministry of Health initiated the process to procure an appropriate health information package. Representatives of Siemens in the Middle East came to Seychelles for presentations on the functions of the package and return visits were undertaken to Abu Dhabi and Dubai by senior health officials to observe the health information package in action.
The Ministry of Health concluded that the Siemens health information package was appropriate for the needs of the Ministry and that the package should be purchased as a matter of urgency. The Department of Information and Communication Technology concurred with the conclusion of the Ministry of Health.
Funds to pay for the package were to be provided through a line of credit from the Government of India. At the end of 2014, those funds were yet to be released.
Parallel with the steps to procure the health information system, the Ministry of Health took steps to regulate the management of medical records. Medical Records management has remained an unregulated area of health care for several years.
A Cabinet Memorandum which sought to request the Attorney General to draft a medical records bill was approved towards the end of 2014. The main tenets of an eventual Medical Records bill were forwarded to the office of the Attorney General. The Attorney General’s Office, however, expressed an opposing view as to the merit of such a bill and to date, a draft of the bill has not been finalized yet.
The Ministry of Health will continue to emphasize that it is absolutely essential to properly regulate the management of both paper-based and electronic medical records through an appropriate legal instrument.
Partnerships for Health
Principles
The Health Task Force recommendations put a lot of weight on partnerships and called upon the Ministry of Health and its agencies to continue to strengthen partnership for Health.
|Actions in 2014 |
| |
|The Ministry of Health participated in the drafting of the Medium term National Development Strategy for Seychelles [2015- 2019], an |
|initiative of the Ministry of Finance. |
|The aim of the strategy is to improve the strategic planning process at National Level to make it more result based oriented. A draft |
|document was prepared and circulated. The Final version was awaited from the Consultants at the end of 2014. In 2014 the Ministry of |
|Health was active in the Social Renaissance Campaign, led by the Ministry of Social Affairs, Community Development and Sports, with |
|far reaching programmes and projects. |
|The Ministry of health collaborated with the Ministry of education to reinvigorate the Health Promoting School concept |
|The Ministry collaborated with the Institute of Early Childhood Development to finalize a dictionary of early childhood terminologies.|
|The long standing Child Development Study continued in 2014. A new research was undertaken on the CPD risk factors in collaboration |
|with the University of Lausanne |
|Actions in 2014 |
Health of our Nation – My health, my responsibility Campaign
Most observers agree that this Campaign which the Ministry launched in February 2014, has contributed immensely to change the image of the Ministry of Health and to emphatically place responsibility for one’s health back to where it belongs – i.e. on the individual.
In the framework of that campaign, the Ministry of Health organized two successful conferences in 2014.
The first conference was held around 7th April 2014 (Health Workers Day and World Health Day) and the Second Conference, focusing exclusively on opinions of Young People below 30 years on health issues, was held on the 1st September 2014.
The Reports of both conferences have been published, presented to the Cabinet and are available for reference in the public domain. A number of actions to be undertaken by the Ministry Of Health and by other partners have been outlined in these reports. The Ministry of Health is implementing them in earnest.
The mantra of the campaign has been adopted by many segments of society ranging from young children to the youth and the elderly. They have espoused the slogan through engaging more actively in healthy lifestyles or even acting out healthy lifestyles through marches in the streets, theatrical role plays and sustained programmes of physical activity such as the SEYX30 campaign of the Youth Department.
The Young Athlete Health Promotion Award which was introduced for the first time in 2014 and the accompanying preparation of athletes who participated in the school athletics competition on the 29th June 2014 managed to reduce incidents of trauma and injuries associated with that event by 70% compared to the previous year.
The clarion call My Health, My Responsibility Campaign was set to continue resonating throughout 2015 and beyond to galvanize all sundry that the health of our nation is the responsibility not just of the Ministry of Health but of every man, woman and child and every organization that exists in Seychelles.
Health Diplomacy
The Ministry was very active in health diplomacy in 2014.
• The Minister of Health attended meetings of, and intervened at, the World Health Organization (World Health Assembly), the Southern Africa Development Community (SADC), the Joint United Nations Programme against HIV and AIDS (UNAIDS).
• The Health Minister also attended and intervened at the first joint meeting of Ministers of Health of the African Union and the World Health Organization, held in Angola from 14th -17th April 2014.
The Minister of Health was present at the Extraordinary meeting of the SADC Ministers of Health on the Ebola Virus outbreak held in Johannesburg, South Africa on the 6th August, 2014
The Health Minister led a delegation to Sri Lanka from 16th - 19th August 2014.
• Although the Ministry of Health was not physically present (because of fears of Ebola), at the Regional Committee Meeting of WHO-AFRO in Burkina Faso in Burkina Faso where the new Regional Director for WHO Africa was appointed by African Ministers of Health, the Ministry strongly advocated for Seychelles’ presence and the Ministry of Foreign Affairs dispatched a staffer of the Embassy of Seychelles in Ethiopia to attend the meeting.
• The Botswana and SADC Candidate, Dr Matshidiso Moeti succeeded in securing the appointment. She was officially confirmed by the Executive Board of WHO in January 2015.
• The Health Minister also led a large delegation of over 30 participants from Seychelles to the Indian Ocean Symposium on HIV and Hepatitis held in Reunion from 8th – 15th October 2014.
• The Minister of Health attended the second International Conference on Nutrition held at the Food and Agriculture Organization, Rome (Italy) from 19th - 21st November 2014. A meeting was programmed with DR Margaret Chan, WHO Director-General, in the fringe of the meeting.
The value of the international meetings where Seychelles is represented by the Minister is that these meetings allow Seychelles to make its voice heard internationally.
Visit of UNAIDS Executive Director
The Executive Director of UNAIDS, Michel Sidibe, visited Seychelles in 2014 and spoke very positively about the efforts Seychelles is making in the fight against HIV and AIDS.
Seychelles was offered the opportunity to make its case, as a unique small island state with challenges as well as opportunities to be the first country that could succeed at reaching the UNAIDS targets of zero new HIV infection, zero death from AIDS and zero discrimination against HIV at the Executive Committee Meeting of UNAIDS.
Visit to Sri-Lanka
The Minister for Health paid a visit to various government and private health sector institutions in Sri Lanka. A number of avenues for cooperation were opened following the visit.
1. Seychelles is now sending patients for treatment in Sri Lanka, in addition to India, and Reunion. Twenty three patients were sent to Sri Lanka in 2014.
2. Sri Lanka has offered to provide training opportunities to Seychellois health professionals. These offers have been fully followed up.
3. Training of doctors in Sri Lanka requires their registration by the Medical Council of Sri Lanka – a matter that has not been adequately negotiated with the right Sri Lankan authorities.
Cooperation with South Africa
The Ministry of Health participated in the Joint Seychelles-South Africa Commission. In the meeting the Ministry of Health put forward its desire to have the young Seychellois doctors trained in South Africa, both for their internship and for their specialization.
The desire was recorded in the minutes of the joint Commission and through other diplomatic channels but that request is yet to bear substantial fruit.
Cooperation with Cyprus
In March 2014, the Ministry of Health participated in the Seychelles-Cyprus Joint Commission and expressed the desire to see attachment and training opportunities for Seychellois Health professionals opened up in Cyprus. This might, however, prove somewhat difficult, as English speaking institutions run by the government of Cyprus are few and far between.
The Joint Commission expressed recorded the interest of both sides to cooperate in the field of Health and Medical Science. The two sides agreed to sign a draft agreement after the agreement would have been reviewed by the competent authorities of both parties.
The draft agreement included cooperation in the following areas.
a) Research in the health care field, public health, water sanitation, environmental health, biomedical research funding and evaluation of services, technology and health care systems, the economics of long-term health care services, social determinants of health, primary health care delivery systems research and alternative ways of extending health care delivery beyond institutional settings.
b) Exchange of basic information systems for health and epidemiology, incorporating telemedicine, statistical methods and exchange of information.
c) Quality and standards in healthcare and service provision.
d) Health planning.
e) Exchange of the latest legislation on food safety and control.
f) Exchange of experts and other health care professionals for short or long term employment or facilitating internships and advanced courses for Cypriot and Seychelles’ nationals.
g) Exchange of information on narcotics (especially new ones) and their control.
h) Any other areas in the field of health and medical science agreed upon by both Parties.
The finalization of that agreement was still pending at the end of 2014.
Cooperation with Reunion Island
Cooperation with Reunion continued in 2014 according to the Memorandum signed in 2011. The cooperation was characterized by exchange of health professionals on attachment and support from Reunion to support critical areas of health care in Seychelles such as infection control, emergency care services, training of midwives and nurses in specific areas of care.
Visit to Chennai and MIOT Hospitals
The Vice President, the Minister for Health and the Principal Secretary for Health were all in Chennai in February 2014 to commemorate the 15th Anniversary of MIOT Hospitals. The Vice President was representing the President.
During the visit, a Memorandum of Understanding was signed by the Minister for Health, Mrs. Mitcy Larue and Mrs. Malika Mohandras the Chairperson of MIOT Hospitals.
Through that MOU,
1. MIOT would provide attachments opportunities to health professionals from medicine, nursing and other fields as will be determined jointly by Seychelles and MIOT.
2. MIOT would provide a medical consultant in internal medicine for a period of six months, and other consultants for shorter term periods to assist Seychelles in strengthening its health services.
3. MIOT would assist Seychelles in strengthening its clinical laboratory, starting with a comprehensive needs assessment and providing technical assistance in the form of a hospital planner and designer to develop the Seychelles hospital.
Cooperation with the Khalifa Foundation of Abu Dhabi
In June 2014, the Ministry received the first visit from the Project Manager of the Khalifa Foundation of Abu Dhabi in connection with their offer to build a Woman and Child Hospital in Seychelles.
As the project started to take shape some months later, it became evident that the sponsors want to donate a stand-alone hospital rather than an annex to the existing hospital.
The disadvantages of siting a brand new hospital in away from the main hospital at Mont Fleuri was emphasized by the local health experts and communicated to the Health Minister.
The experts pointed out that there would be serious issues with resources, especially human resources. There would also be a need to duplicate many functions for which resources are also extremely thin on the ground.
Donations
The Ministry continued to receive significant donations from many of its partners. These donations permit the Ministry to put its own finite resources to other good uses.
| | | | | |
|Donors |Donations Received | |Value in (SR) of the Donation |
|UNAVFOR |Blood Bank | | 250,000.00 |
|Bio System Company of Spain |Biochemistry Analyzer | | 350,000.00 |
|World Health Organization |Microbiological Safety Cabinet; Data Logger | | 294,045.90 |
| |Digital; Thermometer Microscope; Eliza Reader | | |
| |Coat paint antenatal and Surgical Outpatient | | 250,000.00 |
|Seychelles Trading Company |Department | | |
|Hon. David Pierre (Leader of the |Surgical Instruments (Laparoscopic dissector; | | 185,000.00 |
|Opposition in the National |cervical biopsy punch) | | |
|Assembly) | | | |
|Best Way Plumbing |Photo Voltaic Cells | | 120,000.00 |
|Seychelles Dhevatara Hotel |Ophthalmic Portable Microscope | | 165,000.00 |
|World Health Organization |Mobile Blood Bank | | 1,406,250.00 |
|Sovereign Military Order of Malta|Defibrillator | | 2,112.50 |
|Airtel |Fans, Nebulizer, Overhead Projector, TV Screen | | 15,000.00 |
|Emirates Foundation |Wheelchairs | | 150,000.00 |
|AV Group |Water Dispenser | | 80,000.00 |
|Grand Total | | | 3,267,408.40 |
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|Table: Donations to MOH in 2014 and their monetary values |
|Figures provided by the Director of International Cooperation, Mr. Jean Malbrook |
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Consultants
The Ministry of Health sought the assistance of the following Consultants from the World Health Organization to consolidate the health system
1. An expert in Health Services Costing to cost the different services being offered by the Ministry
2. An expert in Strategic Planning, Monitoring and Evaluation to update the National Health Policy, develop the new Strategic Plan and develop the Monitoring and Evaluation Framework
3. An expert in National Health Accounts to train the local team in the new national health account software and to consolidate the process of institutionalizing national health accounts into the monitoring and evaluation system of the Ministry of Health.
Overseas Treatment
The Overseas Treatment Programme of the Ministry of Health continued in full force in 2014. A total of 180 patients benefited from the programme, which in 2014 came to a total cost of just over 20 million rupees, two million rupees short of the 2013 figures.
India continued to be the main country of destination of the overseas patients and in India, most of the patients were sent to MIOT.
In 2014, following the visit of the Health Minister to Sri Lanka, Sri Lanka (and notably Lanka Hospital) became a new destination for some of the patients. Sri Lanka attracted 23 out of the 180 patients (12.1%) in 2014.
|Country |Hospital |2013 |2014 |
|India |MIOT |79 |125 |
| |Balaji Clinic |4 |5 |
| |Apollo | |2 |
|Mauritius |Apollo Bramwell |25 |20 |
|Reunion |CHU |3 |4 |
|Sri Lanka |Lanka Hospital | |23 |
|Others | |3 |1 |
|Total | |114 |180 |
|Cost | |22.5 million SR |20.1 million SR |
Table: Distribution of patients per according to selected overseas facilities
In 2014, approximately 71% (14.2/20.1 million) of the overseas treatment budget was paid to the overseas treatment centres, 11% (2.2/20.1 million) was paid to airlines and travel agencies, and 6% (1.2/20.1 million) was paid to individuals, mostly as refunds for treatment not going through normal procedures. The sum 1.1 million rupees was paid out to a total of 27 different individuals. This means that other than the 125 that were processed through the overseas treatment board, there were some 27 others who benefited from the programme in 2014, making a total of 152 patients.
Only SR73, 200 appear to have been paid as per diem to staff accompanying patients.
In 2014, the largest portion of the overseas treatment budget went to MIOT Hospital. When every single rupee of the 20.1 million spent was considered, 11.7 million (57%) of that sum was paid to MIOT, 1.8 million (9%) was paid to Seashell Travels, 1.6 million (8%) was paid to Lanka and 1.4 million (7%) to Apollo Hospital.
• At MIOT hospital therefore, the average cost per patient was SR 93,000 (11.7 million rupees for 125 patients)
• At Lanka Hospital the average cost per patient was 69,565.22 (1.6 million for 23 patients)
• At Apollo Hospitals, the average cost per patient was 63636.36(1.4 for 22 patients. Please note that the report did not make a distinction between Apollo Mauritius and Apollo India.
However, these comparisons are moot given that the illnesses for which patients were sent to these different facilities and the state of their illness were totally different. More thorough analyses are required to determine which country and which Hospital offers greater value for money for each of the pathologies for which patients are sent overseas.
|MIOT |11743008 |57 % |
|SEASHELL TRAVEL |1812714 |9% |
|LANKA HOSPITAL |1577463 |8% |
|APOLLO |1374331 |7% |
|INDIVIDUALS |1110439 |5 % |
|SAINTE CLOTHILDE |809756.8 |4% |
|CHU-REUNION |443915.5 |2% |
|BEVERLY HOTEL |356545 |2% (rounded off) |
|HILTON LABRIZ |195000 |Less than 1% |
|MAURITIAN COMMERCIAL BANK |192596.9 |Less than 1% |
|INTERNATIONAL MEDICAL HOSPITAL |177319.6 |Less than 1% |
|VISION VOYAGE |175708 |Less than 1% |
|AIR SEYCHELLES |174833 |Less than 1% |
|MFA (SEYCHELLES MISSION) |157577.2 |Less than 1% |
|BALAJI CENTRE |155899 |Less than 1% |
|STAFF |73200 |Less than 1% |
|MEDICAL AND SURGICAL CENTRE |51712.5 |Less than 1% |
|PROCARE |8125 |Less than 1% |
|IDC |800 |Less than 1% |
|TOTAL |20590943.5 |100% |
Table: Distribution of expenditure per overseas treatment facilities in 2014
We have published above the breakdown of how the overseas treatment budget was distributed in 2014.
It must be noted that whilst strengthening tertiary and quaternary care in Seychelles will change the kind of pathologies for which patients are sent overseas, the actual overseas treatment budget may not necessarily decrease as criteria for sending patients overseas might also change. For example patients who are not being sent now, might have to be sent in future. Or else, even if the number of patients decreases, the cost per patient might increase because the conditions for which they are sent might be more complicated or even, the cost of treatment will have risen.
In the table above, although patients were significantly less in 2013, the cost of the programme was significantly higher.
Projects and Procurement
A cross-government committee of senior executives supervised the implementation of new projects,
In 2014 the Ministry of Health completed the following projects
|Project |Investment in SR |
|Procurement and installation of backup generator |4.5 million |
|Total refurbishment of the dialysis centre |8.5 million |
|Total refurbishment of the operating centre |11.7 million |
|Construction of the new decompression Chamber Unit |Donated by Qatar Development Fund |
|Construction of the new Central Medical Store with the assistance |10 million |
|of the Social Security Fund | |
|Purchase of two dental caravans for the Ministry of Education to | |
|improve dental services in primary schools | |
|Installation of new generators at Seychelles Hospital and Anse | |
|Royale Hospital | |
|Mobilization of goodwill and resources for the construction or | |
|renovation of the following health centres | |
|Les Mamelles | |
|Mont Fleuri | |
|Anse Aux Pins | |
|Anse Royale (An outpatient facility to deliver the primary health | |
|care programmes is required near the new hospital | |
|Anse Boileau | |
|Baie Ste Anne | |
Table: Projects undertaken in 2014 and their costs
Procurement
The Procurement Oversight Committee of the Ministry of Health continued to consider and approve procurement of supplies amounting to more than 150,000 rupees.
The Committee has observed that the Procurement Unit which operates the day to day functions of procurement is extremely understaffed.
In addition, the staff manning the central medical store where the procurement unit stores the millions of supplies of material they procure, are also extremely understaffed.
The result is that the Ministry of Health continues to make unnecessary purchases at times or purchases expire before they are put to good use, costing the government millions of rupees. It would be wiser to invest in people and technology to ensure that all resources are put to good use.
Better procurement and stores management teams and a fit for purpose stores management software are required.
The Ministry of Health will continue to impress upon the powers that be to make these possible as a matter of urgency.
Outsourcing of Services
For several years now, the Ministry of Health has been outsourcing the following services
|Cleaning of clinical areas proper |Outsourced to the Cleaners Cooperative |
|Cleaning and maintenance of the grounds of the health |Outsourced to various small and medium size contractors all |
|facilities |over the country |
|Catering services |Outsourced to Skychef-Servair |
|Security |Outsourced to Isles Security |
|Laundry |Outsourced to Doby Laundry |
Table: Outsourced services and contractors
Most, if not all, the outsourced services did not deliver the quality of care required by the Ministry of Health and by the patients who are the end users of their services. At the same time, cost paid to these companies are forbiddingly high. It is clear that the Ministry is not getting value for money and that outsourcing has not brought about neither greater efficiency nor better services
The following areas of weakness have been observed
1. Internally, an officer qualified and dedicated to managing contracts of this nature is required. The Ministry of Health has not obtained the resources yet to be able to recruit and adequately remunerate such a person.
2. The companies who has been given these services are working in an environment of “no competition”. They operate in an environment where they know that the Ministry almost cannot get rid of them because there is no other operator offering similar services on the market. This problem however, could be overcome if the Ministry could have the resources to hire a competent contract management person.
Miscellaneous Topics
National Assembly
The Minister of Health answered 19 questions in the National Assembly during 2014. The questions were distributed as follows:
| Member |Number of questions |
|Leader of the Opposition |3 |
|Member for Anse Aux Pins |2 |
|Member for Anse Boileau |2 |
|Member for Baie Ste Anne |1 |
|Member for Beau Vallon |2 |
|Member for Bel Air |1 |
|Member for English River |1 |
|Member for La Digue |2 |
|Member for Les Mamelles |1 |
|Proportionately Elected Member Maria Payet-Marie |4 |
|Proportionately elected Member Sylvianne Valmont |1 |
|Total |19 |
Table: Breakdown of questions to the Health Minister in the National Assembly in 2014
The number of questions and the topics of interest point to the engagement and the concern of the local politicians and the people they represent with the health sector. The Ministry of Health endeavoured to provide the credible information to the members as much as possible.
The assurances Committee of the National Assembly paid a visit to the Seychelles Hospital and ascertained that the assurances given by the health Minister in the National Assembly were all on track. The Committee visited the Operating Theatres which were under renovation and the Decompression Chamber which was under construction.
Special Projections
Costing of Seychelles Hospital
In the first quarter of 2014, a Consultant recruited with the assistance of the World Health Organization, Dr Mark Bura, handed his report on the costing of Seychelles Hospital to the Ministry of Health. The costing exercise had taken place between the 10th and 21st December 2013.
The cost analysis of Seychelles Hospital can be used by management and planners for:
( Control of the use of health resources
( Accountability
( Assessing efficiency in use of resources
( Establishing standards
( Pricing and Cost Recovery
( Cost Projections
( Comparing costs and Revenues generated
The Consultant opined that the findings of the costing of Seychelles Hospital show health care managers and policy makers that costing of services is doable and can be used as a systemic management tool.
The Consultant made a number of recommendations among which were the following:
• The need to institutionalize costing through the creation of an appropriate post within Policy and Planning Unit
• The need to improve the Data management system to facilitate costing and other research
• The need to decentralize budgets and expenditures to cost centres
• The need to connect major utility-consuming cost centres e.g. CT, MRI, A&E, OPD etc. to their own meters
• The need to adopt Programme Based Budgeting (PBB) to better manage resources.
The Ministry of Health has started to discuss a Contract Agreement with the Health Care Agency, the Public Health Authority and the National AIDS Council.
These contracts will be guided by the National Health Policy and overall strategic plan of the Ministry of Health.
New MoH Headquarters
The Ministry of Health is yet to move to separate new headquarters although the movement formed part of the recommendations of the Health Task Force Recommendations and has, in principle, been approved by the Cabinet.
New MoH Headquarters have been identified next to the Ministry of Foreign Affairs on the other side of the Mont Fleuri Road. Delays in the completion of the building did not permit the Ministry to move to its new location in 2014.
All key-players in the health sector, agree that the Ministry needs to truly function at arm’s length from the health sector entities if the new structure stands any chance of succeeding.
Medium Term National Development Strategy for Seychelles
The Ministry of Health participated in the drafting of the Medium term National Development Strategy for Seychelles [2015- 2019], an initiative of the Ministry of Finance.
The aim of the strategy is to improve the strategic planning process at national level to make it more result-oriented. A draft document was prepared and circulated. The final version was awaited from the international consultants at the end of 2014.
Preparations for the Ebola Virus Epidemic
In 2014 most countries of the World were on tenter-hooks as they prepared to face off the Ebola epidemic which was wreaking havoc in Western Africa.
Seychelles began its preparations on four fronts:
1. Mobilization of resources and good will by the Parent Ministry of Health
2. Strengthening of structures and processes for border control by the Public Health Authority
3. Strengthening of the health services by the Health care Agency to treat any eventual case of Ebola.
4. Support and assistance by the Office of the World Health Organization in Seychelles
Anse Royale Hospital was selected as the main facility to treat patients with the infection should a case of the infection occur.
At the end of 2014 not a single case of Ebola had come near to Seychelles.
Preparations for that infection re-emphasized the need for the Ministry of Health to have a dedicate isolation facility, sooner rather than later.
Conclusion
The Ministry of Health exists to give expression to the Government’s (hence the people of Seychelles) health sector priorities. Its raison d’être is, essentially, to protect, promote and support the restoration of the health of the Seychelles Nation.
The Policy Cluster of the Ministry of Health (The Modernization Secretariat) advises the Minister of Health with regard to health sector priorities, policies, legislations and partnerships for health. The Minister communicates the government’s position to the Nation and mobilizes resources and goodwill to implement the intent of government.
In order to tackle the two-pronged disease burden of Seychelles (i.e. the rising prevalence of non-communicable diseases and emerging and re-emerging communicable diseases), the Ministry of Health recognizes that it must build the requisite national and international coalitions to reverse the trends of major risk factors and the diseases associated with them.
The Ministry of Health recognizes that it must do so, not only by successfully promoting healthy lifestyles but also by effectively managing illnesses in its care institutions at primary care, secondary care and tertiary care levels and overseas. Many of these functions have now been delegated to the implementing agencies – the Health Care Agency, the Public Health Authority, the National AIDS Council, the Professional Regulatory Councils, and the NIHSS.
Complaints are numerous and expectations of the public and national leaders for higher quality health care services are high. These expectations need to be carefully dissected on a continuous basis, to really reveal to what extent they are consistent with the level of funding and the availability of resources on the ground.
To build the kind of health care service such as a country like Singapore (for example) has and such as the people of Seychelles want, the level of health care spending and the quality of professionals trained and recruited must be equivalent to that of Singapore. Other resources must also be similar. Higher quality of health professionals, for example, would require substantially higher investment in the training of current health professionals and the recruitment of better quality professionals from overseas.
Nevertheless, in general, despite many imperfections, the three tier health system of Seychelles, with its gate-keeping mechanisms that exist to rationalize access to care services according to need, works, in most cases.
Whilst health promotion must be further intensified throughout the country, pre-hospital and in-hospital care quality must also improve.
The Ministry of Health recognizes that it can only achieve the set national health targets by continuing to strengthen the national health system so as to achieve, and maintain, first and foremost, universal health coverage, equity and financial sustainability.
Although, it has continuously received one of the largest shares of the government budget since the late 1970s, the Ministry of Health does indeed recognize that resources for health are finite.
It therefore, acknowledges the imperative upon it, to be efficient, responsive, transparent and accountable to the people that it serves, especially so in the changing political, economic, environmental, social and technological context.
References:
Annual Epidemiological Report, (2015), Disease Surveillance and Response Unit, Ministry of Health, Victoria
Annual Report of the Directorate of Family Health and Nutrition (2015), Directorate of Family Health and Nutrition, Health Care Agency, Victoria
Annual Statistical Report, (2015) Disease Surveillance and Response Unit, Ministry of Health, Victoria
Health Task Force Report 2013, (2013), Ministry of Health, Ministry of Health, Victoria
NCD Survey Report 2013-2014, (2015), Unit for the Prevention and Treatment of Cardiovascular Diseases, Public Health Authority, Victoria
Report of the National Assembly Committee on Government Assurances to Seychelles Hospital, (2015), National Assembly, Victoria
Overseas Treatment Ledger, (2013), Ministry of Finance, Unpublished
Overseas Treatment Ledger, (2014), Ministry of Finance, Unpublished
National Assembly Order Papers (2014), National Assembly, Unpublished
World Macroeconomic Research 1970-2013, (2014) by Ivan Kushmir,
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