Health Service Delivery Profile Fiji 2012 potx

Fiji faces challenges in health service delivery, with many public health facilities in deteriorating condition and shortages of pharmaceutical and medical supplies a regular occurrence9

Health Service Delivery Profile

Fiji

2012

Compiled in collaboration between WHO and Ministry of Health, Fiji

Fiji health service delivery profile

Demographics, social context and health profile

Fiji is an island nation in the south-west Pacific Ocean, located between Vanuatu and Tonga Fiji's Exclusive Economic Zone covers about 1.3 million square kilometers of the Pacific Ocean with 330 islands, of which a third are inhabited The total population was 837,271 in the 2007 census, 51% females, and 49% males, and 29 under the age of 15 The ethnic composition is diverse, with 57%, Indigenous Fijians (iTaukei), 37% Indo-Fijian population and 6% others (including other Pacific Islanders, Chinese and those of European descent)1 Fiji has an increasingly urban population, with the Suva-Nasinu-Nausori corridor being the most heavily populated This has been accompanied with

an increase in urban unemployment2

Fiji experienced rapid growth after independence in the 1970’s, based on its sugar and tourism industries However, a series of 4 coups, the first in 1987, has led to high levels of migration3 and static Gross domestic product (GDP) The Reserve Bank of Fiji reported a per capita GDP of FJ$6,608 (at current prices) in 2011, with a GDP growth rate of 1.9% (at constant prices)4 Infant and maternal mortality rates have been halved since the 1960s3 However, poor economic growth has contributed to fluctuating progress on key health indicators, and an increase in rates of non-communicable disease Selected development indicators are presented in Table 1

Table 1: Key development indicators in Fiji

Indicators Measure Year Comment/ notes

Human development

index

0.688 2011 Ranked 100, above average for countries in

the medium human development group5 Literacy rate 93% 1996 Education is compulsory for school aged

children6 Total health expenditure

as a % of GDP

4.8%22 2010 Population living under

the poverty line

31% 2008-09 2008–09 Household Income and

Expenditure Survey7 Life expectancy at birth 69.2 2011 Gradually increasing5

Infant mortality rate 13.1 2010 Infant and maternal mortality rates have

been halved since the 1960s,3, but Currently fall short of the proposed Fiji targets for the millennium development goals (MDGs)8

Under 5 mortality rate 17.7 2011

Maternal mortality rate 22.6 2010

Sources: UNDP 20115, Ministry of Health 2011 22 , Fiji Bureau of Statistics20107, Fiji Bureau of Statistics1,

Ministry of Health 2011 20

Health system strategies, objectives and legislation

In light of this demographic and social context, the Fiji health system is attempting to cope with the triple burden of communicable disease, non-communicable disease and injuries30 Fiji faces challenges in health service delivery, with many public health facilities in deteriorating condition and shortages of pharmaceutical and medical supplies a regular occurrence9 To respond to this situation, the Ministry of Health developed a five year Strategic Plan 2011-2015 It aligns with the broader Fiji government’s Roadmap for Democracy and Sustainable Socio-economic Development 2009-2014, with the objectives that:

• communities are served by adequate primary and preventive health services thereby

protecting, promoting and supporting their well-being; and

• communities have access to effective, efficient and quality clinical health care and

rehabilitation services

The vision of the Ministry of Health is ‘a healthy population driven by a caring health care delivery system’, with a mission to ‘provide a high quality health care delivery system by a caring and committed workforce working with strategic partners through good governance, appropriate technology and appropriate risk management facilitating a focus on patient safety and best health status for the citizens of Fiji’ Values of equity, responsiveness, and respect for human dignity; uphold the principle of universal coverage and equal access to health services for all Fiji citizens The seven key outcomes of the Strategic Plan are:

1 Reduce the burden of Non-Communicable Diseases

2 Begin to reverse the spread of HIV/AIDS and preventing, controlling or eliminating other

communicable diseases;

3 Improved family health and reduced maternal morbidity and mortality;

4 Improved child health and reduced child morbidity and mortality;

5 Improved adolescent health and reduced adolescent morbidity and mortality;

6 Improved mental health; and

7 Improved environmental health through safe water and sanitation

A number of government decrees and acts provide the regulatory framework for the health system in Fiji, including:

• Tobacco Control Decree 2010 – Tobacco Control Regulation 2012

• Food Safety Act 2003

• Food Establishment Grading Regulations 2012

• Radiation Health Decree 2009

• Medical Imaging and Technologist Decree 2009

• Quarantine Act (Cap 112)

• Medical and Dental Practitioners Decree 2010

• Mental Health Decree 2010

• National Ambulance Decree 2010

• Child Welfare Decree 2010

• Code of Marketing Control of Food for Infants and Children

• Nurses Decree 201110

• Allied Health Practitioners Decree 2011

• HIV/AIDS Decree 2010

• Public Health Act (Cap 111)

• Methylated Spirit Act (Cap 113)

• Methylated Spirit Act (Cap 225A)

• Medical Assistants Act (Cap.113)

• Dangerous Drugs Act (Cap 114)

• Pharmacy Profession Decree 2011

• Medicinal Products Decree 2011

• Optometrist Decree 2012

• Burial and Cremation Act (Cap.117)

• Animals (Control of Experiments) Act (Cap.161)

• Private Hospitals Act (Cap 256A)

• Public Hospitals & Dispensaries Act (Cap 110)

A review of the Public Health Act was planned for 201213 The 2011 Corporate Plan states intention to establish a Health Policy Commission13 to align service delivery with this myriad of regulations An Optometrist Decree is currently being formulated for approval by Cabinet

Service Delivery Model and Provider Network

Health services in Fiji are tax funded, provided manly at public facilities and primarily free of charge The Ministry of Health and service management are broadly speaking, are divided into curative, and public health and preventative (see Table 2) Under the umbrella of public health services, the Ministry of Health operates via a system of four decentralised divisional offices, geographically based: Central and Eastern (often combined) in Suva, Western in Lautoka, and Northern in Labasa (Map 1) The divisional offices are responsible for provision of public health services, operation of the sub-divisional hospitals, health centres and nursing stations, and are led by a Divisional Medical Officer, reporting to the Deputy Secretary Public Health Also reporting to the Deputy Secretary Public Health

is a number of national advisors for specific public health areas, including: family health, non-communicable diseases, health promotion, non-communicable diseases, food & nutrition, environmental health and oral health

Curative services are led by a Deputy Secretary of Hospital Services Fiji offers a range of specialised services, supported by overseas medical treatment teams Across Fiji’s divisional and specialist hospitals there are approximately 1185 inpatient beds available This equates to a ratio of 2.05 beds per 1000 population8 A National Clinical Service Planning Framework was first developed in 2005, and reviewed in 2009 Following this, Clinical Services Networks were established in 2010 to facilitate clinical quality improvement by linking clinical services and strengthen the communication with divisional public health offices which is vital to improve services in areas such as maternal and child health, mental health and NCDs11 A revised Clinical Services Plan for 2010-2014 was also developed and implemented with ten objectives12

There are also various statutory bodies, councils and committees (such as the National Blood Service, National Food & Nutrition Centre, the National Health Promotion Council, and the National Diabetic Service) that provide supportive roles in the management and administration of specific health services

This service delivery organisational structure, essential services, performance targets and planned capital works are documented annually in a corporate plan13 and reported upon in an annual report

Table 2: Levels and types of health services provided in Fiji, 2012

Level of service Type of service

Village health

workers

Volunteers, from the community or villages; trained for six weeks to provide basic first aid and treatment Communities financially support their village health workers, while the Ministry of Health provides training, pharmaceuticals and equipment8

Nursing

Stations

Staffed by a single nurse who conducts outreach visits into communities within a designated nursing area Services provided include: population health monitoring, maternal/child clinics, general outpatients, school health, family health,

reproductive health and domiciliary services

Health Centres Staffed by a medical officer or nurse practitioner in addition to nurses They are the

first level of referral from a nursing station Services provided include: 24 hours on-call services, population health monitoring, maternal/child clinics, general and special outpatients, school health, family health, reproductive health and domiciliary services Health centres vary in services based on the size of the population it services Larger urban health centres have a pharmacy, laboratory, radiology unit, dental unit, environmental health officers, dieticians and nurses who conduct school visits8

Sub-divisional

hospitals

Staffed with general practitioners, midwives and registered nurses They provide a range of primary health and acute care, including: accident & emergency services, general inpatient care, routine obstetrics, dental services, limited diagnostic services (laboratory and radiology) and facilitate the provision of outreach services

to the nursing stations within the sub-division

Level of service Type of service

Divisional

hospitals

• Colonial War Memorial Hospital based in Suva in the Central Division,

• Lautoka Hospital in the Western Division and

• Labasa Hospital in the Northern Division

These three divisional hospitals provide a broad range of basic services including: accident and emergency, medical, surgical, orthopaedic, ophthalmology, obstetrics, gynaecology and paediatrics services, and outpatient clinics More complex services are also provided including: critical care services (intensive care/high dependency and coronary), laboratory services, oral surgery and dental services, radiology services, acute psychiatric admissions, chemotherapy and palliative care12 The Colonial War Memorial Hospital in Suva is the national referral hospital for Fiji and services are also accessed by other Pacific Island Countries9

Emergency

transportation

services

The 3 divisional hospitals offer 24-hour accident and emergency departments

St John’s Ambulance service provides transportation of patients to hospitals in some areas The Ambulance Services decree 2010 transferred this responsibility

to the National Fire Authority for coordination purposes in national emergencies8

Specialist

national

hospital

There are three specialised hospitals in Fiji, all based in Suva:

• PJ Twomey Hospital which provides services for tuberculosis and leprosy In

2010, the hospital treated 11,747 outpatients and provided outreach and screening services

• St Giles Psychiatric Hospital Services for mental health are significantly supplemented by non-government organisations

• Tamavua Rehabilitation Hospital provides services for stroke, spinal cord injury and amputee patients and the aged It has 20 beds, with 64 admissions in 2010

General

Practitioners

(GP)

Approximately 130 private general practitioners registered in Fiji providing primary health care The majority of these are found in urban areas9 A Fiji College of General Practitioners provides professional development and support

Aged care

services

There are three public aged care facilities in Fiji in Suva, Lautoka and Labasa with

115 beds, inadequate for the growing demand for specialised aged care

Traditionally the elderly were cared for in the home by the family and community

Private

hospital

The Suva Private Hospital is well-established, with approximately 40 beds, providing medical, surgical and obstetric care There are also medical centre services in Nadi that can provide minor day surgeries and services for the tourist population, and a small private maternity hospital in the Western Division that is co-funded by the Ministry of Health

Other

specialist

services

(non-government

organisation

funded) –

selected

examples only

Pacific Eye Institute Funded by the Fred Hollows Foundation NZ runs a Diabetes Eye clinic and provides specialist ophthalmologic training14

Counselling services are provided by an NGO called Empower Pacific They provide programs such as social work, employee assistance, targeted inventions for gender based violence, voluntary HIV testing and a sex worker program They are funded by a range of donors and in-part by the Ministry of Health15

A number or residential homes are available for children with physical disabilities Hilton House for children with learning disabilities is provided by the Fiji Crippled Children’s Society

Traditional

medicine

Medicinal plants are regularly used by both the iTaukei and Indo-Fijian populations

An estimated 60% to 80% of the population use traditional medicine16 The Ministry

of itaukei Affairs maintains and publishes a book on iTaukei herbal remedies from indigenous herbalists17 Fiji is in the process of establishing a national program and policy on traditional medicine18; this may also include regulation of practitioners

Table 3: Number of government health facilities, 2011

Health facility Central

Division

Western Division

Northern Division

Eastern Division Total

Source: Ministry of Health 2012 24

All medical practitioners must be registered with the Fiji Medical Council before they can practice Fees for services provided by the private sector are not regulated in any way, and the cost of consultation fees can vary widely Further, private services also include a number of dentists, pharmacists, optometrists, acupuncturists and other health care professionals There is increasing collaboration between government and private services, through contracting arrangements8

Movement and referrals through the provider network

Patients move through the provider network based on their clinical need Referrals to higher levels of care are often made by village health workers or nurses at nursing stations and health centres In emergencies in rural or remote island locations, care is sometimes facilitated by air evacuation to divisional hospitals or the provision of a flying team In urban areas, many patients are referred directly into a sub-divisional or divisional hospital by private general practitioners There is no national documented protocol for internal referral procedures, and the population can bypass primary care services and go directly to hospitals or be prepared to pay in private hospitals8 Direct presentation of patients at accident and emergency for minor illnesses, regardless of long waiting times, remains a problem of congestion To address these issues, the Ministry of Health further decentralised outpatient services in the Suva area in 2011 by closing general outpatients based at Colonial War Memorial hospital To replace these services the Ministry increased human resources and extended opening hours at six local health centres aiming to ease congestion and move services closer to populations of need19 Overseas referrals for medical treatment are subject to strict national guidelines overseen by an Overseas Medical Treatment Committee12 In 2010, 93 patients were referred overseas, mainly to India20 at a total cost of $FJ 1.6 million22 (approx US$893,000)

Health financing

Funding of the Fiji health system comes from a variety of sources, predominantly financed from general taxation revenue In 2010, Fiji government health expenditure was 4.8% of GDP, and has been fairly constant over the past eight years This is relatively low compared to other Pacific Island countries21 Total Health Expenditure (THE) in 2010 (FJ$250.4 million), was comprised of government spending 61%, private expenditure 30% and 9% from external donors (National Health Accounts 2009-201022) This level of health expenditure in 2010 was calculated to be FJ$295 per capita and an increase since 2007 both in real and constant prices There is also an increase in the contribution of private funds compared with 2007-2008 data Out-of-pocket expenditure at 20% of THE for general practitioner fees, oral health services, inpatient stay in a ‘paying ward or purchase drugs from retail pharmacies The other 10% of private funds of THE is for private insurance for those who can afford it

External support for Fiji’s health system comes from a number of donors and partners, including multilaterals such as: WHO, UNFPA, UNICEF, SPC and the Global Fund for AIDS, Tuberculosis and Malaria Bilateral partners are also very active such as: AusAID, NZAID, JICA, India, Korea and the People's Republic of China Much of these funds are allocated to the prevention of non-communicable disease, working to improve health outcomes related to the MDGs and building human resource capacity

A large proportion of health spending (63%) went towards curative services (hospital services) In

2010, the Ministry of Health undertook a costing analysis of selected public health services provided

in Fiji (for Lautoka Hospital, Colonial Memorial Hospital and Nausori Health centre) The findings from this study were used to estimate unit costs of inpatient, outpatient, ancillary and dental services These will be used by the Ministry of Health to project future costs and improve resource allocation23

Human Resources

The Ministry of Health is the second largest employer of public servants in Fiji Nearly 70% of the health work force is represented in established posts approved by the Public Service Commission (PSC), with the other 30% working as government wage earners in un-established posts Table 4 shows the numbers of government health workers in established posts in 2011 across the various cadres There were 394vacancies in 2011 from established posts24

There is considerable pressure to downsize the health work force due to cost In 2009, in response to these financial pressures the PSC reduced the retirement age from 60 years to 5525.The Ministry of Health lost approximately 331 experienced staff, including 15 doctors and 97 nurses and support staff This was a considerable loss of corporate and technical knowledge and has resulted in re-engagement of staff on contracts26 Concurrent to these reductions, there are known shortages in the number of health professionals located in rural areas and there is a high rate of emigration overseas8 This has been identified as one of the underlying reasons for slow progress in achieving the MDGs8

Table 4: Numbers of government health workers (established posts), 2011

Profession Number Health workers per 10,000

population (837,271)

Source: Ministry of Health 2012 24

The Ministry of Health’s Strategic plan acknowledges the critical need to address human resources development to address the challenge of staff retention, distribution and quality service provision within the Fiji health system30 To address these issues, the Ministry is increasing its intake of student medical officers and nurses, and revising bonding conditions There has been significant reform recently in health care education, with the merging of the Fiji School of Nursing and Fiji School of Medicine into the College of Health Sciences under the Fiji National University in 2009 and the establishment of postgraduate speciality programs It is hoped that this will create opportunities for professional development in-country It is also encouraging integration of care where possible with private practitioners The Ministry of Health regulates health care workers (medical practitioners, nurses and allied health professionals10,27,28) under government decrees by setting the standards for practice and for annual registration, this includes private practitioners Various regulatory councils and bodies ensure that

standards are enforced and monitored for the health professionals registered under them

Medicines and therapeutic goods

Fiji has a relatively well-developed pharmaceutical service, with all public health facilities dispensing pharmaceuticals At a national level procurement, storage and distribution of medicines and therapeutic goods are managed by Fiji Pharmaceutical and Biomedical Services Centre [FPBSC] under the responsibility of the Chief Pharmacist There are 444 essential medicines and 1186 clinical products approved for procurement in 2010 FPBS operated with a total budget of FJ$18.6 million Stock-outs are monitored monthly by the FPBS in 2010; there was an average of 100 SKU shortages

in each 9 categories of products, such as Drugs, Consumables, Dressings, Vaccines, Lab & Dental, etc Stores Officers, Medical Officers and Nurses In-charge of hospitals and other health facilities are responsible for the day-to-day management of pharmaceutical supplied FPBS also coordinates the bulk purchasing scheme of medicines and therapeutic goods for the private sector and other pacific Island countries The FPBS also procures installs and maintains biomedical supplied such as medical anesthetic and dental equipment There are National Biomedical Equipment Committee, National Clinical Products Committee and Consultant National Medical & Therapeutic Committee that oversees requests for new equipment and standardization

Quality of service delivery

The Ministry of Health’s Strategic Plan lists quality as a key value that is cross-cutting in all health system activities and programs One of the key outcomes of the plan includes a series of risk management indicators For example timeliness of unusual occurrence reporting (sentinel events) and compliance rates for hand hygiene30 The Ministry includes a Health System Standards unit which works on clinical governance policies, tools and quality improvement initiatives There is a paper-based system of reporting of clinical incidents in divisional hospitals that is analyzed at a national level, and data from patient information systems is used for the calculation of clinical indicator outcomes These are reported in the Annual report There were 28 incidents reported in 2010 nationally; with a total of 13 deaths where the attributing factor was a delay in receiving appropriate medical treatment20

The Medical and Dental Practitioner’s Decree 2010 requires medical officers to have indemnity insurance; this is negotiated through the Ministry of Health27 Since 2010, there are

an increasing number of Clinical Services Networks being established in all specialties to facilitate clinical quality improvement and the creation of clinical practice guidelines

Equity in service delivery and health outcomes

The Ministry of Health operates under a set of values; including equity, responsiveness, and respect for human dignity; that uphold the principle of universal coverage and equal access to health services for all Fiji citizens Despite these values, it is likely that some barriers to access remain, for example geographical location, cultural background or economic status8 To date there has been no formal assessment of equity of service delivery and health outcomes for Fiji’s health system Recently data

on health outcomes is not publically reported by ethnicity and therefore unavailable for comparison It

is thought that the two major ethnic groups (iTaukei and Indo-Fijians) have maintained much of their lifestyle and dietary differences, and consequently, have differing epidemiological profiles8

Access to primary health care in rural areas via nursing stations and village health workers is generally believed to be equitable However, diagnosis and treatment by a medical officer is not guaranteed even in some health centres due to difficulties in retaining trained staff in rural areas It is

estimated that while about 70-80% of the population has access to primary health care, only about 40% has access to quality health services29 Access to care for more complex or chronic conditions (e.g renal dialysis) is not equitable, with most tertiary services available at Divisional hospitals, or only in Suva, requiring significant travel related costs Services for the aged, mentally ill and physically and intellectually disabled are not widely available across the country To enable access to specialist clinical services not found in Fiji, the Ministry of Health maintains agreements with a number of visiting teams/organizations internationally (e.g Friends of Fiji Heart Foundation)12 and provides for a limited number of overseas referrals for treatment

The majority of services and pharmaceuticals are provided free of charge, however some services (e.g oral health services or an inpatient stay in a ‘paying ward’) require a fee For those that are financially able, private health services and insurance are available Services funded by donors (e.g immunization programs) strive to ensure that equity is maintained across the population at no cost

Demands and constraints on the service delivery model

The Ministry of Health acknowledges the numerous challenges of delivering quality healthcare to its dispersed population with scarce resources20 External donor support to Fiji over the next few years is likely to focus primarily on reducing under-five mortality and maternal mortality to achieve the MDGs8 However, the Ministry of Health recognises that there has been an epidemiological shift within Fiji with

an increase in non-communicable disease, particularly diabetes, circulatory disease and cancer; in addition to still dealing with communicable disease This has resulted in increased policy attention on health promotion and preventive care, recognizing that this is a more cost-effective way of addressing this challenge than expensive curative care Never-the-less there will also be a growing demand for specialized clinical services A public-private partnership for super-specialized tertiary medical care has been proposed to the Fiji government cabinet to commence in 2012 The proposed care will include open heart surgery, plastic reconstructive surgery and advanced neurosurgeries, undertaken

in partnership with overseas hospitals12

A key constraint on the service delivery model is the static health budget allocations despite the increase

in demand and cost of health services For example, in-service training budget has remained at

$400,000 from 2008 to 2010, but the actual in-service training expenditure more than doubled in 201012 Another key challenge is the movement of the population from rural areas to urban cities This has created an imbalance in urban areas in the demand on inpatient and outpatient services at divisional hospitals, while services at health centres are under-utilized The divisional hospitals have seen an increase in the average length of stay for inpatient admissions

Human resources retention is another well documented problem, with emigration of skilled health worker overseas Health care workers can be posted away from home and therefore often suffer from social isolation and the responsibility of being independent, having to make sound judgments on patient treatment and referrals with limited equipment and drugs8 The Ministry is now implementing policies to improve retention of health professionals in Fiji and to address the issues of career path, salaries, working conditions and international networking

Indicators of progress

The Ministry of Health has selected a number of indicators and objectives as part of its Strategic plan 2011-2015 development30 Error! Bookmark not defined.However, baseline results are not

consistently included for determining progress Indicator specifications and key definitions would assist transparency and accountability A suite of key performance indicators were reported in the Ministry of Health’s Annual report for 2010 including comparison with 2009 & 2011 results The results are summarised in Table 5

In 2010, there were reductions seen in the child mortality rate, diabetic foot amputations, rate of teenage pregnancy and prevalence of anaemia in pregnancy A slight increase in the contraceptive prevalence rate was noted The availability of accurate and timely information from the national health information system is critical to track these performance indicators Much health data is collected in Pacific Island countries but rarely utilised to its full potential due to perceptions that it is incomplete

and unreliable The collection of mortality statistics often involves multiple government departments beyond the Ministry of Health, including the Fiji Bureau of Statistics and the police department31

Table 5: Achievement of national health indicators, 2011

Outcome 1: Communities are serviced by adequate primary and preventive health services thereby protecting,

promoting and supporting their well being

Portfolio leadership

policy, Advice and

secretariat support

Increased Fiji resident medical graduates from Fiji School of Medicine from 40 to 50 per year

Increase annual budgetary allocation to the health sector by 0.5% of GDP annually NA NA

No increase as compared to 2010 % of health budget to GDP Public awareness

promotions – public

health

Child mortality rate (0-5 yrs) reduced from 26 to 20 per 1000 live births

23.2 17.7 20.9

Prevalence of anaemia in pregnancy at booking 11.1 10.7 20.9 Maternal mortality rate reduced from 50 to 20 per

100,000 live births

27.5 22.6

39.8 HIV/AIDS prevalence among 15-24 year old pregnant

women reduced from 0.04 to 0.03

Prevalence of diabetes reduced from 16% to 14% (c) (c) (c) Proportion of the population aged over 35 years

engaged in sufficient leisure time activity (d) (d) (d) Prevalence of under 5 malnutrition (e) (e) (e)

Percentage of one year olds immunized against measles increased from 68% to 95%

71.7 71.8 82.5

Communicable

disease prevention

Prevalence of tuberculosis reduced from 10% to 5% 11.3 (e) (e) Prevalence rate of lymphatic filariasis reduced by 10% 8.75 9.5 9.5 (f) Provision of clinical

services

Average length of stay for inpatient treatment reduced from 5 to 3 days

Amputation rate for diabetic sepsis (per 100 admissions for diabetes)

46.9 30.1

43.2 Admission rate for diabetes and its complications,

hypertension and cardiovascular disease

42.5 36.6 83.1

Provision of primary

health care

Prevalence rate of STIs among men and women aged

Contraceptive prevalence rate amongst population of child bearing are increased from 46% to 56%

28.9 31.8

36.5 Outcome 2: Communities have access to effective, efficient and quality clinical health care and rehabilitation services Portfolio leadership

policy, Advice and

secretariat support

Participation of private and health care providers increased from 2 to 10

NA NA

NA Health expenditure increased from the current 2.9% to

at least 5% of GDP by 2013

NA NA 2.4% of nominal GDP

Outsourcing non-technical activities such as laundry, kitchen and security by end of 2010

NA NA Services outsourced

are cleaning and security by end of 2011 Laundry and kitchen are still in the process Health Policy Commission established by 2010 NA NA The Health Policy

Commission is expected

to be established by the end of 2012

Public awareness

promotion, public health Proportion of tuberculosis cases detected and cured under directly observed treatment short course (DOTS) (g) (g) (g)

Provision of clinical

services

Bed occupancy rate of psychiatric beds 101.4 108.2 109.6 Average length of stay in psychiatric beds 102.1 109.7 69.9 Education and

Training –Nurses and

Doctors

Number of staff trained in mental health 60 15 172 Doctors /100,000 population increased from 36 to 42 38.5 38.3 39.9 Supply Medical equip

and Consumables Elimination of stock outs of drugs from present 100 176 72 85