PUBLIC HEALTH PROGRAMME
Introduction
The Public Health Programme (PHP) of the Secretariat of the Pacific Community (SPC) aims to improve the overall standard of health of Pacific Island peoples. It works across numerous public health fields, particularly communicable and noncommunicable diseases and public health policy. It is part of the Social Resources Division of SPC, together with other programmes that support PHP’s holistic approach to public health, such as Culture, Demography/Population, Statistics, Women and Youth.
Public health is concerned with promoting and protecting the health of communities and populations, largely through focusing on identified health determinants and risk factors. Because the health of populations is influenced by an enormous range of factors, many of which are outside what is generally considered to be the “health portfolio”, public health is collaborative in nature. It involves working with government agencies, nongovernment organisations (NGOs) and communities, drawing on the widest possible range of expertise and resources, to improve health in a sustainable, long-term manner.
Public health is a fundamental aspect of sustainable development. A healthy population underpins sustainable development; conversely, development that worsens health is by definition unsustainable. The United Nations Millennium Declaration in September 2000 led to the formulation of the following eight Millennium Development Goals (MDGs):
1.
eradicate extreme poverty and hunger;
2.
achieve universal primary education;
3.
promote gender equality and empower women;
4.
reduce child mortality;
5.
improve maternal health;
6.
combat HIV/AIDS, malaria and other diseases;
7.
ensure environmental sustainability;
8.
develop a global partnership for development.
MDGs 4 to 7 are directly relevant to the public health in the Pacific and to PHP. They substantially confirm the appropriateness of HIV, environmental health and NCD prevention, tuberculosis detection and treatment, and tobacco control as major programme priorities.
Pacific Island countries and territories (PICTs) are at various stages of the “health transition” – that is, the period during which the major causes of ill health and death change from being communicable diseases to noncommunicable diseases. Because they are in this state of transition, PICTs are facing a double burden of disease. Specifically, communicable diseases such as tuberculosis, malaria, diarrhoea, epidemic diseases and STIs remain an important concern in many areas, while at the same time the prevalence of NCDs such as diabetes and heart disease is substantial. Furthermore, mental health is increasingly recognised as an important public health issue, and is adding to the challenges that the region faces. Resource and management issues significantly constrain the capacity of PICTs to act effectively in regard to public health.
In the Western Pacific Region of the World Health Organization (WHO), PICTs consistently have the highest rates of death due to ischaemic heart disease, cerebrovascular disease and diabetes. These rates are often significantly higher than those for more developed countries in the region.
Extensive evidence indicates that these NCDs are of increasing importance in the region. A few examples are that:
the proportion of deaths in Fiji due to heart disease increased from 18 per cent in 1960 to 38 per cent in 1987–1988;
diabetes in Kiribati is estimated to be two to three times more common now than it was in 1981;
the proportion of adults living in rural areas of Samoa who are classified as obese tripled for men and doubled for women between 1978 and 1991, substantially increasing the risk that they would develop NCDs such as diabetes;
the incidence of the most common cancers among Fijian men tripled between 1966–1969 and 1997.
These NCDs are preventable if people adopt and maintain healthy lifestyles (for example, healthy eating and not smoking). Increasing the proportion of the population that does so requires long-term commitment and resources, and presents one of the biggest health challenges in the region.
Meanwhile, communicable diseases continue to result in significant morbidity and mortality.
In general, acute respiratory infections and diarrhoeal diseases are the leading causes of morbidity in the region. Diarrhoeal diseases are also a leading cause of infant and child mortality; they reflect significant environmental health problems in PICTs, particularly in relation to water quality, food safety and overall hygiene and sanitation.
In the three PICTs where it is endemic (Papua New Guinea – PNG, Solomon Islands and Vanuatu), malaria is one of the major causes of morbidity. These PICTs have the highest incidence of malaria in the world, other than in Africa.
Epidemic diseases like dengue fever, measles, influenza and leptospirosis continue to cause preventable mortality and significant morbidity in the region.
Typhoid fever is endemic in many PICTs.
HIV poses an enormous public health threat in the region due to the high prevalence of risk factors such as high rates of other STIs. Experience in other parts of the world shows that the incidence of HIV can increase very rapidly and can affect health, society, the economy and development substantially. PNG is already experiencing a significant epidemic; AIDS is the major cause of death at Port Moresby General Hospital and reported cases are increasing by 15 to 30 per cent a year. Even if the future spread of the epidemic is low, PNG’s working age population in 2020 will be an estimated 13 per cent lower than it would be without the epidemic.
Tuberculosis (TB) remains the leading infectious killer in the world; in WHO’s Western Pacific Region it kills 1,000 people every day. The average notification rate of infectious TB in SPC’s member PICTs is 37 per 100,000 persons, much higher than the average of 23 per 100,000 for the Western Pacific Region as a whole. Seven of these 22 PICTs (Kiribati, PNG, Commonwealth of the Northern Mariana Islands – CNMI, Nauru, Vanuatu, Guam and Solomon Islands) are considered to have a particularly high incidence of TB in international terms. One major potential risk identified in some PICTs is multidrug resistant (MDR) tuberculosis, which costs 100 times more to treat and is incurable in a significant number of cases. A second major risk is co-infection with HIV (as more than 50 per cent of those with HIV die from TB, particularly MDR), which has already been reported in PNG and Kiribati.
Recognition of mental health as an important issue in the Pacific is gradually increasing. The incidence of suicide, for example, is very high in a number of PICTs, in particular among young people and some other population groups.
However, a full appreciation of the impact of many mental health issues continues to be lacking. For example, the disease burden resulting from depression is likely to have been substantially underestimated. Whilst this is a highly complex issue, it is likely that cultural and economic factors play an important role, along with the coexistence of and potential for conflict between traditional and “western” cultures and values.
Public health systems in PICTs are clearly under-resourced. Causes of this shortfall include limited financial capacity to develop and sustain good quality services and programmes, and political perceptions about the relative importance of the sector. Effects include generally low pay for health workers, often difficult working conditions, deteriorating infrastructure, problems with ensuring a reliable supply of essential items, and limited capacity to implement programmes that address emerging issues. Out-migration of qualified staff also places significant stress on national health systems.
However,
within the health sector there has been growing recognition of the importance of
public health programmes relative to curative hospital-based health care. As a
result, a number of PICTs now allocate a larger share of resources to public
health. Some are also implementing modern public health management principles to
improve effectiveness and efficiency in the sector, in particular against the
background of severely limited resources.
Finally, several factors add to the complexity of addressing these issues in the Pacific. Complicating this task, for example, are the dispersed populations of PICTs, along with their political, cultural and linguistic diversity. Moreover, during the period of health transition PICTs face an enormous range of specific, complex public health challenges, while also being confronted with the fundamental fact that achieving health gain anywhere is almost always a long-term process.
The SPC response
PHP strives to promote and protect the health of Pacific Island peoples. It advocates a holistic approach to health, supports sustainable capacity building, and facilitates and promotes collaboration with partners in identifying and responding to current and emerging health priorities. With its exclusive focus on health in the Pacific, the PHP is well placed to make a real contribution to the health of communities and populations in the region. However, it recognises that in an area as complex as public health, it cannot effect substantial change on its own. Partnerships with national authorities, NGOs and other agencies are therefore crucial. Recognising the scale of its operations, PHP is committed to setting public health priorities carefully and realistically, with a concern for those priorities that the region has endorsed and that the programme is able to address effectively.
PHP is planning to address the following challenges.
– Public Health Surveillance and Communicable Disease Control is concerned with the surveillance and control of priority communicable diseases. Priorities for 2003 to 2005 are to maintain effective surveillance systems (PacNet), and to establish and maintain effective case detection (LabNet) and outbreak response (EpiNet) systems.
– In the important area of HIV/STI Prevention, the programme is building its capacity through the creation of a new HIV/STI Adviser position from core funding. Priorities are to redevelop a regional strategic HIV/STI framework, coordinate regional activity, advocate for the need to effectively address the issue in the region, and support national action by providing training and information. Significant additional funding is expected to become available from various donor sources.
– The priority for Tuberculosis Control is to continue collaboration with WHO to introduce Directly Observed Treatment – short course (DOTS) programmes to all PICTs by 2005 and reduce the TB burden by 50 per cent by 2010. In addition to developing human resources, the programme will begin MDR and TB/HIV surveillance to identify high-risk areas; develop and establish a quality assurance system for TB laboratories, designed to improve quality of TB data in the region; and conduct pre-feasibility studies on TB prevalence in the Pacific region and undertake other research and development to support the development of strategies addressing TB/HIV co-infection in selected PICTs including Kiribati.
– NCD Prevention/Lifestyle Health is concerned largely with preventing NCDs by focusing on their major risk factors. In recent years, nutrition was the major issue addressed by the Lifestyle Health Section. From 2003 to 2005, while activities targeting this risk factor will continue, the other major risk NCD factors (physical activity, smoking, alcohol) will receive substantially more emphasis than previously, thus enhancing the focus on NCD prevention. The primary activities will be to develop strategic frameworks, work with PICTs to implement the outcomes of the International Framework Convention on Tobacco Control, disseminate information and provide training. A key initiative is the creation of a new position of Health Promotion Adviser (Tobacco and Alcohol).
– Pacific Action for Health is an integrated health promotion programme, involving both the government and nongovernment sectors, that targets one NCD risk factor among urban young people in each of three PICTs (Kiribati, Vanuatu and Tonga). The priority over 2003 to 2005 is to continue to work with these PICTs to support the implementation of the programme, with the further possibility of extending the programme to a fourth PICT (Solomon Islands).
– Health Leadership and Management has almost finished establishing an ongoing process for developing future health leaders in the region. Following the completion of this SPC project, the University of Guam and the National University of Samoa will undertake implementation jointly.
– A priority for Adolescent Reproductive Health is to support further awareness and educational programmes on prevention of STIs, including HIV/AIDS, and teenage pregnancy for both in-school and out-of-school youth in nine PICTs. It will also expand reproductive/sexual health services by establishing youth centres and clinics.
– In addition, at the time of the development of this plan a new Environmental Health Section is being created with the establishment of the position of Environmental Health Adviser. This initiative has been taken because of the crucial and widely recognised links between health and the quality of the physical environment, and because improved environmental health (and public health more broadly) is a fundamental component of sustainable development. Given the importance of environmental health to health and development in the region, it was important that SPC address this area, which has been a major capacity gap for PHP. Among the priority activities are to create a regional strategic framework and provide technical support, training and information to PICTs.
– PHP’s internal organisation has traditionally been driven by the requirement to present and implement discrete projects for external funding. The current move to programme funding, which involves the donors as partners and major investors in PHP rather than in its individual projects, will facilitate the provision of integrated and responsive public health support for the region. The programme is planning to establish two functional “clusters” within PHP:
– Health Protection, comprising Public Health Surveillance and Communicable Disease Control, HIV/STI Prevention, Tuberculosis Control and Environmental Health;
– Health Promotion, comprising NCD Prevention/Lifestyle Health and Pacific Action for Health.
– The recent re-establishment of the position of Public Health Programme Manager is another important structural change that will strengthen PHP’s capacity.
Priorities
The Public Health Programme’s fundamental strategic approach is to work with PICTs and with other regional organisations to improve the health of populations in sustainable ways. From 2003 to 2005 particular priorities will focus on:
environmental health;
NCD prevention, including an enhanced focus on major risk factors such as tobacco and physical activity;
HIV/STI;
surveillance and control of priority communicable diseases;
a formal process, undertaken with PICTs, to identify core national and SPC public health capacities. This process will build on the work of WHO, the Pan American Health Organization, and countries such as the United States and Australia. The outcome will be of value in future national and regional public health planning.
Mandate
SPC’s
governing bodies, the Conference of the Pacific Community and the Committee of
Representatives of Governments and Administrations (CRGA), provide the mandate
for PHP and set its key directions. The Health Ministers, through their biennial
meetings, and crucially the PICTs, through their involvement in PHP activities,
play an important role in confirming these directions and identifying emerging
problems. PICTs have made it clear that they see SPC’s active involvement in
public health in the region as appropriate, valuable and necessary. For example,
the Madang meeting of the Ministers of Health for the Pacific Islands
Countries (March 2001) encouraged PHP to continue its excellent work in
supporting the countries and territories in the health sector.
PHP is committed to the concept of Healthy Islands (endorsed at the 2001 CRGA). This concept is accepted as the unifying theme for health promotion and protection in the island nations of the Pacific, consistent with the Yanuca Island Declaration (1995) and the Rarotonga Agreement (1997). Healthy Islands involves an integrated, multisectoral approach to the protection and promotion of health, recognising the importance of interventions at community as well as national levels. It builds on widely accepted international approaches.
PHP’s work
is also informed by and consistent with the Ottawa Charter for Health Promotion.
This charter was developed and adopted in 1986 as the means by which health for
all around the world will be achieved.
Mission,
goal and objectives
The mission of the Social Resources Division is:
To maximise the development potential of Pacific Island people in health, culture and information and enhance the empowerment of women and young people
The goal of PHP is:
Healthier Pacific Island communities
________________________