Meeting of the Ministers of Health for the Pacific Island countries : Meeting of the Directors of Health for the Pacific Island Countries, Rarotonga, Cook Islands, 6-7 August 1997 : report

(WP)HRHIICP/HRH/OO2-E Report series number: RS/97/GEI19(COK) RS/97/GE/20(COK) English only

REPORT

MEETING OF THE MINISTERS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES MEETING OF THE D:RECTORS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Rarotonga. Cook Islands 4-5 August and 6-7 August 1997

Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila. Philippines August 1997

Note The views expressed in this report are those of the participants. consultants. temporary advisers .. and observers in the Meeting and do not necessarily reflect the policy of the World Health Organization.

This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for the participants. consultants, temporary advisers. and observers in the Meeting of the Directors of Health for the Pacific Island Countries and the Meeting of the Ministers of Health for the Pacific Island Countries held in Rarotonga, Cook Islands, from 4-5 and 6-7 August 1997, respectively ..

CONTENTS

A. I.

MEETING OF THE DIRECTORS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES. RAROTONGA. COOK ISLANDS. 4-5 AUGUST 1997 .................... I INTRODUCTION ...................................................................................... I I . I Background ........................................................................................ I 1.2 Objectives....... . ...................................................................... I 1.3 Participants and resource persons................................... ........................ 2

2. 2.

OPENING CEREMONIES ........................................................................... 2 PROCEEDINGS ...................................................................................... 3 2.1 Healthy Islands.......... ........................ . ........................... 3 2.2 Human resources fOl health .................................................................. 5 2.3 Pharmaceuticals and essential drugs in the Pacific....... . ......................... 7

3. B. I.

CONCLUSIONS AND RECOMMENDATIONS .............................. .............. 9 MEETING OF THE MINISTERS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES. RAROTONGA. COOK ISLANDS. 6-7 AUGUST 1997 .................. 10 OPENING CEREMONIES................................................................... .. 10

2.

REPORT OF DIRECTORS MEETING .......................................................... II 2.1 2.2 2.3 2.4 2.5 Discussions.. . .... . . .. .......................................................................... Statements from observers.. .... .............................. .. .. ... .. .............. .... Closing session .................................................................................. Summary of main comments raised ......................................................... Closing ceremonies ............................................................................ 12 13 14 14 15

3.

CONCLUSION AND RECOMMENDATION ................................................. 15 ANNEXES: ANNEX I ANNEX 2 AGENDA .......................................................................... 17 PROGRAMME OF ACTIVITIES............................................. 19

A.

MEETING OF THE DIRECTORS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES, RAROTONGA, COOK ISLANDS, 4-5 AUGUST 1997

I.

INTRODUCTION

1.1

Background

A meeting of Ministers of Health for the Pacific islands was convened at Yanuca Island, Fiji, from 6 to 10 March 1995 in response to the rapidly changing social and economic situation affecting quality of life and health in Pacific island countries. Consensus was reached on a course of action to place the health and well-bt:ing of Pacific islanders at the centre of national development plans. This is reflected in the Yanuca Island Declaration on Health in the Pacific in the 21 st Century. The declaration commits countries to act to enhance the quality of life and the continuing well-being ot people through the Healthy Islands approach as the Pacific's response to Nell' horizons in health in the Western Pacific Region of World Health Organization. As agreed at Yanuca. a follow-up meeting of Ministers of the Pacific was convened at Rarotonga, Cook Islands 011 6 and 7 August 1997. A preparatory technical meeting was held (4-5 August) prior to the meeting of Ministers of Health with the participation of Heads of Departments of Health or Directors of Health or their nominees. The participants collaborated with the WHO Secretariat, consultants and temporary advisers to prepaJ:e the necessary background materials in the context of reviewing the status of implementation of the Yanuca recommendations. 1.2 Objectives The objectives of the meeting were: (l)

to review the implementation status of the recommendations of the Yanuca Island Declaration in relation to: (a) health promotion and health protection within the framework of "Healthy Islands" ; (b) health resource development in the Pacific at undergraduate and postgraduate levels; and (c) issues relating to the supply and management of pharmaceuticals and medical supplies within the context of the development of essential drugs policies in each country/area of South Pacific;

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(2) to draft proposals to further strength<!n the implementation of the Yanuca Island Declaration in the overall context of New horizolls ill health for consideration by the .Ministers of Health. 1.3 Participants and resource persons

The meeting was attended by the Permanent Secretaries/Directors of Health or deputized representatives from 20 countries. Four consultants and four temporary advisers from the Region, together with seven WHO Secretariat members comprised the technical resource pool. The observers included representatives of associated UN agencies. bilateral aid and partner agencies. and nongovernmental organizations. Annexes I to 4 contain the agenda, detailed programme of activities and list of participants.

2.

OPENING CEREMONIES

After the traditional opening prayers. Dr Roro Daniel. Director-General of Health for the host country. welcomed all participants to the Cook Islands. and highlighted the importance of the meeting for the Government and people of the Cook Islands in promoting the theme of Healthy Islands adopted in the Yanuca Island Declaration. Dr S. T. Han. Regional Director of WHO for the Western Pacific. presented the opening address for the meeting (Annex 5). Dr Han spoke of the Yanuca Declaration, adopted two years ago by Pacific Island Ministers of Health, in Yanuca. Fiji. which provided the basis for adopting Healthy Islands as the unifying theme for health development in the Pacific beyond the year 2000. This is the Pacific's response to the challenges of the New horiZOlls ill health policy agreed to by the Western Pacific Regional Committee in 1994. The Regional Director explained that at Yanuca, three major issues were addressed: health promotion and environmental protection; human resource development in health; and availability of adequate pharmaceuticals and other health supplies. During the last two yeas, the Yanuca principles had been applied by most of the Pacific island countries in the formulation of their health development plans. Dr Han stressed that. over the next few days, it would be important to identify further steps needed to apply the concept of Healthy Islands. For this purpose it would be necessary to refine countries' common vision of healthy islands. Further strengthening of infrastructures for health through proper training. and the provision of pharmaceuticals. relevant equipment and adequate supplies would also need to be undertaken within this new context of health in the Pacific. The meeting was officially opened by the Honourable Minister of Health. Mr Tupou Faireka. In his address the Minister conveyed the warm welcome of the Government and people of the Cook Islands and informed the meeting that Cook Islands was celebrating its 32nd year as a self-governing island country. The country's national development policy which aims at "achieving a standard of living better than any in the region and in harmony with our culture and environment" is in line with the Healthy Islands concept outlined in the Yanuca Declaration two years ago. Activities reflecting to the Healthy Islands concept that are being implemented in the

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country with excellent results relate to immunization coverage, low infant mortality and maternal mortality rates to name a few. Noting that in order to implement the Healthy Islands concept adopted at Yanuca. it is important for all concerned parties in health to work together, the Minister wished the representatives a productive meeting. The meeting then elected Dr Roro Daniel of Cook Islands as Chairman and Mrs Myriam Abel of Vanuatu as Rapporteur.

3.

PROCEEDINGS

Dr B.P. Kean. Director Programme Management. WHO/WPRO, gave an overview of the issues to be discussed. He reviewed the evolution of the current regional priorities and the adoption of the New horiZOlls ill health as the Region's framework for addressing them. He also recalled that in 1995. the concept of Healthy Islands was adopted by the Pacific island ministers of health at Yanuca Island. as the Pacific island countries' framework for implementing New horizons in health. He noted that all of these activities are contributing to the development of a renewed Regional Health for All Policy for the 21st Century which will be the focus of discussions by the Regional Committee at its 48th session in Sydney next month. The meeting was encouraged to consider further actions towards: • developing national Healthy Islands plans of action; • designating focal agencies and intersectoral steering committees to support coordination and monitoring of plans; and participating in Healthy Islands information sharing exercises.

• 2. I

Healthy Islands

2.1.1 A discussion paper on Healthy Islands prepared by the WHO Secretariat was presented. The paper reviewed Healthy Islands experiences throughout the region in relation to entry points at the family, community. and national level. Experience to date clearly indicates that national and community ownership are critical to success; that broad-based approaches are essential to achieving targets; and that all efforts must be sustainable in the long run if lasting impacts are to be achieved. Also there needs to be a commitment to harmonizing diverse. but related activities, and to establishing coordination mechanisms that help sustain momentum.

It is clear that an effective Healthy Islands framework requires continuous intersectoral and integrated support from the various parties involved. Also, in dev~loping and implementing common approaches within such a framework, we need to allow for individual Pacific island country differences and to respect diversity.

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2. I. 2

Discussions

Dr Puka Temu. Director of Health of Papua New Guinea. informed the meeting that his country has undertaken policy changes during the period since the Yanuca meeting. incorporating its recommendations in a new Medium-Term Development Plan. Ministry of Health interventions reflecting the recommendations of the Yanuca Island Declaration. were timely and relevant to this process. In the present government, health and education are now high priority sectors. The amount of headway made in promoting intersectoral approaches to health has been due. in part to health officials adopting the language that policy makers are familiar with in order to receive acceptance of Healthy Islands concept. Dr Luke Rokovada, Permanent Secretary of Health of Fiji. presented the experience of the Kadavu Rural Health Project which was a unique and comprehensive approach financially supported by AusAID. The four main components of the Kadavu Project were: • Infrastructure (upgrading, building and renovating health centres, buildings etc):

• Community Development (essential for success and sustainability); • Human Resource Development (upgrading skills of all health workers):

• Training (involving at all levels of society). Among other things. the project served as a forum to initiate the Healthy Islands process in Fiji by focusing on ways in which the community could be actively involved in the planning and management of their village environment. Total cost of the project was F$6.5 million. with F$3.5 million for infrastructure and the balance for the other activities. A major outcome of the Kadavu experience is the development of a protocol for improving health and well-being that can be replicated in any village setting in Fiji. The Kadavu experience has also shown the importance of setting up a good. locally managed health information system. Dr Eti Enosa. Director of Health of Samoa. observed that models such as the Kadavu Project have associated costs which may be prohibitive for other island countries. particularly small island states. Priorities for each Pacific island country differ. however it is encouraging to note the general progress being made by all Pacific island countries in implementing the Healthy Islands concept. Dr Caleb Otto. Director of Public Health of the Republic of Palau related that the New horizons ill health and Yanuca Island Declaration principles have been incorporated in three important national documents: the Palau 20/20 National Master Development Plan; the Palau National Population Policy; and the Palau Sustainable Human Development Report. The basic challenge now is to translate the implied support for the Healthy Islands approach in these documents into action.

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The meeting broke into three groups to discuss the possible mechanisms for developing national plans of action for Healthy Islands. including the associated coordination mechanisms. The consolidated outputs of the three groups were as follows: (I) The Pacific island countries are prepared to reaffirm their commitment to Healthy Islands as the unifying theme for health development in the Pacific beyond the year 2000. (2) (3) (4) There is a need to agree on a working definition of the concept of Healthy Islands. Coordinating mechanisms are required at all levels. Action plans should be developed.

Based on the ensuing discussion. the meeting agreed to endorse the recommendations for Agreement by the Ministers. 2.2 Human resources for health

2.2.1 A discussion paper on the status of human resources for health in the Pacific. prepared by the WHO Secretariat w~s presented and discussed. Despite recent progress. in many areas of human resources development. there remains room for improvement in terms of upgrading basic levels of training for health workers and health related workers at all levels. An issue for the meeting to address is how human resources development fits into the Healthy Islands plans of actions that Pacific island countries are putting into place. Pacific island countries' health workforce plans must be updated to take into account the ongoing changes in health technology. Training mid-level practitioners is particularly important in Pacific island countries. given the fact that this group of professionals can offer small. isolated and rural communities a high level of health services at affordable costs. Also of concern is the future direction of undergraduate and postgraduate medical training in the region and the initiatives currently underway at the Fiji School of Medicine (FSM) and the University of Papua New Guinea (UPNG). These two institutions comprise the backbone of health professional training in the Pacific. 2.2.2 University of Papua New Guinea

Dr Barra Amevo gave a presentation on the future plans of the University of Papua New Guinea's Faculty of Medicine. Plans are underway to merge the various related faculties at UPNG into a School of Medicine and Medical Sciences. In general. programmes of study will be divided into pre-clinical. clinical. and community medicine disciplines. In the area of postgraduate studies, the University of Papua New Guinea maintains postgraduate programmes in accident and emergency care, radiology, oncology and rural health, offers a Higher Diploma in Surgery and has a Masters in Public Health Programme. Research degrees are also offered in medical sciences at the Masters and Doctorate levels. A Masters in Dentistry is being developed. Although the total cost of training at UPNG is around K20,ooo per year. fees for students at the Bachelor of Medicine and Bachelor of Surgery (MBBS) level are K3600 (tuition/accommodation); and a minimum of approximately five to ten places are reserved for regional governments to send their students.

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Since the Yanuca Island meeting in 1995, the University of Papua New Guinea has conducted talks with the Solomon Islands concerning registrar training programmes; signed a Memorandum of Understanding (between the Governments of Papua New Guinea and Samoa) to structure programmes designed to alleviate of Samoa's brain drain problem; and hosted a delegation from the Fiji School of Medicine (FSM) to discuss mutual interests. 2.2.3 Fiji School of Medicine

In his presentation on progress at the Fiji School of Medicine (FSM), Dr Jimi Samisoni observed that the Yanuca Island Declaration features the Fiji School of Medicine as an important avenue for training Pacific medical workers. Much work has been done since Yanuca to review the Primary Care Practitioners (PCP) curriculum, with the result that FSM has been able to streamline this programme 10 suit the changing times. Various collaborative efforts to promote postgraduate training demands are being implemented with various Pacific rim medical agencies; for instance, the anaesthetics and child health programmes with the University of Otago's distance education programme. Since Yanuca, the restructuring of the Fiji School of Medicine, to become an autonomous institution has been progressing. Stage Two of the restructuring process for Fiji School of Medicine includes the consideration of full autonomy in 1998. It is envisaged that the restructured FSM council will include three Pacific island country representatives. Also costs involved in operating the school will increase to reflect the real cost of education. 2.2.4 Fiji School of Medicine Tuition Fees

The Council of the Fiji School of Medicine expects fee structures for the School in 1998 in line with the move to full autonomy and operation. Currently, the fee for tuition and accommodation for each student at the Fiji School of Medicine is about F$SOOO (1985 prices). The estimated actual cost is F$IS 000. 2.2.5 Discussions

Discussions focused on the issues of brain drain, the need to ensure that Pacific island in-country efforts in health training and human resources development are not redundant, and the coordination of partner agency input into human resources development. In view of resource constrains, Pacific island countries must be mindful of the high costs involved in maintaining both quality level health workers and service delivery. The area of multi-skill development needs to be explored. It was noted that the most important form of health intervention is at the district and rural levels. It is clear that manpower in the work force will become more technically demanding but will require multi-skilling attributes. Particular attention must be paid to mid-level personnel training. The idea of exploring telecommunications and distance education options for Pacific island countries was supported. Summary of main points discussed included: • a lot of curriculum development taking place (particularly at the postgraduate level); • emphasis needs to be on rural health; • continued dialogue between institutions to avoid duplication and for consistency and coverage;

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•

consideration for more training programmes to be conducted in-country with minimum time outside for training; mid-level workers are still very important and focus on training and deployment of this cadre is important; and cost implications for training programmes and self-reliance; further work to look at what Pacific island countries can afford is required.

•

• 2.3

pharmaceuticals and essential drugs in the pacific

2.3.1 A discussion paper on pharmaceuticals and essential drugs in the Pacific prepared by the WHO Secretariat. was presented. The Yanuca meeting clearly emphasized the desirability of a bulk purchasing scheme for drugs as well as activities aimed at improving the quality of drugs and drug use in Pacific island countries. The Yanuca Island Declaration embodied the concerns of a bulk purchasing scheme for Pacific island countries. quality assurance programmes. and an exchange of information system on pharmaceuticals and medical equipment and supplies. Since the Yanuca meeting. activities conducted or underway in the pharmaceuticals area include: a feasibility study on the bulk purchasing scheme; a seminar conducted on national drug policies for Pacific island countries; preparations for an upcoming Workshop on Drug Supply Management in November 1997; an assessment of the status of national laboratories in certain Pacific island countries; and publication by the University of South Pacific (USP) of a medicinal plants book. It was concluded that in order for any form of bulk purchasing to progress. the following critical factors must be addressed and implemented: a comprehensive list of drugs used in the region with quality specifications; a list of accredited suppliers/manufacTUrers; related procedures and terms and conditions during procurement; a surveillance and monitoring programme needs to be established; communication and information systems for island requirements; and affirm commitment by Pacific island countries to the scheme.

In the case of the proposal for a quality assurance programme. it was noted that sampling and testing of pharmaceuticals must be coordinated and aligned with international quality standards and WHO certification scheme and standards must apply. Other activities would follow on from this. especially (in order of priority): • • • • Exchange of drug information Utilization of WHO Collaborating Centres in the Western Pacific Region for testing drugs (Australia, Malaysia. Singapore) Establishment of common regional laboratories Development of national quality assurance/quality control facilities.

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In the area of the exchange of drug information scheme, proposed activities would include development of (in order of priority): • • • • • Standardized format of information exchange Bulletins/newsletters at various levels Emails & electronic networks at various levels Common drug information centre in the Pacific National drug information services/centres. Discussions

2.3.2

Discussions centred around the testing of the bulk funding scheme, clarification sought on revolving fund schemes conducted by some countries and various Pacific island countries' experiences with purchasing drugs, materials and equipment. An important factor that needs to be considered in relation to the bulk purchasing scheme is reliability, in terms of suppliers. distribution systems, transportation networks, purchasing procedures and cost effectiveness. Also currency differences, timeliness of supply and procurement systems need to be examined. In the case of the proposed drug procurement scheme currently being considered between Tuvalu and Fiji. whereby Tuvalu's drug supplies are included in Fiji's procurement system. this came about because of constraints Tuvalu has due to small population and size. For Tuvalu, combining the procurement of their drugs with Fiji helps ensure the availability of drugs on a timely and cost effective basis. For some Pacific island countries, the procurement of drugs and supplies is being considered in the light of privati sat ion realities. For some Pacific island countries, budgetary constraints and procedures interfere with smooth ordering and procurement of essential drugs. In the case of Pacific island countries with sound ties with the United States of America and France, various USA and French legislation and acts may influence their procurement systems. Summary of discussions • Small island states may consider joining other countries, with priority on high-cost. low quantity drugs. • The Fiji and Tuvalu collaborative effort in bulk purchasing should be encouraged and evaluated so an example for consideration by other interested Pacific island countries. • A programme for coordinated sampling, screening and testing of pharmaceuticals should be established. • An information exchange system should be set up throughout the Pacific.

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4.

CONCLUSION AND RECOMMENDATION

The meeting drafted recommendations Vlhich were later adopted by the Ministers and incorporated into the Rarotonga agreement attached here as Annex 8.

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B.

MEETING OF THE MINISTERS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES. RAROTONGA, COOK ISLANDS. 6-7 AllGUST 1997

I.

OPENING CEREMONIES

After the opening prayer. the Honourable Tupou Faireka. Minister of Health. Cook Islands, gave words of welcome. Dr S.T. Han. WHO Regional Director for the Western Pacific. presented the keynote address (Annex 7) In his presentation. it was noted that the health of over 6 million Pacific islanders would be affected by deliberations emanating from this meeting. The Yanuca Island Declaration adopted in 1995. proposed actions to further enhance health for the people of the Pacific by adopting the Healthy Islands approach to health in the future. Although admirable progress has been made in implementing the concept of Healthy Islands. it is necessary to institutionalize this concept into a policy framework. As the year 2000 draws near. it is important to begin addressing the question of 'how can health systems be changed to keep pace with new development and the advances of modern technology?' The Honourable Prime Minister of the Cook Islands. Sir Geoffrey Henry. addressed the meeting. He proposed that the meeting consider the act of health and healing in totality physical. medical. spiritual. He referred to several important health issues. one of the most important being the cost of being what we are. In the Pacific. the cost of pharmaceuticals is particularly burdensome. It was noted that in the Yanuca Island Declaration. that the bulk purchasing scheme recommendation was supported but apparently little has happened since then. He noted the example of the Caribbean islands where a system was set-up to service all CARICOM members in drugs and medical supplies. Previously. traditional herbal medicine and treatment was banned from being used in the hospitals and health clinics. He proposed that this issue be discussed at this meeting as one way to lower the cost of health to people. The Pacific Forum next month will address many issues and economic reform will be high on the agenda. But health and education are important priorities in all countries. He accepted the Regional Director's request that the recommendations of this meeting be raised at the Forum. In closing. he stated that it was his fervent hope that this meeting will be bold enough to look at the question of lowering the cost of health and of looking at alternative medicines and practises. He wished the meeting good deliberations and officially opened the meeting. The Honourable Tupou Faireka, Minister of Health. Cook Islands. was elected chairman of the meeting. Dr Eti Enosa of Western Samoa and Ms Myriam Abel of Vanuatu were elected rapporteurs.

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2.

REPORT OF DIRECTORS MEETING

After adoption of the agenda. the report of the Directors of Health Meeting was presented by the Chairman. Dr Roro Daniel. In introducing the report. Dr Daniel advised the Ministers meeting that the meeting of Directors reviewed work activities since Yanuca with lessons learnt summarized as follows: • • • • • Some ambiguity in the healthy island concept in relation to the specifics of its content and the processes involved; Agencies of health need to take the lead in facilitating partnerships in promoting healthy island concepts in their programmes; Defining priority health related issues should emphasize community involvement and reflect sociocultural context; Partnerships need to emphasize shared ownership; Partnership process should be action oriented and with clear outcomes and indicators;

• High level political support must be reflected in national development policy and plan framework; • Success in implementing the process depends on clear guidelines. protocols and human and financial resources; • Coordinating mechanisms must he established for national. international and bilateral agencies to coordinate their input; • Opportunities for sharing learning among Pacific island countries must suffice. In the area of human resources for health conclusions. Dr Daniel advised that the Directors meeting acknowledged that appropriate and sufficient human resources in the health sector was essential to achieving Healthy Islands' goals. The main conclusions of discussions on human resources for health are encapsulated in the following headings: reorientation of training programmes towards Healthy Islands; workforce planning and management; training institutions for the health workforce; curriculum development: mid-level health practitioners; and postgraduate medical education. Recommendations emanating from discussions on Pharmaceuticals and essential drugs and medical supplies in the Pacific highlighted: continued support to exploring bulk purchase scheme avenues for Pacific island countries and areas and alternative approaches to improve purchase of drugs; investigating and developing mechanisms to improve the quality of pharmaceuticals purchased and to maintain drug quality standards; and to establish a drug information exchange scheme between Pacific island countries and regions. The secretariat clarified the query from the meeting relating to the Healthy Islands concept having an ambiguity situation. The Directors meeting recognized that some island countries were coming to terms with the Healthy Islands concept in terms of it being a process and a means to an end. Also the meeting consensus was that island health ministries are becoming more aware of the need to perform in partnership with other agencies and groupings.

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2.1

Discussions

The Papua New Guinea representative shared the experience of his country in practicalising the Yanuca Island Declaration and Healthy Islands concept. The Honourable Masao Ueda. Minister cf Health. Palau. suggested the definition of Healthy Islands remain generic/flexible. He commended the coordinating mechanisms and plan of action in the Observations and Recommendations paper and reiterated the importance of top policy level support. In respect to Palau, at the top level, the principles of the Healthy Islands are integrated into Palau's 20/20 Masterplan document, and the outcome of Yanuca are being addressed within the legal national documents in order to be able to seek support locally and internationally for the implementing the Healthy Islands concept. The Honourable Leo B Smith, Minister of Health and Social Welfare, Fiji. informed the meeting that his delegation would field answers to any query on the Fiji School of Medicine in relation to cost structures and other matters. He added that as policy makers for our island countries we need to emphasize partnerships within our countries. For instance collaboration with the education system of our countries and the importance as the paper highlights to partnership in implementing Healthy Islands principles. The Honourable Misa Telefoni Retzlaff. Minister of Health, Samoa, alluded to the main points made by the Prime Minister of the Cook Islands this morning and encouraged the meeting to produce a Rarotonga resolution in the wake of the Yanuca Island Declaration. He made general observations on the bulk purchasing of pharmaceuticals and medical supplies, which can become a reality if credibility is established in our country with the Ministry of Finance. A logical suggestion is for Pacific island countries to bulk purchase in terms of obtaining the tenders for supplying the drugs and then allowing each island member to deal with the suppliers of drugs in terms of quantity and payment. A firm commitment from in our budgets will allow room for exploring these types of options. On the question of alternative medicine it is noted that although Yanuca Island Declaration made mention of this there is nothing in the reports before us. The Honourable Masao Ueda, proposed amendments to the text in the human resource paper. Amendments were received by the Secretariat for amending. The Honourable Minister noted in the record of the Directors of Health meeting that the Fiji School of Medicine would raise their fees from $5000 to $15000. He asked if a break down of what the increase entailed could be given. The Head of the Fiji School of Medicine, explained the proposed expected fee structure increases at the School. The Honourable O'Love Tauveve Jacobsen, Minister of Health, Education, the Environment and Community Affairs, Niue, offered her views on the traditional medicine issue and advised that in Niue there is a place for traditional medicine and each Pacific island countries should examine this issue in the case of their own country. She affirmed the importance of any change being made from the top down and related the experience in Niue in terms of implementing the Healthy Islands project from the top down. As Minister she chairs the 'Moui Olaola' (Healthy Islands) Project Committee which incorporates all NGO and government agencies. Prior to this committee, Healthy Islands related issues were implemented in a fragmented fashion. By bringing all partners with a role to play in promoting Healthy Islands concepts we were able to approach implementation of the project in a wholistic manner. Tobacco smoking was identified as the main health problem. Smoke-free zones were declared and new health policy initiatives declared all public offices smoke-free zones. Visible advertising of tobacco was disallowed. Also school health education modules were developed

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and integrated into the school curriculum from primary to secondary schools. Besides community support. AusAID provided financial support. The Secretary of Health for Papua New Guinea, Dr Temu. shared experience on health promoting schools and HIV/AIDs control in his country. In July 1995, a National Coordinating Committee for Health-Promoting Schools was formed to progress the concept of Healthy Islands in schools. Collaboration was with the Department of Health, Department of Education and WHO. Four provinces in Papua New Guinea have formed Provincial Health Promoting School Committees tasked with expanding health-promoting schools in all the community schools and related institutions, and to coordinate the programme. Work in the area of HIV/AIDs is ongoing. Mr Koji Tsuji, Councillor, International Affairs, Ministry of Health and Welfare, Japan, addressed the meeting. This meeting maintained the importance of human resources development and the specific advocating of the Fiji School of Medicine as an important player in human resources development for health. For the information of the meeting. Japan provided funding support in 1991 to 1992 to Fiji School of Medicine and Colonial War Memorial Hospital (CWMH) for renovating and constructing buildings. He informed the meeting that under a partnership agreement between Japan and WPRO. two new fellowships would be made available from 1998 and annually thereafter to support the training of students at the Fiji School of Medicine for the full six year duration. Dr Han advised the meeting of the content of WHO programme and its focus on herbal medicine and acupuncture and related techniques. The issue of traditional medicine will be included in this meeting's recommendations. 2.2. Statements from observers

Dr James Kember, New Zealand High Commission to the Cook Islands. made a presentation. For the Government of New Zealand, health and education issues feature predominantly and New Zealand has been a major supporter of health development in the region. The outcomes from this meeting will be of interest to both the Ministry of Foreign Affairs and the Ministry of Health in New Zealand. Dr Terrel Hill, Area Representative for the Pacific, UNICEF, made a presentation. UNICEF is encouraged by the meetings consideration of issues relating to the healthy islands initiative, and especially the New HoriZOlls ill health which offers an excellent policy framework for youth health. UNICEF continues to support efforts to prevent against substance abuse and to promote health behaviour of youth and will intensively promote this within the context of the Pacific programme. In the area of Vaccine Indt'oendence initiatives in the region, l2 island countries have been receiving vaccine through this facility and have begun to budget and pay for vaccines. Pacific island countries will also be aware of UNICEF support to modalities for hepatitis B procurement with support from New Zealand and Australia. This week is breastfeeding week and the meeting is reminded of the importance of Pacific island countries encouraging the certification of hospitals as baby friendly. UNICEF is pleased to work closely with the South Pacific Commission, WHO and Pacific island countries to strengthen the Health Surveillance and Monitoring systems. The more and better health information available, the more effective will be island country decision and policy making. Ms Etta Tadesse, UNFPA Representative for the South Pacific, made a presentation. She advised that UNFPA had recently approved their next four-year programme cycle (1998-2001) which reflects some of the issues considered at this meeting, such as mid-level training and institutional capacity building. She noted the meeting consideration of intersectoral collaboration in regard to linking inputs from health education and training, and the importance of adolescence health. Also outer island access to health and management and access to quality is a concern that will be addressed in the next cycle. Announced that UNFPA had approved $10 million for the next programme cycle. In closing she advised that UNFPA would look forward to a more

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streamlined integrated reproductive health programme in cooperation with Pacific island countries. Ms Gayle Nelson. Gender Issues Adviser representing the South Pacific Forum Secretariat. made a presentation. In July this year, Economic Ministers met in Cairns. Australia. An important outcome of that meeting was the recognition by Economic Ministers of the need to conduct analytical studies of the social impacts of the economic reforms in the Pacific island countries. She suggested that the meeting may look at this component as an entry point for progressing the consideration and endorsement of the Healthy Islands initiative with Heads of Governments at the upcoming Forum. For the meeting information. she advised that the Small Islands States meeting taking place before the Forum meeting next month will be considering the issue of bulk purchasing of pharmaceuticals. Dr Clement Malau, Manager. South Pacific Commission Community Health Programme. made a presentation. Since Yanuca. the South Pacific Commission and WHO signed a Memorandum of Understanding (MOU) in September of 1995 to work together. Also the SPC works closely with UNICEF and other regional and international agencies in promoting early warning systems in the region. Concerning health promotion initiatives. a Noumea Declaration (1997) endorses the concepts reflected in the Yanuca Island Declaration (YID). and aligns work to be done on the health issues Pacific island countries are addressing. He briefed the meeting on SPC Health programme activities in the areas of AIDS/STD. nutrition and noncommunicable diseases, public health surveillance network, environmental health and other prioritized areas. 2.3 Closing sessjon

The meeting then addressed the Rarotonga Agreement: Towards Healthy Islands Paper (Annex 8). Included in this paper are the following observations and recommendations: Healthy Islands initiative framework: human resources for health; and pharmaceutical matters. Discussions proceeded on the paper and amendments from the meeting were received by the Secretariat. 2.4 Summary of majn commems raised

The Honourable Tauveve Jacobsen proposed that the next meeting should be timed in the light of other important meetings in order to ensure entry of Health meeting outcomes into those other important meetings. The Honourable Masao Ueda, extended words of appreciation to the hosts and organisers of this meeting. On behalf of the Government of Palau and his delegation he announced the Republic of Palau's interest in hosting the next meeting. The meeting unanimously agreed to the expression of interest from Palau to host the next meeting. 2.5 Closing ceremonies

Closing comments by the Chair included his gratitude for the meeting confidence in his chairmanship. He thanked Minister colleagues for attending and asked representatives of ministers that did not attend to take back the best regards and wishes of the Government of the Cook Islands. He expressed appreciation to the Permanent Heads of Health from island countries and other international agency representatives he thanked them for their active participation at this meeting. Also to Dr Han and the WHO Secretariat he thanked them for administrative, professional and management support to this meeting. On behalf of the meeting, he extended thanks to Dr Daniel and Dr Parkinson for the work they put into organizing this meeting.

- 15 -

In Dr Han's closing address, he extended words of appreciation to all the workers who have been working hard to facilitate this meeting and mentioned the exceptional work of the rapporteurs to the meeting (Dr Enosa and Ms Abel) and the WHO Secretariat. He noted that one of the outcomes of this meeting is the defining of Healthy Islands initiatives and paraphrasing it into concrete plans. These initiati ves will definitely promote the heahh status of the people in the Pacific and will serve as a model for the rest of the world. In the area of pharmaceuticals we have agreed to observe some of the countries that are interested and to learn from that experience. Concerning the Rarotonga Agreement: Towards Healthy Islands, he will follow up by contacting the Forum Secretariat to put forward the outcomes of this meeting at the next possible Forum meeting. He congratulated Palau's intention to host the next meeting and with his Secretariat will work at a suitable time for the next meeting. (A presentation of watches was made to Minister Faireka and Dr Daniel by Dr Han). In closing he thanked all meeting participants for their active deliberations and extended thanks and gratitude to the Government of the Cook Islands and Ministry of Health for their support. The Chair declared the meeting closed.

3.

CONCLUSION AND RECOMMENDATION

The Meeting of the Ministers of Health for the Pacific Island Countries adopted the Rarotonga Agreement: Towards Healthy Islands (Annex 8) a document that summarizes the review of the positive experience of the past two years in implementing the Yanuca Island Declaration. The meeting reaffirms the importance of partnerships among communities, government departments and other sectors in resolving priority health issues.

ANNEX 1

AGEI"DA

1. 2. 3.

Opening ceremony Election of officers and adoption of the agenda Overview of the Meeting of the Directors of Health for the Pacific Island Countries and the Meeting of the Ministers of Health for the Pacific Island Countries. WPR/HRHIDHI(1)97.2 Presentation of discussion paper on environmental health and health promotion: Healthy Islands. WPR/HRHIDHI(I)97.3

4.

5.

Presentation of discussion paper on human resources for health: New Horizons in Human Resources for Health. WPR/HRHIDHI(l)97.4

6.

Presentation of discussion paper on pharmaceuticals: Supply and management of pharmaceuticals and medical supplies WPRIHRHIDHI( 1)97.5

7. 8. 9. 10. 11. 12. 13. 14. 15.

Increase in Fiji School of Medicine fees. WPR/HRH/DHI(l)97.6 Consolidation of conference proposals and motions for the Meeting of the Directors of Health Closing ceremony Opening ceremony for the Meeting of the Ministers of Health Cook Islands Ceremonies of Welcome, opening and keynote addresses Ministers of Health deliberations Regional arrangements - paper by Dr HP. Kean, Directors. Programme Management Adoption of the Statements of the Meeting of the Directors of Health. Closing ceremony

ANNEX 2

PROGRAMME OF ACTIVITIES

Monday 4 August 1997 08.30 09.00 Registration Opening ceremony Welcome address by: Honourable Tupou Faireka. Minister of Health of Cook islands Opening remarks by: Dr S.T. Han. WHO Regional Director for the Western Pacific Introduction of participants Election of Chairman and Rapporteurs (2) 10:30 10:45 11 :00

Group photo session and coffee break Adoption of agenda Presentation of the "Overview of the meetings" by: Dr B.P. Kean. Director Programme Management Presentation of discussion paper on: "Healthy Islands" Open forum and discussions

12:00 14:00 15:30 15:45 - 17:00 18:30

Lunch break Continuation of discussions Coffee break Conclusions and recommendations Minister's Reception

- 20 -

Annex 2

Tuesday 5 August 1997

0830

Presentltion of dis(ussion paper on: "Human Resources for Health" Fiji School of Medicine University of Papua New Guinea Open forum and diswssions

10:30

Coffee break Open forum and discusslOlls Lunch break Presentation of discussion paper on: "Pharmaceuticals and Essential Drugs in the Pac ific" Open forum and discussions

10:45 12:00

14:00

15.30 15.45 to l700

Coffee break Consolidation and review of recommendations Closing and summary of discussions Constitution Day Celehration

18:30 Wednesday 6 August 1997

08.30 09.00

Registration Opening ceremony Welcome address by: His Excellency the Prime Minister of the Repuhlic of Cook Islands Sir Geoffrey Henry Opening and keynote address by Dr S. T. Han. WHO Regional Director fnr the Western Pacific Introduction of participants Election of Chairman and Rapporteurs (2)

10:30

Group photo session and coffee break

- 21 -

Annex 2

10:45 11:00 12:00 14:00 1530 15:45 - 17:00 18:30 Thursday 7 August 1997 08:30 10:30 10:45 12:00 14:00

Adoption of agenda Presentatic·n of the report of the Directors of Health meeting by the Chairman of that meeting. Lunch break Ministerial deliberations and discussions Coffee break Ministerial deliberations and discussions (Cont'd.) Governmelll Reception

Ministerial deliberations and discussions (Cont'd.) Coffee break Ministerial deliherations and discussions (Cont'd.) Lunch break Formal submission of the proposals amI motions by the Chairman Adoption of the statements of the Meeting of the Ministers of Health for the Pacific Island Countries Closing ceremony Appreciation address by: Honourable Tupou Faireka Minister of Health of Cook Islands Response by: Dr S.T. Han, WHO Regional Director for the Western Pacific Official address and closing remarks by: His Excellency the Prime Minister of the Republic of Cook Islands Sir Geoffrey Henry

18:30 Friday 8 August 1997

Regional Director's Reception Departure date

ANNEX 3

LIST OF PARTICIPANTS. CONSULTANTS. TEMPORARY ADVISERS. OBSERVERS. AND SECRETARIAT MEETING OF THE DlRECTO!{S OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES RAROTONGA. COOK ISLANDS. 4-5 AUGUST 1997

I.

PARTICIPANTS

AMERIC AN SAMOA

Dr Joseph Tufa Director of Health Services Department of Health Services Pago-Pago Tutuila Dr Roro Daniel Secretary of Health Ministry of Health PO Box 109 Rarotonga Mr Luke Rokovada Permanent Secretary for Health and Social Welfare Ministry of Health and Social Welfare Kaunikuila House

COOK ISLANDS

FIJI

S!!Y..a FRENCH POLYNESIA Dr Francois Laudon Directeur Sante en Polynesie fran<;:aise B.P. 611 - Papeete

- 24 -

Annex 3

GUAM

Mr Peter John D. Camacho Chief Puhlic Health Officer Division of Puhlic Health Departmelll of Puhlic Health and Social Services Governmelll of Guam P.O. Box 2816 Ag;ma Dr Takeieta Kienene Secretary of Health and Family Planning Ministry of Health and Family Planning Bikeniheu Tarawa Ms Sizue G. YOll1a Administrator Department of Health Services Federated States of M icrnnesia P.O. Box PS 70 Palikir Pohnpei FM 96941 Mr Philippe Chappe Sanitary Health Engineer Direction Territorial des Affaires Sanitaires et Sociales Noumea Mrs Malua Jackson Principal Nurse and Coordinator of Moui Olaola Project (Healthy Islands)

KIRIBATI

MICRONESIA. FEDERATED STATES OF

NEW CALEDONIA

NIUE

AMi South Pacific REPUBLIC OF PALAU Dr Caleh T. Otto Chief of Puhlic Health and Prevelllive Services Ministry of Health

Kill:ill:

- 25 -

Annex 3 PAPUA NEW GUINEA

Dr Puka Temu Secretary for Health Department of Health P.O. Box 807 Waigani National Capital District Dr Eti Enosa Director-General of Health Health Department Apia Mr Francis Ramoifuila Permanent Secretary Ministry of Health and Medical Services P.O. Box 349 Honiara Dr Laumeesi Maiolo Director of Health Nuku'alofa Dr Tiliga Pulusi Acting Director of Health Department of Health P.O. Box 36 Funafuti Mrs Myriam Abel Principal Officer Community Health Department of Health Port Vila

SAMOA

SOLOMON ISLANDS

TONGA

TUVALU

VANUATU

- 26 -

Annex]

'")

CONSULTANTS

Mr Brent POW\S Director. WHO Collaborating Centre for Environmental Health University of Western Sydney. Hawkesbury Bourke Street Riclllllilllil. NSW 27 53 Australia Professor Dzulkifli Abdul Razak University Sains Malaysia 11800 Minden. Penang Pulau Pi nang . Malaysia Dr A.G. Romualdez. Jr. care of WHO Regional Office for the Western Pacific United Nations Avenue Miill.i1!. Philippines Professor A rie Rotem Director. WHO Regional Training Celllre for Health Development School of Medical Educatllln University of New South Wales Sydney. Australia

3.

TEMPORARY ADVISERS

Dr Barra Ame\'o Dean. Faculty of Medicine University of Papua New Guinea P.O. Box 5623 lli2roko N. C. D . Papua New Guinea

- 27 -

Annex 3 Professor Viiay Naiuu Head. School of Social and Economic Development University of South Pacific SuYa. Fiji Dr Jimi Samisoni Head Fiji School of Medicine SuYa. Fiji

4.

OBSERVERS

JAPAN

Mr Koji Tsuji Councillor-in-Charge of International Affairs International Affairs Division Minister's Secretariat Ministry of Health and Welfare Japanese Government 1-2-2. Kasumigaseki Chiyoda-ku Tokyo IOQ-4S. Japan Dr Eiichi Seki Deputy Director International Affairs Division Minister's Secretariat Ministry of Health and Welfare Japanese Government 1-2-2. Kasumigaseki Chiyoda-ku Tokyo 100-45 Japan

JAPAN (Cont.)

- 28 -

Annex 3

NEW ZEALAND HIGH COMMISSION

Dr James Kember High Commissioner New Zealand High Commission P.O. Box 21 Rarotonga Cook Islands Mr Anton Ojala Deputy High Commissioner New Zealand High Commission P.O. Box 21 Rarotonga Cook Islands

SOUTH PACIFIC COMMISSION (SPC)

Dr Clement Malau Manager of the Commission's Community Health Programme South Pacific Commission Post Box D5 98848 Noumea CEDEX New Caledonia Ms Gayle Nelson Gender Issues Adviser Forum Secretariat Private Mail Bag Ratu Sukuna Road SmA. Fiji Dr Terrel Hill Area Representative for the Philippines, Papua New Guinea and the Pacific Pacific Regional Office United Nations Children's Fund 6th Floor NEDA Makati Building 106 Amorsolo St.. Legaspi Village Makati City. Philippines Ms Jacqui Badcock Assistant Representative UNICEF Pacific Regional Office c/o UNDP Private Mail Bag

SOUTH PACIFIC FORUM

UNITED NATIONS CHILDREN'S FUND (UNICEF)

UNITED NATIONS CHILDREN'S FUND (UNICEF) (.)

Sl.IYa Fiji

- 29 -

Annex 3

UNITED NATIONS POPULATION FUND IN THE WESTERN PACIFIC (UNFPA)

Miss Etta Tadesse UNFPA Representative for South Palifil United Nations Development Programme in Fiji Private Mail Bag

SllY.a Fiji

5.

SECRETARIAT

Dr B.P. Kean Director. Programme Management World Health Organization Regional Office for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila Philippines Dr N.V.K. Nair Director. Health Infrastructure World Health Organization Regional Offile for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila Philippines

Mrs L. Kerse Regional Adviser in Human Resources for Health World Health Organization Regional Office for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila. Philippines

- 30 -

Annex 3

Mr S. Tamplin Regional Adviser in Environmental Health World Health Organizatioll Regional Office for the Western Pacific P.O. Box 1931 United Nations Avenue 1000 Manila. Philippines Mr T. Eriksen Scientist. Pharmaceuticals World Health Organization Regional Office for the Western Pacific P.O. Box 1931 United Nations Avenue 1000 Manila. Philippines Dr S.K. Aim WHO Representative in the South Pa<.:ific PO. Box 113 .5.u.Y..a... Fij i Dr A.D. Park111son WHO Representatlle III Samoa. American Samoa. Cook Islands. Niue and Tokelau PO. Box 77 AllliI. Western Samoa

ANNEX 4

LIST OF PARTICIPANTS. CONSULTANTS. TEMPORARY ADVISERS. OBSERVERS. AND SECRETARIAT MEETING OF THE MINISTEES OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES RAROTONGA. COOK ISLANDS. 6-7 AUGUST 1997

I.

PARTICIPANTS

AMERICAN SAMOA

Dr Peter Lauvau Deputy Director of Clinical Services LBJ Tropical Medical Center Pago-Pago AS96799 Tutuila FAX: (684) 633 4590/5343 TEL: (684) 633 1222 Dr Joseph Tufa Director of Health Services Department of Health Services Pago-Pago

JJlli!illI FAX (684) 633 5379 COOK ISLANDS The Honourahle (Dr) Tupou Faireka Minister of Health Ministry of Health P.O. Box 109 Rarotonga FAX: (682) 23109 TEL: (682) 29664 Dr Roro Daniel Secretary of Health Ministry of Health P.O. Box 109 Rarotonga FAX: (682) 23109 TEL: (682) 29664

- 32 -

Annex 4

FIJI

The Honourahle Leo B. Smith Minister for Health ami S(Kial Welfare Ministry of Health and Social Welfare Kaunikuila House

S.u.Ya FAX: (679) 306 163 TEL: (679) 306 177 Mr Luke Rokovada Permanent Secretary for Health and Social Welfare Ministry of Health and Social Welfare Kaunikuila House Syyg FAX (679) 306 163 TEL: (679) 306 177 FRENCH POLYNESIA Dr Francois Laudon Directeur Sante en Polynesie frani;aise B.P. 611 - Papeete Polynesie franc;aise FAX: 430074 TEL: 460000 Mr Peter John D. Camacho Chief Puhlic Health Officer Division of Puhlic Health Department of Puhlic Health and Social Ser\'ices Government of Guam P.O. Box 2816 Agana FAX: (671) 73S-73()S17297 TEL: (671) 734-2066/5910 Dr Takeieta Kienene Secretary for Health and Family Planning Ministry of Health and Family Planning Bikenibeu Tarawa FAX (686) 28152 TEL: (686) 28151

GUAM

KIRIBATI

- 33 -

Annex 4

MICRONESIA. FEDERATED STATES OF

Ms Sizue G. Yoma Administrator Department of Health Services Federated States of Micronesia P.O. Box PS 70 £alikir Pohnpei FM 96941 FAX: (691) 3205263 TEL: (691) 320 2643: 2619: 2872 The Honourable Ludwig Keke Former Secretary of Health Republic of Nauru Central Pacific FAX (674) 444 3106 Dr Jean Paul-Grangeon Medicine Inspecteur dela Sante Adjoint Direction Territorial des Affaires Sanitaires et Sociales Noumea FAX: (687) 277 346 TEL: (687) 286 678 Mr Philippe Chappe Sanitary Health Engineer Direction Territorial des Affaires Sanitaires et Sociales Noumea FAX: (687) 277 346 TEL: (687) 286 678

NAURU

NEW CALEDONIA

NIUE

The Honourable O'Love Tauveve Jacobsen Minister of Health. Education. the Environment and Community Affairs Alofi. N.i!.le South Pacific FAX: (683) 4265 TEL: (683) 4100

- 34 -

Annex 4

Nll1E

(COIl!.)

Mrs Malua Jackson Principal Nurse and Coordinator of MllUi Olaola Project lHealthy Islands) Alo fi. N.iJ.!.e South Pac ifie FAX: (683) 4265 TEL (683) 4100 Dr Puka Temu Secretary for Health Department of Health P.O. Box 807 Waigani National Capital District FAX (675) 301 3604 TEL (675) 3013601 The Honourahle Masao Ueda Minister of Health Ministry of Health P.O. Box 6027

PAPUA NEW GUINEA

REPUBLIC OF PALAU

Killill FAX: (680)4881211;4881725 TEL (680) 488 2813: 488-2552 Dr Caleb T. Otto Chief of Public Health and Preventive Services Ministry of Health

Killill: FAX: (680) 488 1211: 488 1725 TEL (680) 4882813: 488-2552 SAMOA The Honourable Misa Telefoni Retzlaff Minister of Health Health Departmell!

AIlla FAX: (685) 21440: 26550 Dr Eti Enosa Director-General of Health Health Department

~ FAX: (685) 21440: 26550 TEL (685) 23330

- 35 -

Annex 4

SOLOMON ISLANDS

Mr Francis Ralllllifuila P~rlllanent Secretary ~,1inistry of Health and Medical Services P.O. Box 349 Honiara FAX: (677) 200H5 TEL: (677) 23402 Dr Laremeesi MaIolo Director of Health Nuku'alofa FAX (676) 24291 TEL: (67623200 Dr Tiliga Pulusi Acting Director of Health Department of Health P.O. Box 36 Funafuti FAX: (6HH) 20832 Mrs Myrialll Abel Principal COllllllunity Health Department of Health Port Vila FAX: (678)26204 TEL: (678) 22545

TONGA

TUVALU

VANUATU

2.

CONSULTANTS

Mr Brent Powis Director, WHO Collaborating Centre for Environmental Health University of Western Sydney. Hawkesbury Bourke Street. Richmond. NSW 2753 Australia TEL: (045) 701-448 FAX: (045) 783 979

- 36 -

Annex 4

Professor Dzulkilli Ahdul Razak University Sains Malaysia 11800 Minden. Penang Pulau Pinang Malaysia FAX (604) 656 8417 Dr A.G. Romualdez. Jr. care of WHO Regional Office for the Western Pacific United Nations Avenue Miillila. Philippines TEL: (652) 80 I 9290 Professor Arie Rotem Director. WHO Regional Training Centre for Health Deyelopment S~hool of Medical Education University of New South Wales Sydney. Australia FAX: (612) 9663 4946 TEL: (612) 9385 2495

3.

TEMPORARY ADVISER

Dr Barra Amen) Dean. Faculty of Medicine University of Papua New Guinea P.O. Box 5623 Boroko N.C.D. Papua New Guinea FAX (675) 267 187 TEL: (675) 324 380 I Professor Vijay Naidu Head. School of Social and Economic Development University of South Pacific SlmI. Fiji FAX: (679) 302809

- 37 -

AnnexA

Dr J imi Samisoni Fij: School of Medicine SlIY<\. Fiji FAX: (679) 303 469 TEL: (679) 311 700

4.

OBSERVERS

JAPAN

Mr Koji Tsuji Councillor-in-Charge of International Affairs International Affairs Division Minister's Secretariat Ministry of Health and Welfare Japanese Government 1-2-2. Kasumigaseki Chiyoda-ku Tok)'o 100-45. Japan FAX: 81-3-3501-2532 Dr Eiichi Seki Deputy Director International Affairs Division Minister's Secretariat Ministry of Health and Welfare Japanese Government 1-2-2. Kasumigaseki Chiyoda-ku Tokyo 100-45, Japan FAX: 81-3-3501-2532

NEW ZEALAND HIGH COMMISSION

Mr James Kember High Commissioner New Zealand High Commission P.O. Box 21 Rarotonga. Cook Islands FAX: (682) 21-241 TEL: (682) 22-20 I

- 38 -

Annex 4

NEW ZEALAND HIGH COMMISSION (ConI.)

Mr Anton Ojala Deputy High Commissioner "'ew Zealand High Commission P.O. Box 21 Rarotonga Cook Islands FAX: (682) 21-241 TEL: (682) 22-20 I Dr Clement Malau Manager of the Commission's Community Health Programme South Pacific Commission Post Box D5 98848 Noumea CEDEX New Caledonia FAX NO. (687) 26 3818 TEL. NO. (687)26 2000 Ms Gayle Nelson Gender Issues Adv iser Forum Secretariat Private Mail Bag Ratu Sukuna Road Sll.Y.iL F ij i FAX: (679) 302204 Dr Terrel Hill Area Representative for the Philippines. Papua New Guinea and the Pacific Pacific Regional Office United Nations Children's Fund 6th Floor NEDA Makati Building 106 Amorsolo St .. Legaspi Village Makati City, Philippines Fax (632) 810 1453 Ms Jacqui Badcock Assistant Representative UNICEF Pacific Regional Office c/o UNDP Private Mail Bag SuY.a......Fiji FAX: (679) 301 667 TEL: (679) 300 439

SOUTH PACIFIC COMMISSION (SPC)

SOUTH PACIFIC FORUM

UNITED NA nONS CHILDREN'S FUND (UNICEF)

- 39 -

Annex 4

UNITED NATIONS POPULA nON FUND IN THE WESTERN PACIFIC (UNFPA)

Miss Etta Tadt:s~t: UNFPA Representative for South Paci fie United Nations Dt:velopment Programme in Fiji Private Mail Bag ~Fiji

FAX: (679) 313425

TEL (679) 308022

5.

SECRETARIAT

Dr B.P. Kean Director. Programme Management World Health Organization Regional Office for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila Philippines Dr N.V.K. Nair Director, Health Infrastructure World Health Organization Regional Office for the Western Pacific PO Box 2932 United Nations Avenue 1000 Manila Philippines Mrs L. Kerse Regional Adviser in Human Resources for Health World Health Organization Regional Office for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila, Philippines

- 40 -

Annt:X 4 Mr S. Tamplin Regional Adviser in Environmental Health World Health Organization Regional Office for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila. Philippines Mr T. Eriksen Scientist. Pharmaceu!Icals World Health Organization RegIOnal Office for the Western Pacific P.O. Box 2932 . United Nations Avenue 1000 Manila. Philippines Dr S.K. AIm WHO Represematil'e PO. Box 113 Su.Y.a.. Fij i FAX:

III

the South PacItk

TEL:

(679) 300462 (679) 3()-07D: (fl79) 30-4600

Dr A.D Parkinson WHO Represelll31i\"e in Samoa. American Samoa. Cook Islands. Niue and Tokelau P.O. Box 77 Apia. Western Sanlll<! FAX: (685) 23-765

TEL: (685) 23-756 Ms Thelma Ballat Administrative Officer Regional Director's Office World Health Organization Regional Office for the Western Pacific P.O. Box 2932 United Nations Avenue 1000 Manila. Philippines

- 41 -

ANNEX 5

OPENING SPEECH OF DR S.T. HAN. REGIONAL DIRECTOR. WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC, AT THE MEETING OF THE DIRECTORS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES RAROTONGA. COOK ISLANDS. 4-5 AUGUST 1997

PARTICIPANTS. GUESTS. LADIES AND GENTLEMEN. I would like to begin by thanking Honourable Tupou Faireka. Minister of Health of Cook Islands. for his welcome and his generous cooperation in the preparations for this meeting. I would also like to express the deepest appreciation of the World Health Organization Regional Office for the Western Pacific to Dr Row Daniel. Secretary of Health. and to the Government of Cook Islands for their gracious hosting of this very important gathering. Today we are opening a meeting which may very well prove to be crucial to the health of the people of the Pacific far illlo the future. It is now almost three years since the WHO Regional Committee for the Western Pacific adopted New horiZOIlS ill health as the basic framework for health action in the coming celllury. During this time, all of you have been hard at work collaborating with WHO to flesh out the details of how we are to implement positive health through healthier living and protection of human life through healthier environments. Two years ago. on Yanuca Island in Fiji. the Pacific Island Ministers of Health agreed to apply the Nell' //O,.I:olls concepts to the Pacific. The Yanuca Declaration became the instrument for adopting Healthy Islands as the unifying theme for health protection and promotion in the Pac ific. The theme defined Healthy Islands as places where "children are nurtured in body and mind. envirorunents invite learning and leisure. people work and age with dignity. and ecological halance is a source of pride" . You will recall that the discussions at Yanuca addressed three major issues: the development of human resources for health: the need to ensure lhe availability of adequate pharmaceuticals and other health supplies; and the twin approaches of health promotion and environmental protection. The presentations which will follow in this meeting will discuss in detail what has been done during the two years since the Yanuca meeting. However. please allow me to provide you at this time with an overview of the various actions taken to implement the Declaration's recommendations.

- 42 -

Annex 5

In the area (1f the development of human resources for health. the focus ha~ been on programmes in Fiji and Papua New Guinea. The new curriculum at the Fiji Schuol uf Medlcim: appears to be on track. with the further development of postgraduate level programmes in orthopaedics. general surgery. obstetrics and gynaecology and child health. In both Fiji and Papua New Guinea. support for existing and new programmes have been collaborative efforts involving govermnents. bilateral development agencies. the nongovernmental sector and WHO. Innovative training programmes for dental health workers. pharmacists and environmental health officers are now in place and should hegin to improve services in these areas. One issue which still needs increased attention is that of middle-level health workers. The Primary Care Practitioners of Fiji. the Health Extension Officers of Papua New Guinea. and various types of medical assistants like nurses in Kiribati with advanced training all fall into this category. Many countries and areas han~ such middle-level health workers in (lne form or another and there is a continuing need for them. Also there are Pacific Basin Medical Officers Training Programme nurses trained to a higher level. However. this category of health worker continues to pose problems in terms of career path and the ability to cross over into other health professional streams. Perhaps it is time;' IWW to hegin addressing this question. taking into account the general and common needs of your various countries. In the area of pharmaceuticals a number of activities have heen undertaken to begin implementing the Yanuca recommendations. Rational drug use has heen promoted through the revision of the Fiji essential drugs list. the development of national drug policies in the Northern Mariana Islands and Papua New Guinea. and through reviews of existing drug legislation in Cook Islands. Fiji. Samoa. Solomon Islands. Tonga and Vanuatu. Quality assurance mel:ilanisms have been improved through two WHO collahorating centres. the Therapeutic Goods Administration Laboratory in Australia and the National Pharmaceutical Control Bureau in Malaysia. The introduction of quality assessment in procurement processes and utilization of the WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce will also improve the quality of pharmaceuticals available in your countries. Improvements in the availability of needed drugs may he achieved through implementation of bulk purchasing schemes. strengthening of drug supply management. as well as through the upgrading of pharmacy programmes in hoth Papua New Guinea and Fiji. Human resources and the provision of medical supplies and equipment are important components of the infrastructure required to ensure that all Pacific countries and areas are truly "Healthy Islands". However. the Yanuca Declaration emphasizes health promotion and protection as the main basis for health action and indeed most of you have recently revised your national health plans to retlect this. Examples of local activities undertaken under these new policies can he found in all of your countries. I can mention only three as examples here. The Kadavu island project in Fiji demonstrates how community resources can be mobilized for the management of healthy environments. Integrated approaches involving many sectors of the community have led to progress in malaria control in Solomon Islands. Health-promoting schools have heen identified in almost all Pacific island countries.

- 43 -

Annex 5 The experiences of the Pacific islands and the spirit of the Yanuca Island Declaration have inspired similar approaches in other countries and areas of the Western Pacific Region of WHO. The innovative programmes of the Fiji School of Medicine have attracted the attention of such countries as Cambodia and Viet Nanl. The Regional Advisory Committee on Health Research has utilized many island examples in developing the r.ealth protection and promotion framework for the new Western Pacific Region health research strategy.

In summary. in the short space of two years much -has been done in this part of the world towards preparing health systems for the challenge of the 21st century. Nevertheless. a lot more needs to be done in the remaining two-and-a-half years of this century. This week's conference is itself a reaffirmation of our continuing commitment to the vision of Yanuca. In the next few days. we must identify further steps needed to pursue this vision. Further strengthening of the infrastructure for health through proper training. provision of relevant equipment and adequate supplies must he pursued. All Healthy Islands activities should be followed through and the Healthy Islands concept further refined. These activities will all continue to he undertaken within the framework of the three themes of New hori::,olls ill Ilealth. Children and adolescents will be prepared for healthy futures. Health protection will be the ,:hief concern of adulthood. And in later years. everyone must be assured of a good quality of life. The seven regional priorities which have already been identified will continue to be relevant in all these efforts. We must continue to pay attention to human resources. We can never become complacent with respect to communicable disease control. Collaboration and information exchange is essential. As we will see in the coming days. maintaining a healthy envirolUnent requires unwavering commitment. Convincing people to live healthy lives demands constant effort. And all these can be done only in the context of sustained upgrading of management capacities within the health sector. With all these issues to consider. I realize that the tasks you have accepted for the next few days will not be easy. But I know that you will take inspiration from what has taken place already in the last two years. I am therefore sure that you will be able to present to your Ministers recommendations that will continue the work that has already been done towards assuring healthy Pacific islands well into the 21st century. Thank you.

ANNEX 6

STATEMENTS BY THE MINISTER OF HEALTH OF COOK ISLANDS. HONOURABLE TUPOU FAIREKA ON THE OCCASION OFTHE DIRECTORS OF HEALTH MEETING 4-5 AUGl'ST 1997

The Regional Director. Dr S. T. Han. distinguished Ministers. Heads of the Departments of Health. ladies and gentlemen. Kia Orana and welcome to the Cook Islands. In March 1995 during the Ministers of Health meeting on Y ANUCA Island. my predecessor Dr Williams requested the World Health Organization to hold the next Ministers of Health meeting in the Cook Islands. This request was approved at that meeting and today. your Excellencies. the Cook Islands Government is honoured to host this important meeting. The recent election of the Cook Islands onto the Executive Board of WHO and your support for the Cook Islands to represent the Western Pacific Region is greatly appreciated by my Goverrunent. I would like to thank the Regional Director of Western Pacific Region. Dr S. T. Han for being instrumental in eiving my country this prestigious honour. The Cook Islands has undergone a lot of changes during this fiscal year beginning in July 1996. A total of 3.000 government employees were made redundant. 10 of those from the Ministry of Health. There was a merging of 52 Goverrullent Ministries to form n. National priorities were revisited and revised. National assets were put on sale and privatization of some Government services was done too. The new vision for our country towards the year 2005 was coined by our Prime Minister Sir Geoffery Henry during the Heads of Ministries retreat and it states. I quote: (VISION 2005)· "To aclliere (/ stalldard of !i\'illg beTter tllall allY ill tile Regioll alld ill hamIOII\' witll ollr clliture alld ellrirOlllllem". The social well being and quality of life for all Cook Islanders is the supreme concern of my Government. We believe a well educated and healthy nation is the backbone of economic recovery and growth. The Ministry of Health has many success stories as reflected in the health indicators of the country

My people have been spoiled for over a century in having free medical services. In about July 1966 my Government initiated a user pay system for all people on Rarotonga excluding old age people i.e .. 60 years and older. and school children. The Healthy Islands concept as endorsed by the Ministers of Health in Fiji which we now refer to as the Yanuca Island Declaration of March 1995 and the document by the Regional Director on New horizol1s ill health has giving us a new incentives and motivation to work harder in order to elevate our health status to a higher level.

Annex 6

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Besides continuing to work with WHO to execute the Yanuca Declaration we have now an Australia - South Pacific Healthy Island Health Promotion Project. It is a partnership between Austral ia and Cook Islands and four other Pacific countries. The aim of the project is to collaborate with the Cook Islands in the implementation of the Yanuca Islands Declaration. For a start. the Cook Islands proposed to focus their project on the prohlems associated with alcohol abuse. The Ministry of Health hopes to achieve by the year 2000 the following: a. Alcohol consumers on the island will be able to discriminate between the benefit and harmful uses. b. Alcohol rdated problems will be significantly reduced. c. Citizens at risk of negative consequences of alcohol misuse have access to quality information. advice. support and treatment. d. Alcohol related policies and legislation's will be available to protell the welfare of those directly or indirectly affected hy alcohol abuse. Activities already implemented towards this project are: Alcohol awareness week campaign 16-22 Decemher Production of newspaper captions. TV and radio spots Responsibil ity course for har -tenders Production of tlyer and pamphlets Health education talks on alcohol Health staff and an NGO representative attended an alcohol training workshop. The activities related to the Healthy Islands concept that my Ministry is undertaking with excellent outcome are the good coverage of immunization. low infant mortality rate. zero maternal mortality rate. completion of the revised version of the Convention on the Right of the Child which my Government endorsed early this year. The Health Ministry has worked closely with WHO in implementing many health programmes and the school toilet programmes in the Outer Islands is one of the successful projects that is close to completion. Except for four remaining islands. all the schools in the Outer Islands have tlush toilets. With WHO's assistance we hope to provide all the schools in the Outer Islands with flush toilers, a much more hygienic toilet than the pit latrine they use to date. This project has resulted in a reduction of intestinal worms and skin diseases and had had a health promotional effect in encouraging people to adopt such systems in their homes. Health education talks through the radio every Monday. Wednesday and Friday continue to be given by the Health Ministry. Similarly workshops. seminars on important health related issues continue to be conducted especially in the Outer Islands. Mr Chairman. the Ministry also is in debted to NZODA for the support through funding. Two months ago NZODA approved for funding our screening programme for both breast and cervical; cancer.

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Annex 6 Although our health programmes are progressing well towards achieving the aims of Healthy Islands. there are also constrainrs. The following factors aC(;l)unr for and serve to provide constraints to the provision of health services to the public: The shortage of trained health personnel to implement health programmes. Slackness in community involvement in participation of health programmes. Lack of staff commitment and accountability in achieving outputs. Lack of inter-sectoral collaboration and cooperation. The traditional belief that the curative service is much more important than preventive and budget allocation to curative services should be priority. Socio-economic conditions and increasing urbanization and industrialization. The gradual shifting in the lifestyle and healthy behaviour of the people resulting in the increase of lifestyle related diseases. Increasing life expectancy. Although we do not have a well established disease surveillance system we estimated that out of the 18.000 people in the Cook Islands. there are 211 diabetics. 1368 hypertension cases and 13 cancers. My Government has encouraged appropriate models to involve the private sector to assume a complementary role in providing health care and as such reduce the expense on the Government. At this point I would like to acknowledge the substantial technical and financial assistance that my country has received in the past from many funding agencies especially. WHO. UNFPA. NZODA, AusAID. SPC. UNICEF and UNESCO. I would like to thank you all for your assistance and look forward for a good continuing working relationship in the coming years. With our meagre resources to deal with a mammoth problem we believe that the concept of a global village will inspire donor agencies to cominue assistance to our islands. Finally. honourable delegates. ladies and gentleman may I wish this forum a successful and productive deliberation and also ask that you take time to look at our island. experience our culture and know the Cook Islands in totality before your return to your respective home. May I leave you with these wise words of the late Martin Luther King. "We must leam to live together as brothers or perish togeTher as fools".

Meitaki Mama

ANNEX 7

KEYNOTE ADDRESS OF DR S.T. HAN. REGIONAL DIRECTOR. WHO REGIONAL OFFICE FOR THE WESTERN PACIFIC AT THE MEETING OF THE MINISTERS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES

RAROTONGA. COOK ISLANDS. 6-7 AUGUST 1997

HONOURABLE MINISTERS. DIRECTORS AND PERMANENT SECRETARIES. GUESTS. EXCELLENCIES. LADIES AND GENTLEMEN. Let me begin by expressing my appreciation to Your Excellency. the Prime Minister of the Republic of Cook Islands Sir Geoffrey Henry. Honourable Tupou Faireka. Minister of Health of Cook Islands. and his staff for the excellent arrangements for this conference. Through him. I would also like to thank the Government and people of this lovely country for their warm and gracious hosting of this very important gathering. Once more they have shown that "the Pacific way" is more than just a phrase. it is a most pleasant way to arrive at very serious decisions and agreements. There is no question that all of us here today realize the importance of what we are about to do in the next two days. The health of over six million people scattered throughout the vast Pacific will be affected by our deliberations here in Rarotonga. Around the room today. I can see many familiar faces from past health meetings throughout . the region but most memorably from the Ministers' meeting at Yanuca Island in Fiji two years ago. I also see a few new faces and I hope you will bring fresh insights to our plans for a healthy Pacific in the 21st century. We are missing our most senior colleague. Dr Tapa of Tonga. who retired after long and fruitful service to his country. this region and indeed the world. However I am sure that we will all remember his counsel and the manner in which he approached our common problems -- he was truly a Pacific man. At Yanuca in 1995. we all agreed that. throughout the Pacific. progress had been made towards achieving the health goals we had set together in the last two decades of this century. But we also saw that new challenges and opportunities would arrive with the 21 st century. Thus. the Yalluca Is/alld Declaratioll proposed actions to ensure the further enhancement of health of the people of the Pacific by adopting the Healthy Islands approach to health in the future. Those actions concentrated on three major health areas: the development of human resources for health. pharmaceuticals and other health supplies. and the promotion of healthy living and healthy envirorunents. Your Permanent Secretaries and Directors of Health have just concluded a review of these actions. It seems that much has been accomplished in the short period since the Yanuca meeting. Such progress gives us cause for optimism about the future of heath in this part of the world. Without pre-empting their report. I would like to express my confidence that all of you are now on your way to establishing truly Healthy Islands in the Pacific of the 21 st century.

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In the meantime. the international health scene is changing rapidly at the glohal level. As we approach the year ~O()(). countries are taking a second look at the glohal health for all policy and plans for its renewal are being made. Rapid devdopments in health technology. in health systems. and most dramatically in information and communications technology have made it difficult to predict how the health sector will be seen in the next year or two much less in the next decade or two. Difficult as it may be to predict the revolutionary changes that may take place. it is imperative that health leaders be prepared for change. This is the only way to develop the people-centred. positive health orientation that the health sector must adopt in preparing for the 21 st century. I believe that the proposals from your Permanent Secretaries and Directors of Health will help you to do just this. In this sense. the Pacific Island countries are ahead of the rest of the world. Having adopted the Nell' Horizons concepts as the basis for implementing Healthy Islands actions. you are now better prepared to meet the challenges to health in the future. It is my hope that your example can be taken up by the rest of the Western Pacific Region. In this way. our region can continue to make a significant contribution to health in the rest of the world. The Pacific-wide network for the development of human resources for health. based largely on the evolving programmes available at Fiji and Papua New Guinea. remains the major resource for health development in your island countries. A whole range of training and education in the health professions. from basic training to postgraduate levels. is now available to most of you. With continuing commitment from the institutions and the governments that support them. I am certain that training and education possibilities within the South Pacific will continue to grow. even though there will always be a need to maintain academic links with other countries for some levels of training for health professionals. I am especially happy to note that special attention will he given to mid-level health workers. an issue which is of special concern to countries with your geographical characteristics of size and isolation. The good work begun in the implementation of the Yanuca Island Declaration recommendations on pharmaceuticals will be continued. I am happy to see that. through its collaborating centres and global certification scheme, WHO has been of considerable help in this area. Although we may not attain full implementation of a Pacific-wide bulk purchasing scheme immediately. I remain confident that supplies of pharmaceuticals will continue to improve, given your countries' commitments to this venture. A very important aspect of the approaches we agreed upon at Yanuca was the focus on health promotion and envirorunental protection as the main basis for health actions in the Pacific. These notions have been expanded by a number of activities in almost all of your countries during the last two years. It is now time to institutionalize this policy framework. It is in this area that the Pacific island countries can make especially important contributions to the Region's health. The actions recommended to you in this area give hope that, when we meet again in the future. it will be to celebrate the attainment of the goals and aspirations embodied in the concept of Healthy Islands. Finally, let me repeat what I said to the Permanent Secretaries and Directors of Health at the start of their meeting. Much has been done by your countries to prepare health systems for the future. Nevertheless, a lot more needs to be done in the remaining years of this century. It will be necessary to strengthen health infrastructures still further through proper training and the provision of relevant equipment and adequate supplies.

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Annex 7 As we agreed at Yanuca two years ago. Healthy Islands activities will be undertaken within the framework of the three themes of New horizo,1S in health adopted by the Regional Committee for the Western Pac ific at Kuala Lumpur in 1994. Children and adolescents will be prepared to ensure that their futures are healthy. The social and physical environment will be protected for healthy living in adulthood, and quality of life for all in later years will be promoted. The seven regional priorities will continue to be relevant in all these efforts. We must continue to pay attention to human resources. We can never become complacent with respect to communicable disease control. Collaboration and information exchange among each other will always help. Maintaining a healthy environnlent requires unwavering commitment. Convincing people to live healthy lives demands constant effort. And all these can only be done in the context of sustained . upgrading of management capacities within the health sector. . Most of us left Yanuca Island with optimism two years ago. I know that our review here in Rarotonga will reinforce this feeling. I believe that Pacific islanders can be assured of a healthy future if we follow through on our agreements at this meeting. But more than this. the rest of our Region and the other Member States of the World Health Organization will owe you a debt of gratitude for showing them the way to health in the 21st century -- the way of Nell' Horizolls. the way of Healthy Islands. tht "Pacific way". Thank you.

ANNEX 8

THE RAROTONGA AGREEMENT Towards Healthy Islands

Meeting of the Ministers of Health for the Pacific Island Countries Rarotonga, Cook Islands 6-7 August 1997

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Annex 8

THE RAROTONGA AGREEMENT Towards Healthy Islands The Meeting of the Ministers of Health for the Pacific Island countries, meeting in Rarotonga. Cook Islands, on 6 and 7 August 1997. Building on the positive experience of the past two years in implementing the Yanuca Island Declaration. I. REAFFIRMS the importance of partnerships among communities. government departments and other sectors in resolving priority health issues: 2. AGREES, in determining future directions for the Healthv Islallds approach:

(I) to convene and facilitate national and local meetings of the relevant partners in order to come to a common understanding of the Healthy Islands approach; (2) to develop national Healthy Islands Plans of Action and associated coordination mechanisms by the end of 1998; (3) to develop and adapt guidelines and protocols. and train resource people and community leaders to promote and facilitate the application of the Healthy Islands approach at all levels; and (4) to strengthen efforts to attain health and well-being for people living in rural and remote areas through partnerships with local communities and other sectors; 3. AGREES also. in continuing to develop human resources for health:

(I) to strengthen the capacity for training and education of health workers in Pacific island countries through further development of a network of local training institutions; and (2) to intensify cooperation among training institutions, particularly the Fiji School of Medicine and the University of Papua New Guinea. to ensure the efficient and effective use of scarce resources; 4. Further AGREES to identify and take action to overcome obstacles to the implementation of bulk purchasing schemes for pharmaceuticals and other health supplies. and to address related issues such as quality assurance and drug information exchange. through agreements between interested countries in the Pacific; 5. DETERMINES to extend training in the practice of traditional medicine, especially herbal medicine. acupuncture and related practices. building on recent documentation on herbal medicine in the Pacific.

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Annex 8

RECOMMENDATIONS OF THE MEETING OF THE MINISTERS OF HEALTH FOR THE PACIFIC ISLAND COUNTRIES Rarotonga. Cook Islands. 6-7 August 1997

A. GENERAL

1.

The Healthy Islands concept suffers from some ambiguity and should be clarified in

relation to the specifics of its content and the processes involved. 2. Ministries and departments of health should take the lead in facilitating the

identification of those areas which particularly require partnerships in protecting and promoting health. 3. The process of defining priority health-related issues should emphasize community

involvement and reflect the local cultural context. These issues are frequently best addressed in the context of settings such as the home. schools. places of work. markets. and local communities. 4. The partnership process should foster the idea of shared ownership in a framework of

clearly defined organizational responsibilities. 5. The partnership process should be action-oriented. focusing on resolving priority

issues in a timely manner. with clearly defined outcomes and indicators of progress designed to facilitate implementation. 6. High-level political support for the Healthy Islands process should be reflected in

national policies and plans; the allocation of appropriate resources; and sustained programmes. 7. Steps should be taken to ensure the availability of appropriate guidelines. protocols

and skills in relation to identifying and solving complex problems; managing resources; and working effectively with others 8. to

bring about change and development.

Mechanisms should also be established for managing and coordinating the input and

involvement of national agencies and international and bilateral external support agencies. 9. encouraged. Opportunities for sharing learning among communities and countries should be

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Annex 8

B. HEALTHY ISLANDS

I.

Definition of the Healthy Islands concept core elements and framework

Pacific island governments should adopt the following working definition, core elements and framework:

The Healthy Islands concept involves continuously idelllifying and resolving priority issues related to health, de\'elopme/lt and well-being by advocating, facilitating and enabling these issues to be addressed in partnerships among communities, organizations and agencies at local, national alld regional.levels. Implemelltatioll of the concept includes consideration of the fol/oll'ing core e/eme/lts ill ide/ltijied settings: • • • • • • • • • • • • • • • • adequate water supply and sanitation facilities nutrition, food safety and food security waste management housing human resources development communicable and noncommunicable disease prevention and control lifestyle and quality of life issues reproductive and family health promotion of primary health care social and emotional well being population issues ecological sustainability information management tobacco or health alcohol and substance abuse environmental and occupational health The emerging framework reflecting this working definition is presented in the Annex. 2. Coordinating mechanisms

Pacific island governments should establish a national Healthy Islands coordinating mechanism by 30 June 1998.

This is not an exclusive list, and the elements are not listed in order of priority.

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Annex 8 3. Plan of action Departments of health should formulate a Healthy Island Plan of Action for endorsement and support by the government by the end of 1998. The Plan of Action should incorporate: • on-going initiatives and new priority areas for action and their related settings; targets for assessing progress; designation of responsibilities: and timeframes: • collaboration with appropriate national and external support agencies and organizations in selecting and developing suitable protocols, guidelines and Healthy Island indicators to

provide a sound basis for monitoring and evaluation at local. national and regional

levels: • provisions for the development of skills in mobilizing resources. facilitating partnerships. and developing learning systems; and for the promotion of the Healthy Islands concept at national and local levels through collaboration with external support agencies; and • measures to encourage external support agencies [0

establish a mechanism for

coordinating and maintaining their inputs to Healthy Islands processes at national and regional levels. 4. Sharing experiences Pacific island countries should make optimum use of existing information forums and systems. and seek external support for creating additional opportunities to share learning. including intercountry meetings of those involved in Healthy Islands activities. development and distribution of information related to Healthy Islands, and. as appropriate. study lOurs between countries pursuing Healthy Islands initiatives. 5. Pacific political commitment

In cooperation with their counterparts in other Pacific island countries, ministries and departments of health should seek high-level political support through the South Pacific Forum and other channels for the Healthy Islands approach and its implementation.

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Annex 8

c.

HUMAN RESOURCES FOR HEALTH

Acknowledging that appropriate and sufficient human resources in the health sector continue to be crucial to achieving the outcomes expected from implementation of the Healthy Islands approach in the Pacific region. the meeting recommends that: 1. Reorientation of training programmes towards Healthy Islands Pacific countries' ministries and departments of health should initiate or intensify dialogue with education authorities and training institutions to promote the reorientation of their programmes towards the priority requirements emerging from the Healthy Islands approach. 2. (a) Workforce planning and management a long-term worktorce plan should be developed or revised to guide training and

management of health personnel - anticipating and responding to changes in national health priorities. health systems. and availability of resources: (b) the deployment of health workers should be reviewed to streamline the number of

categories of staff and ensure effective uti Iization of staff in the Iight of funding constraints: (c) provisions should be made to promote the retention of staff in national health

services in their countries through career development. opportunities for further training. and effective tinancial and supervisory support. 3. (a) Training institutions for the health workforce To build on the progress achieved thus far by the Fiji School of Medicine and the

University of Papua New Guinea in the development of their programmes in keeping with the directions set by the Yanuca Island Declaration. the two institutions are encouraged to: • maintain close cooperation with institutions in other countries of the Pacific and between themselves in order to attain efficient and effective use of resources and avoid unnecessary duplication of training programmes; and • jointly plan and develop approaches for the training of doctors and other health workers to address the priorities emerging from the implementation of Healthy Islands.

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Annex 8

(b)

Gll\ernment and external support should be provided to the Fiji School of Medicine

and the llniversitv of Papua New Guinea to implement these recommendations. The meeting further emphasized that: (c) Pacific Island countries' training institutions and programmes should be strengthened

to promote development of training which is relevant to local and country level needs and which allows reduction of costs associated with overseas training: (d) Pacific island resource people should be developed to support capacity building

within countries and regionally in the Pacific; (e) steps should be taken to ensure that training institutions and programmes are

recognized by other countries' programmes to enable training undertaken in home countries to be accredited towards higher qualifications; and (f)

governments and sponsoring agencies should be consulted about the cost of training

and the setting of fees. without hindering implementation of programmes. 4. (a) Curriculum development all curricula should be continuously reviewed to renect health workers' changing

responsibilities as mandated by health workforce plans and the need for the increased emphasis on health promotion and health protection as outlined in the Healthy Island concept: (b) (c) quality of training should be improved through training of trainers: various forms of in-service training should be offered. including distance education.

and such training should incorporate opportunities to acquire multiple skills which will enhance mobility along various career paths within the health system; (d) curricula should be provided which allow for multiple entry and exit points. In

particular. it is proposed that the Primary Care Practitioner (PCP) level be maintained as an optional entry and exit point to the MBBS curriculum at the Fiji School of Medicine in order to maintain the opportunity for PCP-type graduates from other countries to move lip to MBBS level.

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Annex 8

5.

Mid-level health practitioners

Mid-level health practitioners should be multi-skilled and should be able to provide basic but comprehensive primary health care services. both curative and preventive. Mid-level practitioners can be trained to diagnose and treat common health problems. manage emergencies. provide basic health care services. and make the critical decisions regarding the referral and transport of the seriously ill. They are especially valuable in district and rural areas in Pacific islands. Recognition should be given to the important role of well-prepared mid-level health workers in all Pacific island countries. and the possibility that for some countries this role will increase in importance as health systems change in response to changing health situations and technological advances. In particular: (a) existing training programmes for mid-level practitioners should be strengthened to

ensure the extension of their skills to prepare them to provide comprehensive services in rural and district areas: and (b) post-basic programmes to train multi-skilled mid-level practitioners should be

developed. 6. Postgraduate medical education

Training programmes should take into account the need to balance the maintenance of skills in general health service delivery. pal1icularly in rural areas. with the provision of tertiary level specialized services. To this end: (a) opportunities should be provided for Pacific island doctors to participate in

specialized training. including rural health and health research: (b) joint collaboration and reciprocal arrangements for recognition and accreditation of

specialized training programmes should be encouraged; and (c) steps should be taken to prevent a "brain drain" of trained specialists by providing

opportunities for career development and continuing education. Particular attention should be given to agreements between governments to help ensure that graduates return to their home country after completion of their studies.

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Annex 8

D. PHARMACEUTICALS

1.

Bulk purchase of pharmaceuticals for Pacific island countries and improved purchasing schemes The issue of bulk purchase was discussed extensively and a number of obstacles to

immediate implementation on a Pacific-wide basis were identified. Alternative approaches were discussed and the following recommendations were put forward for implementation while these obstacles are being overcome: (a) smaller countries should consider joining existing purchasing schemes with other group~

countries or

of countries with priority being given to high-cost and low-volume drugs

as an initial cost-saving step: (b) the proposed arrangement between Fiji and Tuvalu should he encouraged and

evaluated to ensure that both countries are benefiting from the cooperative drug purchasing project: and (c) a plan of action should be developed for joint activities to improve drug supply

management. with an emphasis on product quality and specifications. the selection of accredited suppliers or manufacturers, detailed tender procedures. and the estimation of requirements for and tinancing of drug supplies, with technical support from WHO or other external organ izations. 2. Mechanisms to improve the quality of pharmaceuticals purchased and to maintain the quality of drugs over their shelf life (a) A programme for testing of pharmaceutical supplies in the Pacific should be

established. WHO is requested to identify suitable laboratories in the Region and to negotiate agreements regarding quality control; (b) a programme for coordinated sampling and screening of samples, using simple local

quality control methods, the selection of samples for further testing, and coordinated submission to regional laboratories should be developed; (c) test results should be disseminated to all Pacific island countries through a drug

information exchange programme; and

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Annex 8

(d)

in support of the quality assurance programme, Member States are urged to

participate in the revised WHO Certification Scheme on Pharmaceutical Products Moving in International Commerce. In addition, the development of national drug policies and legislation should be further strengthened. 3. Drug information exchange scheme between pacific island countries

The quality and rational use of drugs could be improved through better use of available information among Pacific island countries. The possibility of joining existing networks (e.g. PAC -NET. and PEACE-SAT) for exchange of information among drug regulatory authorities should be explored as an altnnative to establishing a drug information scheme solely for Pacific island countries

E. THE USE OF TRADITIONAL MEDICINE

The use of traditional medicine, as defined in the WHO Western Pacific Region programme (herbal medicine, acupuncture and related practices) should be encouraged where appropriate. Steps should be taken to incorporate its use in the health care system. In this regard. it was noted that. in 1997. WHO will publish "Medicinal Plants in the South Pacific" and in 1998-1999 \vill support national level workshops on traditional medicine. WHO will also continue to encourage incorporation of traditional medical practices into health systems in the Region.