Please write a XXXXXXXXXXword executive summary touching on each building block of the assignment attached. Basically our group assignment consists of 6 building blocks which are provided. You will only need to write the summary on 5 out of the 6 building blocks as 'Health Service Delivery' has not been done by one of the students as they have dropped out of the course.
Cook Islands health system is currently challenged to respond to the NCD epidemic, health workforce issues, disasters (natural and human induced), emerging infectious diseases and outbreaks, ageing population and rising communities’ expectation on health care services. In addition, the Cook Islands Government and Te Marae Ora are committed to tackling health inequalities through targeted health promotion and better access to health care for those in need.
Therefore, please add some information about health workforce issues...just to highlight the current issues facing Cook Islands. A quick summary about all the building blocks needs to be included in the executive summary.Many thanks.
Building Blocks included (2-7):
1. EXECUTIVE SUMMARY2. GOVERNANCE, STEWARDSHIP3 HEALTH SERVICE DELIVERY (disclosed still numbered)4 HEALTH WORKFORCE5 HEALTH INFORMATION SYSTEM6 HEALTH FINANCING7 MEDICINES, VACCINES AND TECHNOLOGY
1.
Executive Summary
GOVERNANCE, STEWARDSHIP
Leadership and Governance: Cook Island
Cook Islands uses a national health care system. Health Care is governed by their Ministry of Health, Te Marae Ora (TMO).
The Ministry of Health is divided into 3 directorates: Community Health Services, Hospital Health Services, Funding and Planning.
Introduction
In 2007 the Government of Cook Islands National began their National Sustainable Development plan (NSDP) for 2007-2020. This plan listed goals and strategies framed for the islands’ present and future challenges in national sustainability. It also addressed the need for improving the accountability of the government and the interconnectedness with communities. The NSDP provided the framework to improve the government operated national healthcare system. Over the last 10 years Cook Islands government have made large efforts to improve on several aspects of their healthcare according to their goals listed in their NSDP. Cook Islands have taken on policy changes to ensure that essential medicines were extensively secured, opened nursing school to meet the demands of the workforce,
The Te Marae Ora Ministry of Health (TMO), the government branch in charge of the national health care and water sanitation for Cook Islands, (CK IsD website) developed a 2012-2016 National Health Strategy. This strategy focused on current problems: amount of government spending, the need for larger health care workforce and for health information system, a platform and budget for public health surveillance, and research budget.
From objectives of the National Health Strategy, the TMO gathered stakeholders, local organizations, religious groups, non-government organizations including WHO, created the Clinical Health Workforce Plan 2015-2020. This plan addressed the nation’s overall issues: the rise of non-communicable diseases on the islands, sustainable healthcare and workforce retention for the outer islands. Their workforce plan also proposed strategies to keep healthcare cost within the constraints of the country’s budget (ClN WFP 2015-2020).
Rules-based/Outcome-based indicators for Measuring Health System
Governance Determinants
The Ministry of Health strategize with Ministry of Finance and Economic Management, the Ministry of Education to find more effective ways to extract information on the country. In the Household Expenditure Survey of 2005-2006, questions on education and health expenditure were added to the survey. The Ministries found opportunities to ascertain the broader needs the citizens through the questions in the country’s census. Future census now accounts for specific areas of social surveillance including: health of the household, labour and income, workforce, education, water quality. This opportunity in the led to better constructed questions, sampling methods, data gathering and information management in later census surveillance (Cook Island Population Census 2006). These changes guided Cook Islands government towards effective goals, indicators and strategies to drive decisions that help establish laws and policies. Furthermore, these changes drove the need for the fluidity of the questions in future census surveying as needs change over time.
Dissemination of this data gave insight for the need for several different databases to track the workforce entry/exit, facilities management, labour productivity and earnings, Database management????
The frequency of the census is often enough to have a good picture of the Health/workforce of the Country and idea of Country’s budget???
All of which lead to the goals set for the Country and the strategies need to obtain those goals and indicators by which to measure those goals for further improvement.
Core Indicators
Recently, in 2015-16 the Ministry of Finance for Cook Islands conducted the second Household Income Expenditure Survey in the planning of the Clinical Health Workforce Plan 2015-2020.
Recommendations:
Stability in the Country’s budget for surveillance and data management
*HEALTH SERVICE DELIVERY (disclosed still numbered) *
HEALTH WORKFORCE
Health Workforce of Cook Islands
Shortages
Cook Islands’ development is challenged by its narrow economic base, limited natural resources, fragile environment, shortage of skilled labour and relatively remote location (DFAT, 2019). The shortage of skilled workforce is due to either the internal or international migration pattern (emigration and immigration) of health workforce. Emigration of Pacific Island SHWs (Skilled Health Workforces) occurs at all occupational levels, and especially among those with postgraduate and specialist qualifications (Doyle & Roberts, 2013). Cook Islands is one of the Pacific Islands countries which experienced a loss of health workforces. They are enhanced to leave Cook Islands and migrate to NZ (New Zealand) easily because of the strong cultural tradition to move to NZ and also as a result of dual citizenship.
It has been reported recently that the migration of SHWs from the selected PICs (Pacific Island Countries) is not well documented and that there are currently no formal processes in place specifically designed to collect migration and mobility data (Doyle et al. 2012). In Cook Islands, the availability of migration data is partially recorded (see appendix …). Information and procedures regarding training overseas (pre-service, post-basic or postgraduate) for individuals, health practitioners, and other health workers are gained through the Human Resource Division, The Ministry of Health of Cook Islands, while there is no data for national emigration policy.
Internal migration, including the movement of SHWs from rural to urban centres, has been described as ‘ubiquitous’ throughout countries within the Asia Pacific region [Connell 2010 p. 15]. The rural and remote areas are the critical challenge to affect the health systems being firmly performed. The health workforces are facing working difficulties, feeling being isolated and uncomfortable living conditions. That factors hamper the retention of staff in outlying areas. Another form of internal migration is the movement of SHWs from the public to private sector. The Cook Islands has a pool of private health practitioners consisting of 3 medical practitioners, 1 dentist and 1 pharmacist [Cook Islands MoH n.d.b]), flows of health workers to the private sector have been in evidence. Gallina in 2010 mentioned that the Human Mobility Report also notes that education and training often became the reason of migrating health workforces, with sizable flows from a number of PICs (Pacific Island Countries) including Cook Islands, Samoa, Solomon Islands and Vanuatu to the University of the South Pacific.
Distribution?
Compared to the Western Pacific region with 14.5 doctors per 10,000 population, Cook Islands is considered a country with a low density of health workforces which only had 12 doctors per 10,000 population over 2000 to 2010. Highly dispersed population becomes the challenge for the distribution of the health workforces.
Rarotonga is the island with the densest population where majority of the health workforce is concentrated (78%). In the same time, Aitukaki with only 9% of the total workforce is maintaining a small workforce together with other islands focusing on health protection and dental services. A small pool of medical officers are allocated in the outer islands to lead health services (nurse practitioners and registered nurses).
Disparities between the Main Island and outer islands in relation to access to healthcare reflect differences in the health workforce. During recent years, the Ministry of Health has concentrated on providing sufficient general practitioners to provide health services in the outer islands. Whilst four islands (Pukapuka, Penrhyn, Mitioro and Rakahanga) have health officers they do not have a resident doctor.
As of September 2012, Cook Islands has approximately 294 medical staff distributed throughout the population. Nurses, much like many other Pacific nations, are the largest workforce within the Cook Islands. There are currently 64 nurses at Rarotonga hospital, comprising of six charge nurses, 48 registered nurses, two enrolled nurses and eight nurse-aid positions. There are 36 nurses on the outer islands, which includes five nurse practitioners.
Monitoring of hw?
Registered health professional Medical and Dental Council (Medical and Dental Practitioners), Nursing Council (Registered Nurses, Community Nurses, Nurse Aides, Midwives, Nurse trainee). Allied health professionals Pharmacists
Optometrists, Psychologists, Acupuncturists, Radiographer, Physiotherapists, Speech therapists, Occupational therapists, Chiropractors, Podiatrists, dieticians and nutritionists, naturopaths, laboratory and other technicians, hygienists or assistants in relation to health services, ambulance officers and para-medics, traditional healers.
-Review meeting
In 2014, the Office of the Public Service Commissioner (OPSC) established a human resource information management system and policy set to support the proper collection, management and dissemination of information in order to guide workforce planning, recruitment and retention processes, appropriate remuneration and employment conditions, fair and transparent staff performance management, quality controls that include regular assessment and measuring of competencies, access to training and development, and up-to-date workplace
Challenges
Challenges to maintaining the clinical workforce in the Cook Islands includes: outward migration and attraction to higher incomes and better employment conditions overseas, small numbers of students completing professional training, professional isolation, limited career pathways and opportunities for clinical practice. Additional challenges include an ageing workforce, with a significant number of clinical staff due to retire within the next decade, difficulty in recruiting for outer island positions and limited training and CPD options. Although the Cook Islands meets the WHO minimum threshold of 2.52 well trained healthcare workers per 1000 population, the geographical setting and isolation of small pockets of population in the 5 islands in the north and 6 in the south makes it difficult to provide services equitably. Accordingly, an internal patient referral system is in place. It is anticipated that with CPD for outer islands staff and the introduction of telemedicine that the costs of internal referrals will be contained to some degree.
All countries with a HRH crisis have HRH policy and strategic plans. Th ese documents generally identify priorities and establish an action plan for the implementation of strategies to strengthen HRH. In the Region, all plans are integrated into the national health policies
Education and training?
Geographically, Cook Islands is isolated from the “developed” countries and, to a large extent, from each other. This limitation affects education, training and development. The ability of the country to provide accredited institutions for HRH (Human Resources for Health) training is being limited, therefore, the demand for in-country training can only be fulfilled partially. This condition leads the health workforces to leave Cook Islands and migrate overseas for joining the training program.
Developing a skilled workforce is also comprised in the Cook Island’s National Sustainable Plan 2016-2020 (indicator 8.4). Cook Islands is committed to have the most productive society and labour force possible and aspire to increase the proportion of the population that has formal tertiary or vocational qualifications by providing educational opportunities including scholarships, university extension courses, and programmes provided through the Cook Islands Tertiary Training Institute. Cook Islands Government and health sector also have clearly identified the development of a skilled and competent health workforce as a national priority through several plans comprised in the Health Workforce Plan 1998-2020.
To support the human resource development, Cook Islands is collaborating through the joint commitment program with New Zealand and Australia. One of the agreed priority sectors stated on Joint Commitment for development between New Zealand, Cook Islands and Australia is human development particularly education. They committed to build better educated and skilled Cook Island’s population. New Zealand has invested $7 million to support secondary and tertiary education master plan of Cook Islands and $9.5 million was invested to implement the master plan. Likewise, the human development program was also conducted to improve the level of wellbeing of Cook Islands population through health sector program which resulted in the strengthened health system services and improved professional skills and capability of the health workforce.
HEALTH INFORMATION SYSTEM
According to World Health Organization (2010), ‘a well-functioning health information system (HIS) is one that ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status.’ A health information system generates population and facility-based data, has the capacity to detect, investigate, communicate and contain public health emergencies and synthesises information into knowledge that can be applied across the health system (Health Metrics Network, 2012).
According to the Cook Islands Strategy for the Development of Statistics, Cook Island’s HIS is an existing collection of statistics managed by the Ministry of health (MOH) (Cook Islands Statistics Office, 2015). The MOH is assisted by other departments on topics related to the health system e.g. Ministry of Marine resources collects environmental health data with MOH for the Cook Islands Sustainable Development plan 2016-2020(Cook Islands Statistics Office, 2015). Within the MOH there is an established HIS committee (the Cook Islands Health Information Unit) thatcoordinates and takesleadership by following the Health Information System Strategic Plan 2015-2019 but there are no formal policies or terms of refences for HIS (Ministry of Health, 2014b; World Health Organization, 2017).
To review Cook Islands HIS, indicators of Health Information System Performance Index (HISPIX) was examined with Cook Islands scoring 15/30 (see appendix…) (Health Metrics Network, 2012). Moreover, a Health Metrics Network (HMN) HIS assessment was formally conducted in 2013 and in 2016 Cook Island participated in a conference on Strengthening HIS in the Pacific reviewing progress of HMN indicators (Ministry of Health, 2014b; World Health Organization, 2017). ReviewingHIS resources, constraints withfinances and human resourceswas identified (World Health Organization, 2017). It was reported that there was a lack of trained workforce in the health information department with challenges including capacity building, the provision of training courses and follow up (McPherson et al., 2017; World Health Organization, 2017). This problem may be expedited by the lack ofinformation policies to guide the workforce through the HIS (Ministry of Health, 2019). Assistance was available to health or HIS staff at a subnational level, but specific budget line items for HIS was unavailable in national budgets (Ministry of Health, 2014b; World Health Organization, 2017). Indeed, there were no points allocated forHealth Systems Resource Trackingin HISPIX (refer to appendix…)
The primaryHIS infrastructure is the MedTech32 health information system which allows health workers to enter and access patient information from all islands; collecting basic information from hospital activities (Ministry of Health, 2014b). However, operation of MedTech32 required further financing and staff resulting in the loss of a regular statistical reporting system from the MOH (Cook Islands Statistics Office, 2015). All other activities such as data from communicable disease programs and surveys are all paper based (Ministry of Health, 2014b). There are enough forms, papers, pencils and other supplies that are needed for recording health information at the national and subnational level whilst support is provided for IT infrastructure (World Health Organization, 2017).
In 2016, the Cook Islands had 20 national coreindicators that were being regularly reported (Ministry of Health, 2014b; World Health Organization, 2017). According to HISPIX observations in appendix … these indicators were targeting health problems rather than health determinants and health system inputs. Furthermore, Cook Islands gathers from manydatasources with a census every 5 years where morbidity and mortality were reported, a functioning civil registration and vital statistic systems (CRVS) and the International Classification of Disease was used (Ministry of Health, 2014b). A nationally representative survey (WHO STEPs) was conducted before 2016, a household income and expenditure survey provided data on people’s living conditions, income or expenditure patterns in 2016 and there is a National Health data dictionary explaining case definitions of diseases (Cook Islands Statistics Office, 2018; World Health Organization, 2011, 2017).
Fordata management, there is an integrated data warehouse containing data from population-based and institution-based sources, but infrastructure and financial resource problems hindered maintenance of the warehouse (World Health Organization, 2017). Data processing and compilationis poor as written procedures for data management and a metadata dictionary are unavailable (World Health Organization, 2017).For procedures and policies to ensure quality, in 2016 Cook Islands reported data quality checks were being conducted at a national level and activities to improve processes were undertaken e.g. assessment of its CRVS system presented challenges with human resource capacity (World Health Organization, 2017). However, HISPIX observations in appendix … demonstrated that datasets were unavailable at a district level and outdated data was presented. Indeed, Cook Islands only met 2 of 13 core capacity scores of WHO’s 2005 international health regulations (IHR) (World Health Organization, 2018).
In 2016 Cook Islands stated that reports were being generated from the HIS unit such as the Cook Islands 1999-2013 CRVS report (World Health Organization, 2017). However,dissemination and use are largely ‘information based’ as opposed to ‘knowledge based’ (Ministry of Health, 2014b). This may stem from misconceptions within the MOH that MedTech32 data is the HIS (Ministry of Health, 2014b). Additionally, the Cook Island HIS Unit does not receive feedback from superiors on the information it produces suggesting the data is not being communicated well (World Health Organization, 2017). Lastly, subnational information is regularly reported to the national HIS unit, but human resource capacity and processes were hindering existing vertical reporting systems (World Health Organization, 2017).
Recommendations
A lack of HIS workforce is affecting all areas of the HIS. A WHO HIS advisor or assistance from overseas e.g. Australian Aid volunteer program should be consulted to build HIS capabilities in the existing workforce (Department of Foreign Affairs and Trade, 2019; Ministry of Health, 2014a; World Health Organization, 2017).
The revised 2005 IHR and fundamental principles of official statics should be used to create HIS information policy (Health Metrics Network, 2012). A regulatory and legal framework will guide HIS workforce e.g. assist with accreditation of non-state health providers and establish mechanisms for data collection, quality and dissemination (Health Metrics Network, 2012).
There is no formal funding for HIS within national budgets which impacts on the ability to collect data and maintain MedTech 32 (Cook Islands Statistics Office, 2015). Additional funding should be acquired to make HIS a priority.
Health System Resource Tracking indicators on HISPIX should be investigated allowing current resources to be considered in decision making.
HMN assessment should be conducted every three years to monitor, strengthen and evaluate the HIS system (Health Metrics Network, 2012).
The current Health Information strategy ends in 2019(Ministry of Health, 2014b). A new strategy should be created considering these recommendations.
HEALTH FINANCING
Current health expenditure
Cook Islands is currently considered an ‘’upper middle income’’ country (Development Assistance Committee [DAC], 2018). Some of the key indicators of Cook Island’s financing of health care are:
Cook Islands spends 3.4% of its gross domestic product (GDP) on health (WHO, 2016). This has been relatively consistent since 2000 (the earliest available data; figure 1) (WHO, 2016).
Expenditure on healthcare by the government represents 5.7% of total government expenditure (World Health Organization [WHO], 2016)
An estimated NZ$15.1 million was spent on healthcare during the financial year of 2017/18 (Ministry of Finance [MOF], 2017)
The 2017/18 budget allocates 64% of the healthcare spending to personnel (presumably wages and salaries), and a further 18% to operating costs (MOF, 2017). The amount spent on health personnel corresponds to 7.8% of total government expenditure (MOF, 2017).
It has been calculated that governments ought to spend at least 5-6% of GDP on health care, in order to achieve universal health coverage and minimise risks of financial catastrophe to individuals (McIntyre, Meheus, & Rottingen, 2017). According to this calculation, the amount spent by Cook Islands is currently inadequate.
As shown in figure 2, the majority of funding for Current Health Expenditure comes from the public (i.e. domestic general government health expenditure) (WHO, 2016). Cook Islands has no private health insurance[1], so the 6% of funding from the private sector corresponds to out-of-pocket costs paid by consumers at the time of service (WHO, 2009, 2016). This low out-of-pocket cost is admirable, as out-of-pocket financing is the most inequitable form of funding and does not offer the protection against financial catastrophe that comes with mandatory prepayment (such as via taxation or health insurance) and pooling mechanisms (Gottret & Schieber, 2006). The remaining funding is from external sources (WHO, 2016), mostly from New Zealand bilateral aid programs (Ministry of Health [MOH], 2017b). The 12% external funding of 2016 represents a large increase from the previous year (figure 3), in which only 1.5% of health expenditure was from external sources (WHO, 2016). It is not clear why there was such fluctuations.
As seen in figure 4, the majority of the health care expenditure is on hospital services (WHO & MOH, 2012). An unspecified amount of the budget (therefore not included in figure 4) is also used to fund travel for Cook Island residents for specialist services in New Zealand (WHO & MOH, 2012). Pharmaceuticals comprised 5.2% of total health expenditure in 2011 (MOH, 2013), and 33% of pharmaceuticals are financed by out-of-pocket payments by the public at the time of purchase (WHO, 2009). However, medications are provided for free for those: under age 5 years; elderly; pregnant; outer island residents; and those who cannot afford them (MOH, 2013).
There are three different fee levels for health care in Cook Islands (WHO & MOH, 2012):
No fee, for those under age 16 years or over 60 years
Partial charge, for inpatient services, outpatient services, clinical support services, and radiology
Full charge, for non-residents
That Cook Islands waives fees for medications and for healthcare services for certain vulnerable groups within the population demonstrates horizontal equity, meaning that people of equal (i.e. “horizontal”) need of health care receive the same treatment, regardless of their income or other social factors (Wagstaff et al., 1991).
Household spending on health (including medications, and medical, hospital and dental services) was estimated from a household survey to be 0.2% of total household expenditure (Cook Islands Statistics Office, 2018). Whilst this is nearly thirty-fold lower than the amount spent by Australians (5.8%; Australian Bureau of Statistics, 2017), it is consistent with the low household expenditure on health by other Pacific Islands, such as Tonga (0.2%; Tonga Statistics Department, 2017) and Fiji (0.9%; Fiji Islands Bureau of Statistics, 2011). Although there is no data available on the proportion of Cook Islanders who encounter financial catastrophe as a result of healthcare expenditure, this is likely to be minimal, due to this low average household expenditure, and low proportion of out-of-pocket costs (Cook Islands Statistics Office, 2018; WHO, 2016).
Future planning
TheCook Islands National Health Road Map outlines a plan for the health care system for 2017-2036 (MOH, 2017a). Admirably, this includes a plan for government funding for health care to increase to 5% of GDP (and so meet international standards [McIntyre et al., 2017]), to keep out-of-pocket expenses minimal, and strengthening financial safety net resources for vulnerable populations. TheRoad Map includes a commitment to improve the efficiency of the health care system. Although efficiency is important for all countries, it is particularly important for developing countries, since the total amount available to spend on healthcare is limited (Gottret & Schieber, 2006). TheRoad Map also lists the possibility of introducing health insurance, which is another means of supporting health financing (Gottret & Schieber, 2006). WHO is assisting with a feasibility study on insurance options for Cook Islands (WHO, 2019).
An emerging potential issue is the likely graduation of Cook Islands to be considered a developed or high-income nation, as this status will make it ineligible to receive some sources of financial assistance (Bertram, 2016). This decision is currently under consideration (DAC, 2018).
Possible solutions
In order for a government to increase its spending on health care, it requires revenue generation (Gottret & Schieber, 2006). One possible means is through increasing taxation on harmful substances, such as tobacco, alcohol and sugar-sweetened beverages. Not only does this raise revenue to support the health care system, but raised price are known to decrease consumption of these substances and so improve health outcomes (Blecher, 2015).
TheRoad Map lists health promotion as being a priority area (MOH, 2017a), however there is no information available on expenditure on health promotion or education. Given the cost-effectiveness of prevention strategies (Hagberg & Lindholm, 2006; Shroufi et al., 2013), allocating a proportion of the health budget to such programs would be a wise investment.
MEDICINES, VACCINES AND TECHNOLOGY
Access to Essential Medicines is considered as a part of ‘Right to Health’ in the National Legislation of Cook Island (Cook Island Ministry of Health, 2013). There are legal provisions for providing patents to the medicines manufacturers which involve medical supplies, laboratory supplies, pharmaceuticals and the equipment. However, there are no licensed manufacturers and marketing authorisations of the medicines in the country. Generally, the medicines are imported from New Zealand and Australia. There are no legal provisions for wholesalers and distributers to follow the Goods Distribution Practices or provisions to control the market of medicines. There are legal provisions to control the advertisement and promotion of both prescription and non-prescription medicines (Cook Island Ministry of Health, 2013).
The access to medications is publicly a responsibility of the Pharmacy Department under the Health Ministry. A list of essential medicines is approved by the Ministry of Health Drug and Therapeutics Committee to be present in the pharmacies, clinics and hospitals. The medicines are chosen based on their effectiveness, cost and safety. The essential medicines are aimed to address the treatment of commonly found medical conditions and emergencies in the country by ensuring the equal access for the general public of these medicines. Only the medicines listed in the essential medications list are made available in the hospitals and pharmacies. The essential medicines are produced by reliable suppliers to comply with the international standards in manufacturing the medicines.
The Cook Islands is characterised by the prevalence of non-communicable diseases, due to alcohol use, tobacco use, high blood pressure, physical inactivity, high level of blood glucose and cholesterol, and malnutrition (STEPS Report, 2012). In relation to this, the National Strategy and Policies of Cook Islands was revised in 2015 to provide improved care for NCD patients. Several revisions were made in relation to provision of care, medicines and reduction of NCD’s in Cook Islands (Te Marae Ora, 2015).
The core indicators of access to essential medicines in the Cook Islands is identified by the indicators such as: Maintaining the average availability of minimum 14 essential medicines in private and public healthcare facilities, maintaining a median consumer price ratio of 14 essential medicines in private and public care facilities (WHO, 2010). The data collected is based on the national survey of availability and medicine prices of essential medicines.
In 2017 the most highly demanded medicines in the Cook Islands were folic acid and iron tablets (UNICEF, 2019).
Procurement
There is a public sector procurement policy to ensure the quality of medicines (Cook Island Ministry of Health, 2013). The Procurement is based on the supplier’s prequalification and involves a minimum of three quotations from the chosen suppliers. The procurement is limited by the monetary value by the authoritative power, in other words, companies can procure as much as their financial condition permits. The process of quality assurance also depends on the prequalification of the products and suppliers. The public procurement process also involves tenders from international companies and direct purchasing. It is an important task to track the expiry dates of the medicines at the public Central medical Stores. There are no legal provisions for licensing the distributors and wholesalers in private sector.
National Structures
Cook Island has National Structures and Policies to govern the selection of essential medicines and to encourage the rational use of drugs in the country. There is a publicly available list of essential medicines known as Essential medicines List (EML) which comprises of 430 medicines (Cook Island Ministry of Health, 2013). The medicines in the list are selected by the National Drugs and Therapeutic Committee undergoing through written consent. The country has National Standard Treatment Guidelines (NSTG) for the treatment of common illnesses. However, the mechanism to align the guidelines with the EML is under way. There are no independently funded or public national medicines information centres which could offer details about the medicines to dispensers, consumers and the prescribers. There is no regularity in public education campaigns over the topic of rational medicinal use. The National Drugs and therapeutics committee ensures the promotion of rational use of medications. The medicine education pamphlets are distributed by Pharmacy departments in collaboration with Community Health Service Directorate.
The EML for the country involves medicines for children specifically chosen on the criteria of disease pattern and the medicines’ cost. There are no national strategies for identifying the antimicrobial resistance programs however the quality management department promotes the right use of antimicrobials and the prevention of infection (Burroughs et al., 2003). It does this through educating distributors, consumers and prescribers regarding medicines and disease prevention strategies. No national reference laboratory is present to coordinate epidemiological surveillance of antimicrobial resistance across the country.
To better handle the increasing NCD’s in the region, the National Strategy for NCD’s was revised in 2015. The revised strategy included aimed specifically at reducing the incidence of NCD’s and reduction of premature deaths.
The main objectives of the revisions were:
To strengthen partnerships for implementing NCD strategies
To reduce alcohol and tobacco consumption
To reduce obesity
To reduce salt intake in residents’ diet
To increase fruits and vegetable intake in residents’ diet
To prevent a control NCD through health strengthening system
To ensure equal opportunity for medicines to those with mental illnesses
To reduce physical inactivity
To improve monitoring and evaluation of NCD’s
The National strategy has allocated $17000 annually to ensure there is up to 80% availability of basic health equipment and medicine to treat NCD patients in both private and public sectors (Te Marae Ora, 2015).
Distribution
The Pharmacy Department has a Central Medical Store (CMS) which distributes the medicines nationally (Cook Island Ministry of Health, 2013). There are specific Ministry of Health (MOH) guidelines to safeguard the goods Distribution Practices (GDP). The Central Medical Stores employ several practices like forecasting of order quantities, requisition, preparation of picking up the medicines, reporting the stock in hand, reporting the outstanding orders, management of expiry dates and reporting the out of stock products.
The medicines are distributed free of charge to certain population groups like children under 5, poor people, elderly people, pregnant women and residents of outer islands.
Pharmacist Training
The pharmacists are provided mandatory training for the dispensing practices of pharmacy in the Cook Islands. The curriculum of training basically involves the concept of EML and the use of STGS. The country allows substitution of generic medicines at the private and public dispensaries. The antibiotics are sometimes sold without a prescription over the counter although the injectable medicines are not sold this way. There is no professional code of conduct to direct the pharmacists’ behaviour. Sometimes the nurses prescribe the prescription only medicines at the level of primary care at the public sector facilities.
Recommendations
National Medicines Policy needs to be implemented to address the incision of outstanding issues. The Drug and therapeutic Committee needs to have a strong role to monitor the Antibiotic Resistance through the implementation of National Medicines Policy (Division of Health Sector Development, n.d.).
The Pharmacovigilance capacity need to be improved to recognise and report the adverse reactions of medicines.
Drug and Therapeutic Committee should play a strong role in monitoring the antibody resistance through implementation of NMP.