SITUATIONAL ANALYSIS OF SPECIALIST CLINICAL SERVICES

Transcription

1 SITUATIONAL ANALYSIS OF SPECIALIST CLINICAL SERVICES In Cook Islands STRENGTHENING SPECIALISED CLINICAL SERVICES IN THE PACIFIC PROGRAM An Australian Government, AusAID initiative Implemented by the Fiji School of Medicine

2 SITUATIONAL ANALYSIS OF SPECIALISED CLINICAL SERVICES IN COOK ISLANDS 2010 Printed in Suva, Fiji August, 2011 Strengthening Specialised Clinical Services Program, College of Medicine, Nursing and Health Sciences, Suva

3 Acknowledgements This Situational Analysis report of Specialist Clinical Services in the Cook Islands is the result of a combined endeavor of multiple individuals and organizations. We would like to acknowledge everyone s commitment and determination towards the successful conduct of the situational analysis and finalizing of the report. The situational analysis is a collaborative undertaking between the Ministry of Health in the Cook Islands and the Strengthening Specialised Clinical Services program (Fiji School of Medicine). We would like to thank the Minister of Health Mr. Nandi Glassie for his generous support and time taken to meet with the team. We would like to acknowledge the support and contributions of the Secretary of Health Mr. Tupou Faireka, Senior clinicians and nurses, members of the Executive Management Team, the New Zealand High Commission and the Cook Islands Aid Management Unit who contributed to the discussions regarding the development and provision of specialized clinical services in the Cook Islands. We would like to thank Dr Fran McGrath and Mrs. Helen Sinclair for their support in facilitating the visit and coordinating the various meetings including sourcing the information required for the situational analysis. We also gratefully acknowledge the support of the various Ministry of Health units who shared information on their human resources capacities and policies. The Data collection tool was reviewed by the consultants recruited to conduct the situational analysis Mrs. Debbie Sorensen, Dr Rosalina Saaga-Banuve, Dr Gregory Dever; the SSCSIP Senior Clinical Advisors Mr. Eddie McCaig and Mr. Kiki Maoate; and the DaCT team Dr Berlin Kafoa and Dr Silina Fusimalohi. The Situational Analysis was conducted in the Cook Islands by Dr Kiki Maoate, supported by Mrs. Debbie Sorensen, and the write up of the report was undertaken by Mrs. Sorensen. The final report was reviewed by Mr. Faireka, Mrs. Sinclair, Dr Tikaka, Dr Solomone, Dr Francis Agnew and Dr Kiki Maoate. The report was reviewed by the SSCSIP s Technical Advisory Group comprising of Professor Ian Rouse, Mr. Eddie McCaig, Mr. Kiki Maoate, Dr Gregory Dever, Lord Viliami Tangi, Dr Ifereimi Waqanibete, Mrs. Debbie Sorensen, and Mrs. Paulini Sesevu (AusAID). The Situational Analysis and the publication of this report would have not been possible without the funding support provided by the Australian Government, through the SSCSIP Program. The Fiji School of Medicine organized the printing of this report on behalf of the Ministry of Health in the Cook Islands. Page 2 of 128

4 Table of Contents Acknowledgements 2 Foreword 6 Acronyms 7 Executive summary Background and rationale Objectives Methodology Results The National Context Demographics Socioeconomic Situation Health Status Ministry of Health s Mission, Vision and Objectives Organisation of Health Services Delivery Systems Health Care Financing General Clinical Services Visiting Specialised Clinical Services Providers Visits in 2010/ Planning for Visiting Specialised Clinical Service Providers The Ministry of Health Support for Visiting Teams Allowances Payable to Visiting Teams Capacity Building Reporting and Monitoring 22 Page 3 of 128

5 4.4 Human Resources Registered Medical Professionals Postgraduate Training Specialist Nurses Allied Health Workers Funding Support for Specialised Clinical Training Renumeration for Local Doctors Offshore Referrals for Specialised Clinical Services The Overseas Medical Referrals The Referral Process Referral Centres and Agents Budget and Spending for Offshore Referrals in Recommendations Annexes 30 Annex 1: Organisational Structure Annex 2: Doctors Practicing in the Cook Islands in 2011 Annex 3: Cook Islands Health Strategy Annex 4: Cook Islands Patient Referral Policy Annex 5: Situational Analysis Data Collection Tool Page 4 of 128

6 List of Figures Figure 1: Map of Cook Islands in the South Pacific page 13 Figure 2: Map of the Cook Islands page 13 List of Tables Table 1: Cook Islands Development Indicators page 15 Table 2: Visiting specialised clinical teams to Cook Islands in January 2010 June Table 3: HSW Programme 01 July - 31 December Table 4: HSW Programme 01 January June Table 5: Medical Professionals Registered in the Cook Islands as Specialists or with Specialist Qualifications 24 Table 6: Cook Island Allied Health Professionals and Allied Health Professionals currently undergoing training 25 Table 7: Salary band example 26 Table 8: Breakdown of referrals by specialty 28 Page 5 of 128

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8 Acronyms APLS AMD CCrISP DaCT EMST HDI HSV MBBS MDG s MFEM MOH CI MSV NZAID O&G PIC RACS SSCSIP SPEC WHO Advanced Paediatric Life Support Aid Management Division Care of the Critically III Surgical Patient Development and Coordination Team Early Management of Severe Trauma Human Development Index Health Specialist Visits Bachelor of Medicine Bachelor of Surgery Millennium Development Goals Ministry of Finance and Economic Management Ministry of Health Cook Island Medical Specialists Visits New Zealand Aid Obstetrics and Gynaecology Pacific Island Country Royal Australasian College of Surgeons Strengthening Specialised Clinical Services in the Pacific South Pacific Bureau for Economic Cooperation World Health Organization Page 7 of 128

9 Executive Summary The Cook Islands cover 240 square kilometres and covers a broad geographical area from the Northern Group of Manihiki, Nassau, Palmerston, Penrhyn, Pukapuka, Rakahanga and Suwarrow; and to the Southern Group of Aitutaki, Atiu, Mangaia, Manuae, Mauke, Mitiaro, Rarotonga and Takutea. The geographically dispersed islands and relatively small numbers of people on isolated islands provide a challenging environment in which to plan and develop health services. The Cook Islands has a total population of 22,000. The Cook Islands Ministry of Health s vision is:- All Cook Islanders living healthier lives and achieving their aspirations To provide accessible and affordable health care of the highest quality, by and for all in order to improve the health status of the people of the Cook Islands. The health status of the population continues to improve. The Ministry of Health services help maintain very good maternal health, a low infant mortality, and high childhood immunisation coverage of over 90%. Of concern though is the very high level of risk factors for non-communicable diseases including heart disease, strokes, diabetes, and cancers and the impending large increase in these conditions. As a small Pacific Island the increasing pressure to provide a full range of primary, secondary and tertiary health services from a population who has expectations that health services will be delivered at an equivalent level and mix to New Zealand and Australian health services continues to challenge both the Government and health sector. Limited by resource constraints in both facilities and workforce the Ministry of Health s strategy is to provide core primary and secondary health services with access to higher level secondary and tertiary services through Visiting Medical Specialist teams and referral to health services in New Zealand. The Cook Islands is the only country in the Pacific region to self-manage the Overseas Referral programme and Visiting Health Specialists programme, funded by donors, without the assistance of a Managing Services Contractor. This has enabled the country to align the needs of the population with the specialist services provided and to continue to develop and refine the programme to consider the contribution it is able to make to the on-going development of the health services and to building capacity and capability of the workforce. Page 8 of 128

10 The situational analysis found the following: 1. The Cook Islands delivers an adequate range of general clinical services in the core areas of surgery, medicine, anaesthetics, obstetrics, gynaecology and paediatrics appropriate to the country population health needs. 2. The Cook Islands plans, manages and coordinates inputs of specialist clinical teams and hosts teams in an efficient and effective manner. 3. Planning of the Health Specialist Visiting programme is aligned with the Ministry of Health s core documents including the Health Strategy and Workforce Development Plan. Planning is also aligned with the National Sustainable Development Plan priorities. 4. External support to address access to high level secondary and tertiary services includes visiting teams in all core secondary areas. Access to secondary and tertiary in patient services and some diagnostic services is through referral to the New Zealand health services. (Primarily at Counties Manukau District Health Board) 5. Capacity building needs include: Access to advanced specialist nursing training Access to clinical placements for medical staff to gain additional skills and build competencies Access for Allied Health staff to advanced clinical training positions Access to on-going Professional Development including attending annual professional meetings and short term attachments 6. Priority areas for advanced specialist training are Paediatrics, Medicine, Surgery, Anaesthetics and Obstetrics and Gynaecology and Psychiatry to enable the Ministry of Health to plan for long term replacement and sustainability of the system. The system is vulnerable due to small numbers of clinical staff and the long lead in time from undergraduate training to the completion of specialist training. 7. Referral for patients requiring specialist clinical services off shore is managed efficiently and effectively by the Ministry of Health 8. There is no evaluation of clinical outcomes for patients treated by Health Specialists Visits or for those referred overseas. Page 9 of 128

11 In summary the Cook Islands has managed both its Health Specialist Visiting Programme and Referrals Overseas in an efficient and effective manner. The Ministry of Health has continued to evolve the programme to meet the changing needs of its population and health sector development. Access to services in country seems to be adequate particularly with the increase in funding from 1 July 2011 to $1.5 million over the next 3 years. The areas of need in specialist services development appear to now be the ability to train Doctors, Nurses and Allied health staff at an advanced level through attachments and placements overseas. There is also a growing demand for evaluation and monitoring of health outcomes associated with the programme and in renewing equipment and some facilities to meet the increased technical skill base as the workforce continues to develop and to keep pace with emerging new technologies. Summary of Recommendations 1. To support the Ministry of Health to continue to plan, manage and coordinate access to specialist services through the Health Specialists Visiting Programme and referral overseas 2. To include the Directors responsible for managing the Overseas referral process and the Health Specialists Visiting Programme in SSCSiP work programmes to share best practice and lessons learnt with other countries 3. To support the access of Cook Island nurses to advanced nursing training in the core specialty areas 4. To support the training and placements of Doctors to Masters level training in the core secondary disciplines 5. To support the advanced training of Allied Health practitioners to enable the extension of secondary services such as technicians in Anaesthetics 6. To support access to ongoing Professional Development Activities through attendance at professional meetings and short term attachments. 7. To collaborate with the Ministry of Health Cook Islands to implement an evaluation and monitoring programme for the Health Specialist Visiting programme Page 10 of 128

12 1.0 Background and Rationale A core element of a functional health system is the ability to provide curative health services. While community level primary care is the mainstay of these services (and is acknowledged as such in national health strategic plans in the Pacific), there is a parallel need for secondary and tertiary services to address more complex established or non-preventable conditions, support health care workers in the community, and meet community expectations of effective health care. The isolation and relatively small populations of many Pacific Island countries and the capacity of their health workforce often restrict the range of specialised clinical services that they are able to provide. For more than two decades, gaps in these services have been filled by visiting indi-vidual specialists and teams (funded through government, donors and charitable organisa tions), and by off-shore referral for treatment in countries able to provide a higher level of care. While service delivery and quality are highly appreciated, Pacific Island countries have requested a greater focus on enhancing their own capacity to deliver more of these specialised services, and a greater level of coordination of assistance for specialised clinical care Strengthening of Specialised Clinical Services in the Pacific (SSCSiP) is a new AusAID-funded Program tasked with a) supporting Pacific Island countries to plan for, access, host and evaluate specialised clinical services; and (b) strengthening local health worker skills, capacity and capability to meet clinical service needs. The underlying rationale for the program is to achieve better planning and improved local capacity to meet secondary and tertiary health needs in a way that is appropriately balanced against each country s primary and preventive care priorities. The FSMed has been engaged by AusAID to implement the program, from June 2010 initially for 24 months; thereafter extension of the contract would be considered for a further 2-4 year period following an independent review of the Program s effectiveness and efficiency. The program is currently implemented by the Development and Coordination Team (DaCT), based at the Fiji School of Medicine, which will work closely with all participating countries and specialised clinical service providers. The work of the DaCT team will be guided by the SSCSiP Working Group, the program Clinical Specialist Advisors, the Technical Advisory Group and the Pacific Island Ministries of Health. Page 11 of 128

13 2.0 Objectives Given the diversity in clinical services capacity around the region, there will be no one size fits all solution for the region s specialized clinical needs. To allow DaCT to better plan and fulfill its role in supporting and strengthening specialized clinical services in the Pacific, there is a need for country-specific baseline data to allow the Program to map the required needs of each country. Specifically, the situational analysis aims to: Document the capacity of each country to deliver general clinical services. Document how each PIC plans for, access and hosts specialist clinical teams. Document the contributions of each visiting specialist team s towards capacity building of local staff, reporting and evaluation. Map national capacity for specialised clinical services, and the current external support provided to address service needs. Identify capacity building needs for nominated specialised clinical services. Document the process for referring patients requiring specialist clinical services offshore. 3.0 Methodology In March 2011, six consultants were recruited to conduct the situational analysis in all the 14 participating countries, assisted by the clinical directors of each PIC. The data collection tools used for this exercise are attached as Annex 5. The data collection mainly involved interviews with various Ministry of Health officials, looking back at past records and collection policies and guidelines relating to specialist clinical services in the islands. Page 12 of 128

14 4.0 Results 4.1 The National Context Demographics 1 The Cook Islands is made up of fifteen small islands distributed over two million square kilometers of the South Pacific Ocean (See Figure 1 below). The largest island of Rarotonga has a land area of 67 square kilometers. Rarotonga is the capital and the country s dominant driver of economic growth. The Southern Group of outer islands is situated within 300 kilometers of Rarotonga. The remote Northern Group of outer islands are more than 1250 kilometers from the capital and are made up of atolls and sand cays with little arable land (refer to Figure 2). These islands instead benefit from large productive lagoons that support pearl farming and are the main base for the country s fishing industry. The Cook Islands is particularly vulnerable to natural disasters. In 2005, over a two month period, five cyclones swept the country. Figure 1: Map of Cook Islands in the South Pacific Figure 2: Map of the Cook Islands 1 Cook Islands Paris Declaration Evaluation 2011 Page 13 of 128

15 The People The resident population of the Cook Islands is 14,200 people, and the total Population is 22,100 (Cook Islands Statistics Office, 2008). Seventy percent live in Rarotonga with around 20 percent of the population living in the Southern Group of outer islands. Development continues to occur in the face of a long-term decline in the resident population. Cook Islands residents hold New Zealand citizenship and can freely access the New Zealand and Australian job markets, as well as the New Zealand health, education, and social security systems. More than three times as many Cook Islanders live overseas than in the Cook Islands. The decline in the resident population, and the rising number of foreign workers and investors (9 percent of the 2006 resident population), have some locals concerned about the potential erosion of traditional Cook Islands identity (Asian Development Bank, 2008b). Christianity is the predominant religion, with the indigenous language of Cook Islands Maori (and Island dialects) and English being the official languages of the country. Free Association On July , the Cook Islands became a state in free association with New Zealand. Free association means: The Cook Islands Government has full executive powers. The Cook Islands Government can make its own laws and New Zealand cannot make laws for the country unless authorised by the Cook Islands Government. Cook Islanders keep New Zealand citizenship. The Cook Islands remains part of the Realm of New Zealand and Queen Elizabeth II is Head of State of the Cook Islands. For much of the first decade of free association the Government s focus was on domestic affairs and implementing basic social and economic programmes. The aim was to promote national development and reduce dependency on New Zealand Aid. In 1972, the Cook Islands helped form the South Pacific Forum and the South Pacific Bureau for Economic Cooperation (SPEC). This was the beginning of the Cook Islands participating as an equal partner with New Zealand and increasing its involvement, as a country, in international affairs. Over the next two decades the Cook Islands expanded its involvement internationally with participation in international organisations and treaties in its own right. It has broadened its base with bilateral and multilateral treaties. The Cook Islands is a member of Food and Agriculture Organisation, the Asian Development Bank, the International Civil Aviation Organisation, and the World Health Organisation. It is an Associate member of both the Commonwealth and the United Nations Economic and Social Commission for Asia and the Pacific Islands Forum. In June 2000 the Cook Islands signed the Cotonou Agreement, paving the way for financial and technical assistance from the European Union, and its Asia, Caribbean and Pacific Group (Source: Cook Islands Government Website Page 14 of 128

16 4.1.2 Socioeconomic situation Social indicators are favourable, with the Cook Islands achieving the highest human development index (HDI) rating among the Pacific regions independent nations. Life expectancy is high at 71 years; births average nearly one child per day; infant mortality is low at 3.8 per 1,000 (2008) live births; immunization reaches almost 100%; secondary school enrolment rates exceed 90%; adult literacy is high; and most MDGs will be met by Total marriages equal approximately two marriages per day with 90 percent of these being non-residents, an indicator of the Cook Islands being marketed as a tropical islands wedding destination. These achievements reflect a long history of substantial government investment in health, education, and welfare, a natural resource base which attracts tourism, and the benefits of close association with New Zealand. A substantial improvement in the quality of economic and public sector management since the financial crisis of the mid 1990s has also underpinned the improvement in living standards. The Cook Islands is setting its own benchmarks, and considers New Zealand standards as a base. Table 1: Cook Islands Development Indicators (Source: Cook Islands 2008 Social & Economic Report Equity in Development Tango-Tiama o te Kimi Puapinga Asian Development Bank Asian Development Bank (ADB). The Economy Cook Islands Development Indicators Annual Population Growth (%) 0.9 Adult Literacy Rate (%) 99.0 % of pop in urban areas 74.5 % of pop living below the Poverty line 28.4 Under 5 mortality per/1000 live births 15.0 % population using better drinking water 95.0 The Cook Islands economy has grown strongly since the mid-1990s and the current GDP per head, of more than $13,648, is the highest among independent countries in the Pacific. The total value of exports for 2008 stood at $5.9 million, a decrease from $7.1 million in the year ending Total revenue for the public sector for the year end 2009 was estimated to be $116.6 million, with taxation revenue making up 69% of the total revenue. Tourism is the major sector with 100,600 arrivals for Seventy two percent of tourists came for vacation purposes. The Tourism sector was affected by the global economic crisis with reduced visitors numbers recorded during early The Cook Islands is vulnerable to global events that impact on the economy including rising fuel and food costs, distance from markets, outmigration of Cook Islands people, and climate and environmental change. Cyclones and other adverse impacts related to climate change remain a significant threat to the lives of people and the economic viability of the islands. Page 15 of 128

17 4.1.3 Health Status The health status of the population continues to improve. Ministry of Health services help maintain very good maternal health, a low infant mortality, and high childhood immunisation coverage of over 90%. Of concern though is the very high level of risk factors for noncommunicable diseases including heart disease, strokes, diabetes, and cancers and the impending large increase in these conditions. The medium population scenario projection is that the total population will be 16,261 by 2030 and 15,977 by Fertility rates are projected to continue a moderate decline, and net migration to decrease by 65 people per year. The median age is projected to increase from 27.5 years (2006 census) to 33.4 years by 2030, with an annual average growth increase of 0.2%. Life Expectancy In 2009, overall life expectancy at birth was estimated at an average of 71.5 years: 70.0 years for men and 73.1 years for women. This is good, but less than life expectancy in New Zealand (78.4 years for males and 82.4 years for females) and Australia (79.2 years for males and 83.7 years for females). Population composition Infants projected to decline from 31% to 22% of the population by year olds projected to decrease to 3,000 by 2015, and to 2,600 by 2030 due to the lower birth rate and increased emigration of parents and their children year olds projected to remain at 58% in 2006, and 59% in 2030 Over 60 year olds projected to increase from 11% in 2006 to 19% of the population by 2030 Births and Deaths (2009) Total births 280, Birth rate 21.2, Total deaths 84, Infant deaths 2 (7.1%) Most common causes of mortality (2009) cardiovascular diseases (30 deaths), neoplasms/cancers (19), endocrine, metabolic/diabetes (9), injuries including motor vehicle accidents (7) Page 16 of 128

18 Common reasons for admission to hospital or consulting a doctor: Hospital admissions were stable from 2005 (2,035) to 2010 (2,064; F 1,176; M 888) Referrals overseas varied little between 2005 and 2010, fluctuating between 140 and 160 per annum Outpatient consultations over 2005 to 2010 were stable, fluctuating around the 2010 level of 37,984 per year (average of 100 people/day), and relatively evenly split male to female. Notifiable conditions (2010) high reported numbers for acute respiratory conditions 6,615, skin diseases 1,256, conjunctivitis 307, pneumonia 286, influenza 221, diarrhoea/ gastroenteritis conditions 808, and ciguatera 79. Leading rates of non-communicable diseases (2010) 1,413 patients with hypertension, 862 patients with diabetes, 1,213 patients that are obese and 157 patients with asthma. Patient Satisfaction Survey 69% of patients said they were satisfied or very satisfied with inpatient services. This is good but relatively low compared with levels in NZ and Australia which are over 80%. Major issues were signage, waiting time till seen by doctor, and courtesy/friendliness of receptionist Ministry of Health's mission, vision and objectives The Ministry of Health s vision is o All Cook Islanders living healthier lives and achieving their aspirations o To provide accessible and affordable health care of the highest quality, by and for all in order to improve the health status of the people of the Cook Islands. This guides the Ministry s plans for and beyond. The Cook Islands Health Strategy published in 2006 highlights the following priorities: 1. Population health gain - Improving the health of the population through focusing on the prevention, early intervention and treatment of communicable and non-communicable diseases and injury prevention. 2. Infrastructure and systems - The development of infrastructure which will support the future development of the health sector by investing in information technology, telecommunication systems, workforce, developing and maintaining facilities, developing quality systems and processes, ensuring a sound legislative regulatory framework and ensuring sustainable health financing. 3. Effective communication - Improving communication with individuals and communities, within the health sector between the Ministry of Health and operational services, and between Departments to ensure the effective and efficient delivery of health services. 4. Intersectoral partnerships - To strengthen partnerships locally with civil society, Non- Governmental Organisations (NGO s), community and church groups, internationally with health service providers, research organisations and donors which contribute to the improvement in the health status of Cook Islanders. Page 17 of 128

19 5. Health sector responsiveness - The further development of disaster response and emergency management capacity in the health sector and community. To enhance the capacity to respond in a timely and effective manner to global health issues as they arise such as Avian Influenza Strategic Health Objectives for the health sector to focus on have been selected for the impact they will have on improving the health status of the population 1. To improve the health of children by reducing the mortality and morbidity rate 2. To improve the health of young people through reducing the incidence and impact of risk taking activities 3. To improve the health of women and mothers through reducing maternal mortality and morbidity 4. To improve the health of men through reducing the incidence and impact of noncommunicable diseases, cancer, alcohol and trauma. 5. To strengthen health support services for older people. 6. To strengthen health services which support independence for people with disabilities. 7. To strengthen mental health services including alcohol, drug, tobacco cessation and gambling cessation services. 8. To reduce the impact of non-communicable diseases and injury with an emphasis on obesity, diabetes, cardiovascular disease, respiratory disease, oral health, and cancer. 9. To reduce the impact of communicable diseases with an emphasis on Sexually Transmitted Infections (STI s), HIV/AIDS, vector borne diseases and the emergence of new infectious diseases. 10. To improve environmental health focusing on food safety, safe water, clean air, improved sanitation, and waste management. 11. To support families and communities to lead healthier lives. 12. To strengthen the infrastructure of the health system to ensure it has sufficient capacity to meet the health needs of the population. 13. To enhance human resources and research capacity Organization of health services and delivery systems The health services in the Cook Islands range from public health services (inclusive of primary care) to secondary care services. The services are provided by private and publicly funded providers. These services are supplemented by Visiting Specialist teams. Access to tertiary services is through referral to overseas providers. The main referral hospital is located in Rarotonga with smaller hospitals and health centres located in the outer islands. There are a total of 127 hospital beds, 9 outpatient clinics, 10 dental clinics, 6 health centres, and 50 child welfare clinics, 4 private clinics, 2 private dental clinics and 4 private pharmaceutical outlets. Page 18 of 128

20 4.1.6 Health care financing Total health expenditure amounted to $10,467,201NZD for the 2010/2011 year. The appropriation is broken down in the following areas. Community Health Services $1,673,128 Hospital Health Services $5,739,353 Outer Islands Health Services $2,276,789 Funding and Planning $ 777, General Clinical Services The Cook Islands is relatively well provisioned to provide basic primary and secondary level care. The country does not provide high level secondary or specialist services such as renal dialysis, complex urology and complex orthopaedics. 4.3 Visiting Specialised Clinical Services providers To provide Cook Islanders with access to specialist services not available the Cook Islands, since 1994, the New Zealand Government has funded and initially managed medical specialist visits to the Cook Islands. Between 2004 and 2008, these visits took place under the Medical Specialists Visits (MSV) scheme and from 2008 to the present, under the Health Specialist Visits (HSV) scheme. Both schemes provided funding under tripartite arrangements between the New Zealand Agency for International Development (now the New Zealand Aid Programme), Ministry of Health Cook Islands (MOH CI) and the Cook Islands Ministry of Finance and Economic Management (MFEM), with management of the schemes now delegated to the MOH CI. The schemes aim to improve the health status of Cook Islanders through access to visiting specialist health services and have objectives relating to: equitable access to specialists; emphasis on women s health; increasing local capacity; effective follow-up to screening programmes funded by MSV/HSV; and effective local management of scheme funds. New Zealand Government funds approved for the schemes were for $160,000 per annum for the first four years, rising to $175,000 for 2008/09 and to $350,000 for 2009/10. The 2009/10 allocation to the HSV represented just over 3 percent of the total Cook Islands health budget. 2 The current allocation announced on 30th June 2011 will see $1.5 million NZD available for the programme over the next 3 years. Under these arrangements, New Zealand provides funding to MFEM through AMD. AMD funds the MOH CI which now manages the schemes. The purpose of the tripartite arrangement for the MSV was to meet the costs of medical specialist visits to the Cook Islands so that all Cook Islanders could have access to medical specialists in order to improve their health status. In 2008 with the change of name to the HSV, the scheme expanded to include allied health practitioners, biomedical engineers, technicians, and support staff. 2 Report of the Evaluation of the Cook Islands Medical/Health Specialist Visits Scheme Sonja Easterbrooke Smith and Vaine Williams. New Zealand AID Programme Page 19 of 128

21 The MSV/HSV schemes have the following five objectives: Objective 1: Equitable access to medical specialists Objective 2: Emphasis on women s health Objective 3 Increasing local capacity Objective 4: Effective follow-up to screening programmes funded by MSV/HSV Objective 5: Effective local management of the MSV/HSV fund Visiting in 2010/2011 Table 2: Visiting specialised clinical teams to the Cook Islands in January June 2010 Health Specialist Visit (HSV) Programme - 01 January - 30 June 2010 Clinical Team No. of visits in 2010 Source/origin of assistance Comments Womens Health 1 NZ Aid Rarotonga General Medicine 1 NZ Aid Rarotonga Mental Health 2 NZ Aid Rarotonga, Mauke Endoscopy 1 NZ Aid Rarotonga Diabetes Management 1 NZ Aid Rarotonga, Atiu, Mangaia Intensive Care Evacuation 1 NZ Aid Rarotonga Orthopaedic 1 NZ Aid & AusAID- PIP Rarotonga Ophthalmology 1 NZ Aid Rarotonga, Aitutaki, Mangaia, Atiu Clinical Advisor 1 NZ Aid Rarotonga Urology 1 NZ Aid Rarotonga CME: Ultrasound Training 1 NZ Aid Rarotonga, Aitutaki CME: MedTech Training 1 NZ Aid Rarotonga, Aitutaki, Mangaia, Mauke, Atiu, Mitiaro CME: Nurse Training 1 NZ Aid Rarotonga A total of 13 health specialist programme visists were complete from 01 January to 30 June Table 3: HSV Programme - 01 July - 31 December 2010 Clinical Team No. of visits in 2010 Source/origin of assistance Comments Adult Neurology 1 NZ Aid Rarotonga Paediatric Cardiology 1 NZ Aid Rarotonga Mental Health 2 NZ Aid Rarotonga, Mauke Orthopaedic 1 NZ Aid Rarotonga General Medicine 1 NZ Aid Rarotonga, Aitutaki ENT 1 NZ Aid & AusAID- PIP Rarotonga Adult Cardiology 1 NZ Aid Rarotonga Orthodontic 1 NZ Aid Rarotonga Mammography 1 NZ Aid & AusAID- PIP Rarotonga CME: Nurse Wound 1 NZ Aid Rarotonga Training Intensive Care Training 1 NZ Aid Rarotonga Accident & Emergency Care Review at the Rarotonga Hospital 1 NZ Aid Rarotonga A total of 12 specialist health programme visists were complete from 01 July to 31 December Page 20 of 128

22 Table 4: HSV Programme - 01 January June 2011 Clinical Team No. of visits in 2010 Source/origin of assistance Planning for visiting specialized clinical service providers During the period from visits were planned in consultation with the MOH Finance and Planning Section with input from the Director of Clinical Services and outer island staff. From 2008 planning moved to the hospital setting. Health Specialist Visiting Coordinators were also appointed. From 2009 the Director of Clinical Services has planned the programme in consultation with the HSV coordinator. Planning for Visiting Specialised Clinical Service Providers is driven by the Ministry of Health and intends to reflect the population health needs. The Ministry is totally responsible for the identification of the level, mix and composition of visiting teams, the scheduling, the briefing and monitoring of team performance and the evaluation and review post visit. The Ministry of Health is also responsible for the payment of Visiting Health Specialists fees, organizing and coordinating visit related international and domestic travel and associated expenses, organizing and paying for internal travel for patients to and from outer islands who require access to visiting specialists (this includes accommodation and living expenses), approving and paying reasonable expenses for family members required to travel with patients, hire costs of medical equipment, including freight costs/insurance and associated supplies, purchases of consumables directly related to equipment used but not stocked by the Ministry of Health and further devices or further diagnostic testing to implement the recommendations of health specialists during or after the visit. The Ministry is also responsible for all promotion of visits and appropriate acknowledgement of donor support The Ministry of Health support for visiting teams Comments Womens Health 1 NZ Aid Rarotonga Paediatrics 1 NZ Aid Rarotonga Ophthalmology 1 NZ Aid Rarotonga, Aitutaki, Mangaia, Mauke, Mitiaro Urology 1 NZ Aid Rarotonga Orthopaedic 1 NZ Aid Rarotonga Mental Health 1 NZ Aid Rarotonga, Mauke A total of 6 specialist health programme visits were completed from 01 January to 30 June 2011 The Ministry of Health provides excellent support for all Visiting Specialist teams including: All logistical arrangements Meet and greet at the airport Transport (although some teams have a car). It is expensive to move teams around outer islands. Pre briefing and liaison prior to arrival in the Cook Islands Coordination of in country arrangements Allocation of in country counterparts (both clinical and coordinator) Lunch or dinner is provided including the awarding of thank you certificates signed by the Secretary of Health. Customs clearance of equipment and freight movement between islands Page 21 of 128

23 4.3.4 Allowances payable to visiting teams All visiting teams are paid the following allowances: Per diems at the published New Zealand Aid Programme rate for accommodation and meals Daily allowance paid to Specialists of $250 per day, Nurses $200 per day, Technicians $100 per day (Local specialists in training receive MOH daily per diem) Capacity building Visiting Specialists have contributed to building capability through on the job skills training, seminars and formal teaching sessions held by visiting staff and observations of clinical practice during visits. There is a high involvement of local staff in all visits with the appropriate medical, nursing and technical staff involved in all visits. Cook Islands Ministry of Health staff indicated that over the period of time those Specialists have been visiting they had benefited resulting in improved clinical and diagnostic skills, increased confidence to expand clinical procedures and roles and an improved ability to refer and discuss cases with colleagues overseas. Increased access to attachments and short term training has also resulted from the programme with both doctors and nurses undertaking short term placements and attachments. As the programme has developed it is now being used to deliver more formal training programmes including ultra sound training, intensive care and high dependency training and visits from a clinical specialists to provide strategic advice to the Ministry of Health Reporting and monitoring All visiting clinical teams are required to make a report of their visit. An example of the summary data report to New Zealand Aid programme is attached in Annex 4. Formal evaluation of the benefits/outcomes of the services provided by visiting teams is not routinely done in the Cook Islands. 4.4 Human resources The Ministry of Health Cook Islands published a Workforce Development Plan for They recognize that in order to meet the health needs of the population a well-trained, highly skilled and competent health workforce is required. The mission statement of the Health Workforce Development Plan is: To have a workforce with the capacity and capability to provide excellent health care services to achieve better health outcomes for the people of the Cook Islands Page 22 of 128

24 The key areas and goals are: 1. Preparing the workforce - This involves significant investment in formal training and the development of health workers. This includes progressing students through a primary growth pipeline to ensure they have the right skills and competencies to be health professionals. 2. Workforce productivity and performance - To progress secondary growth, involves enhancing the performance of the workforce through appropriate remuneration, performance management and healthy work conditions for staff to remain effective, productive and engaged. 3. Sustaining workforce growth and excellence - This area promotes the continuous professional development of staff and the tertiary growth stage for employees. This will include mentoring to prepare employees for post graduate studies and or clinical or management roles. 4. Supportive framework - This area includes ensuring that the workforce is supported to remain with the health sector. There is a strong commitment to developing the capacity and capability of the current and future workforce. The development of clinical skills and clinical leadership in the secondary area including Goal 5.3 in the workforce plan to: Develop a database of clinical staff in specialist training and ensure training alignment to the workforce plan is prioritized and staff are well supported in their development. Projected additional specialist staffing requirements in the plan are identified as: Anaesthetist x 1 Pediatrician x 1 (community focused) Obstetrics and Gynaecology x 1 Physician x 1 General Surgery x1 Psychiatrist x 1 Accident and Emergency x 1 TOTAL 7 additional Specialist positions Projected additional Specialist Nursing training areas of focus include: Diabetes, Cardiology, Respiratory, Gynaecology, Paediatrics, Orthopaedics, Emergency Care and Mental Health. Additional training required includes 6 month attachments for Theatre nurses and Paediatric Nurses. 13 nursing positions are projected to require the upgrading of nursing skills over the next 4 years. 6 new Nurse Specialist positions will be required in Medicine, Surgical, Maternity, Theatre, Emergency Medicine and Paediatrics. Page 23 of 128

25 4.4.1 Registered Medical Professionals At the time of the situational analysis there were 28 doctors registered in the Cook Islands. Of these, 16 (60%) are locals and 12 (40%) are non-locals. There are 7 Doctors registered as Specialists in country, however 11 doctors have completed advanced specialist training of some sort. The table below describes details of the registered Medical Professionals in the Cook Islands Table 5: Medical Professionals Registered in the Cook Islands as Specialists or with Specialist Qualifications Name Age Sex Ethnicity Qualification(s) Dr Rangiau Fariu <60 years M Cook Islands Diploma of Medicine and Surgery/Psychiatry Dr Henry Tikaka <60 years M Cook Islands MBBS, PGDip Obstetrics & Gynaecology Dr Zaw Aung <60 years M Cook Islands MBBS/General Medicine Dr Teariki Noovao <60 years M Cook Islands Diploma of Medicine and General Surgery Dr Teariki Faireka <30 years M Cook Islands MBBS, PGDip Ophthalmology Dr Dawn Pasina <30 years F Cook Islands MBBS, PGDip Paediatrics Dr Frank Obeda <50 years M Cook Islands MBBS, PGDip Anaesthetist Dr May Aung <60 years F Cook Islands MBBS, PGDip Obstetrics & Gynaecology Dr Deacon Teapa <30 years M Cook Islands MBBS, PGDip Surgery, Master of Medicine in Surgery Dr Bwabwa Oten <30 years M Kiribati MBBS, PGDip Surgery, Master of Medicine in Surgery Dr Voi Solomoni <40 years M Fiji MBBS/Paediatrics Dr Mary Tuke <40 years F Solomon MBBS, PGDip Anaesthetist Postgraduate Training In 2011 one Cook Island doctor, Dr Deacon Teapa is undergoing Post-Graduate training in Orthopaedics in New Zealand, he is due to complete his training and return in There are currently 3 doctors who hold masters level qualifications and 6 with post graduate diplomas Specialist nurses In the Cook Islands it is intended that each specialty will have a Charge Nurse, Clinical Nurse Specialist, and a compliment of Registered nurses. This will require an ongoing clinical development programme. In the Cook Islands 2 nurses have undergone specialist nurse training. There are currently 55 nurses at Rarotonga Hospital comprising of 6 Charge Nurses, 38 Registered nurses, 4 enrolled nurses and 7 nurse aid positions. There are 36 nurses on the outer islands which includes 5 nurse practitioners. Page 24 of 128

26 4.4.4 Allied health workers The development of the allied health workforce has been steady over the past 5 years. There continues to be gaps in the allied workforce which impact on the ability of the health sector to meet the needs of its population. The Cook Islands Ministry of Health Workforce Plan identifies the Allied health role as one that is critical in the healthcare team. Most Allied Health staff will be based at the main hospital on Rarotonga with a limited number in Aitutaki. Table 6: Cook Island Allied Health Professionals currenly undergoing training Profession Funding support for specialized clinical training Funding support for specialized clinical training usually comes in the form of scholarships from WHO, AusAID and NZAID. In addition to formal Post Graduate training there are formal continuing professional development programs 3 which are offered to clinical staff in the Cook Islands Remuneration for local doctors Total number with formal qualification Number of staff undergoing training in 2011 Number of qualified staff over the age of 50 years Psychology Physiotherapist Radiographers Pharmacists Biomedical engineer/technician Laboratory technician Anaesthetic technicians Occupational therapist Speech therapist Dieticians TOTAL The health workforce and in particular the medical workforce is a key and critical component in the Cook Islands health system. The current remuneration policy is based on a comparative benchmark of 60% of an average New Zealand salary. The capacity and capability of the workforce is dependent upon the ability to recruit and retain highly skilled, well trained clinical staff that can provide clinical leadership within the health services in the Cook Islands. The investment in training clinical staff over a minimum period of 7 years and the high level of responsibility including clinical and legal accountability requires a different strategy than that which is applied to other public servants. A key component of the ability to recruit and retain key staff is the ability of the Ministry of Health Cook Islands to be able to compete regionally with salary scales, ongoing education and quality services. Page 25 of 128

27 Historically the salary scales of medical officers have been closely related to length of service, have no clearly specified criteria for each level and have not recognized ongoing training or skill development. Accordingly, remuneration steps for Medical Officers have been unresolved for some time, despite a number of attempts to remunerate doctors according to their qualification. The Ministry s policy must be consistent with the Public Service Commission (PSC) Job sizing band whereby all public servants must be paid within the band allocated to a position. MBBS Graduate with or without registration: 1. For an MBBS graduate with provisional registration - $34,000 p.a. starting (Internship) salary 2. For an MBBS graduate with full registration - $39,203 p.a. starting (Complete internship and outer islands posting) salary Salary increments will be based on the following: Medical Officer: 1. After 2 years of satisfactory performance on performance reviews (rating of 1A to 2A), remuneration increases by 1 step increment of $3,500 added to salary 2. University Post Graduate Diploma in a relevant specialty medical field plus satisfactory performance on performance review (rating of 1A to 2A), remuneration increases by 2 steps increment of $7,000 added to salary 3. University Post Graduate Masters qualification in a relevant specialty medical field, plus satisfactory performance on performance review remuneration increases by 3 steps increment of $11,500 added to salary. Table 7: Salary band example $NZ Medical Officer (B and L) 2 yearly Salary Consultants (B and M) Every 2 years Salary Starting salary 29,203 Starting salary 45,075 Step 1 3,500 42,703 Step 1 4,000 49,075 Step 2 3,500 46,203 Step 2 4,000 53,075 Step 3 3,500 49,703 Step 3 4,000 57,075 Step 4 3,500 53,203 3 Examples - APLS, EMST, CcRISP Page 26 of 128

28 Consultant: 1. After 2 years of satisfactory performance on performance review (rating of 1A to 2A), remuneration increases by 1 step increment of $4,000 added to salary 2. University Post Graduate Diploma in relevant specialty medical field plus satisfactory performance on performance review (rating of 1A to 2A), remuneration increases by 2 steps increment of $8,000 added to salary 3. University Post Graduate Masters qualification in a relevant specialty medical field, plus satisfactory performance on performance review remuneration increases by 3 steps increment of $12,000 added to salary Points to consider: 1. A medical officer who reaches the maximum (Step 4) may be eligible to apply for a Consultant position; 2. The increases in remuneration are based on 2 year intervals and satisfactory performance appraisals each year; 3. Even if no relevant postgraduate diploma or masters qualification is obtained, an officer can still progress to the top of the band based on satisfactory performance over a number of years; Only satisfactory performers will be eligible for increments in salary Benefit/allowances The salary is all inclusive of allowances. Some doctors may be eligible for a housing allowance for the first year of employment only of $250 per week or $13,000 per annum. Continuing Medical Education is negotiated by each doctor on an individual basis. 4.5 Offshore referrals for specialized clinical services The Overseas Medical Referrals Overseas Medical referrals are coordinated by the Director of Hospital Services and the Chief Medical Officer. The Secretary of Health approves all referrals. Visiting medical teams may also assess and recommend that a patient is referred overseas for treatment. Referrals are still required to be referred through the personnel above. Page 27 of 128

29 4.5.2 The referral process All Cook Islands citizens are eligible for treatment in New Zealand through the New Zealand publicly funded health system. Referral of patients offshore for specialized clinical care is guided by the Overseas referral Policy [Annex 4]. The first step in the referral process is for the consultant or senior medical officer to recommend a patient for referral to the Chief Medical officer or Director of Hospital Services. Once the referral is approved by them they seek the approval of the Secretary of Health. Following approval the Overseas Referral Coordinator will then liaise with the overseas accepting specialist for an appointment or admission. The Cook Islands MOH pays for airfares for the patient and escort if necessary Referral centers and agents Offshore referrals for specialized clinical care are made to New Zealand Budget and spending for offshore referrals in 2010 Funding for health services in the Cook Islands comes from the Government. The total Health budget for 2010/2011 is NZD $10,467,201. The allocation of funds for referral overseas is $500,000 per annum. In 2009/2010, a total of NZD $467,000 was spent for referral of 290 patients to overseas hospitals. This cost is only the airfare costs not treatment costs. Table 8: Breakdown of referrals by speciality Speciality Number of referral in 2010 Orthopaedics 60 Interplast 2 Ophthalmology 32 ENT 6 Complex Pregnancy 13 Urology 9 Gastroenterology 4 Neurology 7 Neurosurgery 8 Paediatric Surgery 5 Stroke 5 Oncology 73 Renal 6 Complex Medical 56 Cardiology/Cardiac Surgery 47 General Surgery 36 Paediatric 7 Spinal Surgery 4 Gynae 9 Disability 1 TOTAL 390 Page 28 of 128

30 5.0 Recommendations 1 To support the Ministry of Health to continue to plan, manage and coordinate access to specialist services through the Health Specialists Visiting Programme and referral overseas 2 To include the Directors responsible for managing the Overseas referral process and the Health Specialists Visiting Programme in SSCSiP work programmes to share best practice and lessons learnt with other countries 3 To support the access of Cook Island nurses to advanced nursing training in the core specialty areas 4 To support the training and placements of Doctors to Masters level training in the core secondary disciplines 5 To support the advanced training of Allied Health practitioners to enable the extension of secondary services such as technicians in Anaesthetics, psychologist. 6 To support access to ongoing Professional Development Activities through attendance at professional meetings and short term attachments. 7 To collaborate with the Ministry of Health Cook Islands to implement an evaluation and monitoring programme for the Health Specialist Visiting programme Page 29 of 128

31 6.0 ANNEXES

32 Annex 1: Ministry of Health, Cook Islands. Organisational chart 2011

33 Annex 2: Doctors practicing in the Cook Islands in 2011 NAME AGE SEX ETHNICITY QUALIFICATION(S) Dr Rangiau Fariu 67 M Cook Islands Diploma of Medicine and Surgery Dr Henry 60 M Cook Islands MBBS, PGDip O & G Tikaka Dr Zaw Aung 61 M Cook Islands MBBS Dr Teariki Noovao 64 M Cook Islands Diploma of Medicine and Surgery Dr Teariki Faireka 32 M Cook Islands MBBS, PGDip Ophthalmology Dr Dawn Pasina 34 F Cook Islands MBBS, PGDip Paediatrics Dr Auemetua 66 M Cook Islands MBBS Taurarii Dr Terrence 33 M Cook Islands MBBS Henry Dr Frank Obeda 54 M Cook Islands MBBS PGDip Anaesthetist Dr May Aung 61 F Cook Islands MBBS, PGDip O & G Dr Karmen Boyadjiev Dr Philadelphia Ngarua Dr Jacob Wuatai Dr Deacon Teapa Dr Janet Matenga 43 M Cook Islands MBBS 41 M Cook Islands MBBS M Cook Islands MBBS 32 M Cook Islands MBBS, PGDip Surgery, Master of Medicine in Surgery 25 F Cook Islands MBBS

34 Dr Teokotai Maea Dr Ni NI Wynn Dr Zizawur Maung Dr Bwabwa Oten 29 M Cook Islands MBBS 50 F Myanmar MBBS 31 F Myanmar MBBS 38 M Kiribati MBBS, PGDip Surgery, Master of Medicine in Surgery Dr Voi 45 M Fiji MBBS Solomoni Dr Mareta 37 F Fiji MBBS Jacob Dr Aung Lin 35 M Myanmar MBBS Dr Mary Tuke 40 F Solomon MBBS, PGDip Anaesthetist Dr Win Tun 61 M Myanmar MBBS Dr Ko Ko 48 M Myanmar MBBS Lwin Dr Shwe Win 31 F Myanmar MBBS Dr Tekaai Nelesone Dr Min Min Thant 44 m Tuvalu MBBS, Master of Public Health 32 F Myanmar MBBS Page 4 of 4

35 The Cook Islands Health Strategy July 2006

36 The Cook Islands Health Strategy Hon Dr Terepai Maoate Minister of Health July 2006 The Cook Islands Health Strategy ii

37 Published in July 2006 By the Ministry of Health P O Box 109, Avarua, Cook Islands The Cook Islands Health Strategy iii

38 Foreword Kia orana The Cook Islands Health Strategy builds on previous health related policies and plans and will guide the future development of health services to better meet the needs of all Cook Islanders. It highlights the priorities the Government considers to be most important in order to improve the health outcomes for all Cook Islanders and secure the future of our children and nation. I want to emphasise the principle that to reduce the incidence and impact of illness and disease, we require a strong focus on prevention, health promotion and healthier environments. Furthermore, health services need to reflect our cultural and historical values including traditional medicine and to be evidence based, cost effective and sustainable. The success of this Strategy will rely on a high degree of cooperation and collaboration between our Ministry, the people we serve, other government departments, as well as non governmental organisations. This can be achieved firstly through all our health workers working as a team and doing the right thing, by providing leadership, being role models and living healthier lives, and secondly engaging all Cook Islanders and stakeholders to work with us to improve our health services. I encourage us all to work together to achieve our vision of Healthier Cook Islanders achieving their aspirations through this Strategy and move towards enjoying a healthier future. Kia manuia. Hon Dr Terepai Maoate Minister of Health The Cook Islands Health Strategy iv

39 The Cook Islands Health Strategy v

40 Contents Foreword... iv Contents... vi Executive Summary... vii Introduction...1 Our Country.Our people..our health....3 Health Services...4 Health Status...5 Our Vision...6 Our Mission...6 Guiding Principles...7 Values...8 Priorities...9 Objectives Population Health Gain Goal: Improve and protect the health of all Cook Islanders Objective 1: To improve the health of children by reducing the mortality and morbidity rate Objective 2: To improve the health of young people through reducing the incidence and impact of risk taking activities Objective 3: To improve the health of women and mothers through preventing maternal mortality and reducing morbidity Objective 4: To improve the health of men through reducing the incidence and impact of non communicable diseases, tobacco, cancer, alcohol and trauma Objective 5: To strengthen health support services for older people Objective 6: To strengthen health services which support independence for people with disabilities Goal: Encourage healthier lifestyles and safer environments Objective 7: To strengthen mental health services including alcohol, drug, tobacco cessation and gambling cessation services Objective 8: To reduce the impact of non communicable diseases and injury with an emphasis on diabetes, cardiovascular disease, respiratory disease, cancer and oral health. 22 Objective 9: To reduce the impact of communicable diseases with an emphasis on STIs/HIV/AIDS, vector borne diseases, hepatitis and tuberculosis Objective 10: To improve environmental health focusing on food safety, safe water, clean air, sanitation and waste management Goal: Support community development Objective 11: To support families and communities to lead healthier lives Strengthened infrastructure and health systems Objective 12: To strengthen the infrastructure of the health system to ensure it has sufficient capacity to meet the health needs of the population Objective 13: To enhance human resources and research capacity Acknowledgements Guiding principles Glossary The Cook Islands Health Strategy vi

41 Executive Summary The Cook Islands Health Strategy identifies the Government s priority areas for Health. It will guide the development and delivery of health services for the next 10 years and will ensure that all efforts are focused on supporting Cook Islanders to collectively take ownership and responsibility for the health of our people and the environment that we live in. The strategy will focus on delivering services that are people focused and quality driven and ensures that people are empowered through information to reduce future risks to their health. It recognises the need to provide a robust infrastructure for health services which will support the future development of the health sector in the Cook Islands. The strategy aims to provide a framework which will deliver improved health outcomes for all Cook Islanders. It has been developed following a process of consultation and discussion with community groups, non governmental organisations, professional groups and health workers. It recognises that the major determinants which influence the health status of the population include poverty, housing, employment, education, and lifestyle factors. The health sector has a unique and important contribution to make to improve the health status of the population however individuals and communities, non governmental organisations and other sectors equally have an important role and responsibility to participate in this process. The strategy identifies as its Vision: Healthier Cook Islanders achieving their aspirations The Mission statement: "To provide accessible and affordable health care of the highest quality, by and for all in order to improve the health status of the people of the Cook Islands The strategy is guided by the same Principles articulated in the Cook Islands National Sustainable Development Plan It has identified six Values which provide for the foundation for the development and delivery of health services now and into the future: Respect People focused Equity Quality Integrity Accountability The Cook Islands Health Strategy vii

42 The strategy highlights the following Priorities: 1. Population health gain Improving the health of the population through focusing on the prevention, early intervention and treatment of communicable and non-communicable diseases and injury prevention. 2. Infrastructure and systems The development of infrastructure which will support the future development of the health sector by investing in information technology, telecommunication systems, workforce, developing and maintaining facilities, developing quality systems and processes, ensuring a sound legislative regulatory framework and ensuring sustainable health financing. 3. Effective communication Improving communication with individuals and communities, within the health sector between the Ministry of Health and operational services, and between Departments to ensure the effective and efficient delivery of health services. 4. Intersectoral partnerships To strengthen partnerships locally with civil society, Non Governmental Organisations (NGO s), community and church groups, internationally with health service providers, research organisations and donors which contribute to the improvement in the health status of Cook Islanders. 5. Health sector responsiveness The further development of disaster response and emergency management capacity in the health sector and community. To enhance the capacity to respond in a timely and effective manner to global health issues as they arise such as Avian Influenza 13 Strategic Health Objectives for the health sector to focus on have been selected for the impact they will have on improving the health status of the population 1. To improve the health of children by reducing the mortality and morbidity rate 2. To improve the health of young people through reducing the incidence and impact of risk taking activities 3. To improve the health of women and mothers through reducing maternal mortality and morbidity 4. To improve the health of men through reducing the incidence and impact of non-communicable diseases, cancer, alcohol and trauma. 5. To strengthen health support services for older people. The Cook Islands Health Strategy viii

43 6. To strengthen health services which support independence for people with disabilities. 7. To strengthen mental health services including alcohol, drug, tobacco cessation and gambling cessation services. 8. To reduce the impact of non communicable diseases and injury with an emphasis on obesity, diabetes, cardiovascular disease, respiratory disease, oral health, and cancer. 9. To reduce the impact of communicable diseases with an emphasis on Sexually Transmitted Infections (STI s), HIV/AIDS, vector borne diseases and the emergence of new infectious diseases. 10. To improve environmental health focusing on food safety, safe water, clean air, improved sanitation, and waste management. 11. To support families and communities to lead healthier lives. 12. To strengthen the infrastructure of the health system to ensure it has sufficient capacity to meet the health needs of the population. 13. To enhance human resources and research capacity. The objectives identify the areas which will have most impact on improving health outcomes for the population. These need to be supported by detailed annual planning and work plans and budgets in each area In summary, we have developed a challenging 5-10 year Health Strategy which will lead us into a future with a health system we can be proud of, quality health services we have confidence in and a health workforce which leads by example. Join us on our journey. The Cook Islands Health Strategy ix

44 Introduction The Cook Islands Health Strategy identifies the Government s priority areas for Health. It will guide the development and delivery of health services for the next 10 years and will ensure that all efforts are focused on supporting Cook Islanders to collectively take ownership and responsibility for the health of our people and the environment that we live in. The strategy will focus on delivering services that are people focused and quality driven and ensures that people are empowered through information to reduce future risks to their health. It recognises the need to provide a robust infrastructure for health services which will support the future development of the health sector in the Cook Islands. The strategy aims to provide a framework which will deliver improved health outcomes for all Cook Islanders. It has been developed following a process of consultation and discussion with community groups, non governmental organisations, professional groups and health workers. It recognises that the major determinants which influence the health status of the population include poverty, housing, employment, education, and lifestyle factors. The health sector has a unique and important contribution to make to improve the health status of the population however individuals and communities, non governmental organisations and other sectors equally have an important role and responsibility to participate in this process. The strategy also recognises the role of the Cook Islands as a member of the international community to contribute to the achieving the Millennium Development Goals (MDGs) to progress poverty elimination. While all MDGs are indirectly linked to improved health outcomes, three MDGs which relate specifically to the health sector are: 1 MDG 4. Reduce Child Mortality 2 MDG 5. Improve Maternal Health 3 MDG 6. Combat HIV/AIDS and other diseases. On a national level, the strategy is aligned with the Cook Islands National Sustainable Development Plan (NSDP) in particular: 1 NSDP Goal 2 Well educated, Healthy and Productive people. The sustainable funding of health services is a priority for government. This requires prudent and responsible management of resources to ensure that service planning, funding and prioritisation processes are efficiently and effectively organised. The Cook Islands Health Strategy 1

45 The Cook Islands Health Strategy 2

46 Our Country.Our people..our health. The Cook Islands cover 240 square kilometers and covers a broad geographical area from the Northern Group of Manihiki, Nassau, Palmerston, Penrhyn, Pukapuka, Rakahanga and Suwarrow; and to the Southern Group of Aitutaki, Atiu, Mangaia, Manuae, Mauke, Mitiaro, Rarotonga and Takutea. The geographically dispersed islands and relatively small numbers of people on isolated islands provide a challenging environment in which to plan and develop health services. The total population is estimated to be 18,000 with an annual population growth rate of 1.1% (2001). 52% are male and 48% are female. 68% of the total population resides on Rarotonga, 22% on the other Southern Group Islands and 10% on the Northern Group Islands. In Rarotonga 26.8% of the population were aged 0-14 years, 47.4% of the population aged years, 15.6% aged years with the remaining 10.2% aged 60 years and over. In the other Southern Group islands 35.4% were aged 0-14 years, 37.5% aged years and 27.1% 45 years and over. In the Northern Group islands 40.1% were aged 0-14 years, 42.9% of the population aged years, 8.8% aged years and age group 60 years and over comprising 8.2%. In addition, there are 52,000 Cook Islanders resident in New Zealand and 30,000 in Australia who regularly visit the Cook Islands impacting on the delivery of health services in the Cook Islands. Annual visitor numbers to the Cook Islands average 7000 per year. Location and Map of The Cook Islands The Cook Islands Health Strategy 3

47 Life expectancy has been steadily improving and in 2004 was 68 years for males and 74 years for females. The average number of births over was 303 with 80% of these births being on Rarotonga. The fertility rate in 2004 was 2.9 as compared to 3.5 in the early 1990s. GDP per capita (PPP) is US$ (2001) GDP growth rate is 7.1% (2001) 1 Total Health expenditure per capita is $697 (2002) Total health expenditure as a % of GDP is 4.6% (2002) Health Services The health services in the Cook Islands range from public health services (inclusive of primary care) to secondary care services. The services are provided by private and publicly funded providers. These services are supplemented by Visiting Specialist teams. Access to tertiary services is through referral to overseas providers. The main referral hospital is located in Rarotonga with smaller hospitals and health centers located in the outer islands. There are a total of 127 hospital beds, 9 out patient clinics, 10 dental clinics, 6 health centers, 50 child welfare clinics, 4 private clinics, 2 private dental clinics and 4 private pharmaceutical outlets. 1 Source Government Statistics The Cook Islands Health Strategy 4

48 Health Status The health status of the population is steadily improving. The infant mortality rate (per 1000 live births) over averaged The maternal mortality rate over was zero. From there were 2,743 registered non communicable disease cases, an annual increase of 2%. The main increase is due to more hypertension with 66.8%, 15.3% have both hypertension and diabetes and 17% have diabetes. There were 2,220 admissions to Rarotonga hospital in The main reasons for admissions are diseases of the respiratory system, injuries and poisoning. Most injuries are the result of transport accidents and falls. Diseases of the circulatory system account for 11% of admissions and diseases of the respiratory system 11.6% The most common infectious diseases are acute respiratory tract infections, influenza, pneumonia, skin sepsis, conjunctivitis and gastroenteritis. 111 cases of cancer were reported for of which 53 were male and 58 were female. The majority of cancer is identified in the age group with cancer of the breast and prostate being the most prevalent among women and men respectively. The immunisation rate is 100% ( ). Dental caries in age groups 0 5 years has a mean decay, missing and filled teeth (dmft) of 9.0 (WHO standard is <3) The leading causes of death are diseases of the circulatory system, diabetes, and cancer. The increasing numbers of people with non communicable diseases, the rising prevalence of obesity in the population, the threats to the environment all combine to present a challenge for the health sector and community. 2 Ministry of Health Statistical Bulletin 2003 The Cook Islands Health Strategy 5

49 Our Vision All Cook Islanders living healthier lives and achieving their aspirations Our Mission "To provide accessible and affordable health care of the highest quality, by and for all in order to improve the health status of the people of the Cook Islands The Cook Islands Health Strategy 6

50 Guiding Principles The Cook Islands Health Strategy is guided by the principles of the National Sustainable Development Plan * 1. Sustainable development is a national responsibility for all Cook Islanders 2. Democratic principles, basic human rights, respect for cultural, religious and ethnic diversity and the rule of law 3. Equitable economic development and universal access to basic health and education and environmental sustainability are essential prerequisites for poverty alleviation, social harmony and national security 4. Special needs of the outer islands and disadvantaged groups are recognised 5. National development that reflect appropriate regional and international commitments 6. Good governance promoted through participatory decision-making process at all levels involving key stakeholders, including community, non-government organisations, and government agencies 7. Coordinated and harmonised access to, and effective use of, national resources and development partner support from bilateral, multilateral development partners and regional organisations 8. International and regional foreign relationships and partnerships must be based on mutual respect in the interest of the Cook Islands * Refer to Appendix for further details. The Cook Islands Health Strategy 7

51 Values These values provide the foundation for the development and delivery of health services now and into the future: Respect Acknowledging a person s dignity and rights with compassion and confidentiality People focused Ensuring that our people s welfare remain our priority and that they are well served Equity Providing timely and equitable access to health care services for all Cook Islanders Quality Striving for best practice and excellence in all aspects of our work Integrity Being truthful, sincere, fair and consistent Accountability Our systems are transparent and reflect responsible governance and management The Cook Islands Health Strategy 8

52 Priorities 1. Population health gain Improving the health of the population through focusing on the prevention, early intervention and treatment of communicable and non-communicable diseases and injury prevention. 2. Infrastructure and systems The development of infrastructure which will support the future development of the health sector by investing in information technology, telecommunication systems, workforce, developing and maintaining facilities, developing quality systems and processes, ensuring a sound legislative regulatory framework and ensuring sustainable health financing. 3. Effective communication Improving communication with individuals and communities, within the health sector between the Ministry of Health and operational services, and between Departments to ensure the effective and efficient delivery of health services. 4. Intersectoral partnerships To strengthen partnerships locally with civil society, Non Governmental Organisations (NGO s), community and church groups, internationally with health service providers, research organisations and donors which contribute to the improvement in the health status of Cook Islanders. 5. Health sector responsiveness The further development of disaster response and emergency management capacity in the health sector and community. To enhance the capacity to respond in a timely and effective manner to global health issues as they arise such as Avian Influenza The Cook Islands Health Strategy 9

53 Objectives 13 Strategic Health Objectives for the health sector to focus on have been selected for the impact they will have on improving the health status of the population 1. To improve the health of children by reducing the mortality and morbidity rate 2. To improve the health of young people through reducing the incidence and impact of risk taking activities 3. To improve the health of women and mothers through reducing maternal mortality and morbidity 4. To improve the health of men through reducing the incidence and impact of non-communicable diseases, cancer, alcohol and trauma. 5. To strengthen health support services for older people. 6. To strengthen health services which support independence for people with disabilities. 7. To strengthen mental health services including alcohol, drug, tobacco cessation and gambling cessation services. 8. To reduce the impact of non communicable diseases and injury with an emphasis on obesity, diabetes, cardiovascular disease, respiratory disease, oral health, and cancer. 9. To reduce the impact of communicable diseases with an emphasis on Sexually Transmitted Infections (STI s), HIV/AIDS, vector borne diseases and the emergence of new infectious diseases. 10. To improve environmental health focusing on food safety, safe water, clean air, improved sanitation, and waste management. 11. To support families and communities to lead healthier lives. 12. To strengthen the infrastructure of the health system to ensure it has sufficient capacity to meet the health needs of the population. 13. To enhance human resources and research capacity. The objectives identify the areas which will have most impact on improving health outcomes for the population. These need to be supported by detailed annual planning and work plans and budgets in each area In summary, we have developed a challenging 5-10 year Health Strategy which will lead us into a future with a health system we can be proud of, quality health services we have confidence in and a health workforce which leads by example. Join us on our journey. The Cook Islands Health Strategy 10

54 Population Health Gain The Cook Islands Health Strategy 11

55 Goal: Improve and protect the health of all Cook Islanders Objective 1: To improve the health of children by reducing the mortality and morbidity rate The Cook Islands population has a high proportion of children with 33% of the population being 0-14 years. The leading causes of death in children 0-14 years in 2004 were: a. Infectious diseases - 1 b. Disease of the circulatory system - 1 c. Disease of the nervous system - 1 The leading causes of hospitalisation for children 0 14 years in 2004 were: a. Disease of the respiratory system b. Disease of the digestive system - 28 c. Certain infectious diseases - 25 Whilst the current immunization rate is 100% for children under 2 years it will be important in the future to continue to monitor the rate to ensure it is maintained, review the immunisation schedules and ensure that all children have access to Well Child programs. Breast feeding ensures a healthy start to children in the first years of life. It is recognised that breast milk provides an infant s complete nutritional needs along with a reduced risk of infectious diseases and food allergies. The promotion of breast feeding and ensuring all environments are child friendly will help the growth of children. An ongoing program preventing child obesity will be the focus of reducing non communicable diseases in the older age groups. Preventing accidental or non accidental injuries will remain an area of focus and will strengthen through community action programs. The Cook Islands Health Strategy 12

56 Objective 1: To improve the health of children by reducing the mortality and morbidity rate Action Role Completion date 1.1 Reduce infant mortality to below 9 per 1000 births by (WHO recommended rate: 6 8 per 1000) Clinical Services Directorate Public Health Directorate Maintain the current 100% immunisation rate for children under 2 years Public Health Directorate 2006 Annual 1.3 Ensure 100% Well Child checks for children under 5 years by Achieve exclusive breastfeeding for all babies up to 6months by Achieve child friendly accreditation for all health services by Determine the incidence and prevalence of accidental and non-accidental injuries in children. Clinical Services Directorate Public Health Directorate Clinical Services Directorate Public Health Directorate Clinical Services Directorate Public Health Directorate Ministry Statistical Unit Expand and strengthen the child obesity prevention program for the Cook Islands. 1.8 To achieve a dmft of < 3 for children under 5 years. Public Health Directorate 2008 Public Health Directorate 2010 The Cook Islands Health Strategy 13

57 Objective 2: To improve the health of young people through reducing the incidence and impact of risk taking activities The health status of young people in the Cook Islands has progressively improved. However there are still inherent concerns that affect the health of our young people that need to be addressed. Road traffic crashes are by far the leading cause of morbidity and mortality amongst young people which are often associated with alcohol and high speed. Substance abuse, drugs and smoking continue to be a problem amongst adolescents. Teenage pregnancy continues to be a major concern, although statistics have shown a gradual decline in numbers since There is still an ongoing need to address the issue of teenage pregnancy and counseling of teenage mothers and fathers. Fortunately, there has been no reported case of HIV/AIDS in the Cook Islands involving young people and a proactive public awareness campaign has alerted people of the dangers of unprotected sex, especially with the mobile Cook Islands and Tourist population. Improving the health of young people requires an approach to service delivery which is youth friendly; where young people are supported in an environment that values their belief systems. Many approaches will require collaboration with other sectors such as education and law & order. The Cook Islands Health Strategy 14

58 Objective 2: To improve the health of young people through reducing the incidence and impact of risk taking activities Action Role Completion date 2.1 Reduce the incidence of sexually transmitted infections 2.2 Reduce the rate of teenage pregnancy 2.3 Reduce the mortality, morbidity and injury rate from suicide and road traffic crashes 2.4 Achieve youth friendly environment for all health services 2.5 Strengthen awareness programs in relation to the dangers involved with alcohol, tobacco and drugs. Clinical Services Directorate Public Health Directorate Public Health Directorate Public Health Directorate Clinical Services Directorate Public Health Directorate Public Health Directorate 2010 The Cook Islands Health Strategy 15

59 Objective 3: To improve the health of women and mothers through preventing maternal mortality and reducing morbidity Women comprise 48% of the population and commonly prioritise the health needs of the family over themselves. Utilising breast and cervical screening services remains variable with women continuing to be diagnosed late with cancer which affects their health outcomes. The utilisation of urology and gynaecology services is poor resulting in some women suffering from conditions which can be treated effectively. Contraception is available to all women. On average, 294 babies are born each year in the Cook Islands, the majority of which are through natural deliveries supported by qualified health workers. Utilisation of antenatal care remains low during the first trimester but increases during the second and third trimester. Post natal care is available and well utilised. Action Role Completion date 3.1 Maintain zero maternal mortality. 3.2 Reduce the incidence and impact of cervical and breast cancer. Clinical Services Directorate Clinical Services Directorate Public Health Directorate Improve the quality and utilisation of reproductive health care. Clinical Services Directorate Improve the utilisation of specific health services for women. Clinical Services Directorate Public Health Directorate 2009 The Cook Islands Health Strategy 16

60 Objective 4: To improve the health of men through reducing the incidence and impact of non communicable diseases, tobacco, cancer, alcohol and trauma. Men comprise 52% of the population. Life expectancy remains at 68 years compared with women at 74.3 years. Men have high rates of diabetes, hypertension and cardiovascular disease. Often present late to health services with cancers and they also have high rates of trauma relating to road traffic related injury and alcohol. Action Role Completion date 4.1 Develop and implement a men s health program to educate and support men to live healthier lifestyles. Public Health Directorate Introduce a screening program for cancers. Clinical Services Directorate Public Health Directorate Reduce tobacco and alcohol related harm for and by men. Public Health Directorate Reduce the rate of road traffic related injuries. Public Health Directorate 2008 The Cook Islands Health Strategy 17

61 Objective 5: To strengthen health support services for older people. Older people comprise 8% of the population with population projections expecting this proportion to increase. Older people generally have higher health needs than younger people and the challenge for the health sector is to develop health services which maintain older people s health status and support them to remain independent in their own homes and with families. Key health needs include access to primary care and assessment services, support to access rehabilitation services and the ability to contribute to the family and community. Action Role Completion date 5.1 Improve utilisation of primary care services by older people. 5.2 Support providers to deliver services which maintain independence for older people. Clinical Services Directorate 2008 Clinical Services Directorate 2008 The Cook Islands Health Strategy 18

62 Objective 6: To strengthen health services which support independence for people with disabilities. Disability is the outcome of the interaction between a person with an impairment and the environmental and attitudinal barriers he/she may face. (WHO definition) With the advent of the Cook Islands National Policy on Disability (2003) & National Action Plan ( ), the updated comprehensive Disability data base for all islands and the progress of the Disability Action Team within the Ministry of Internal Affairs, the Ministry of Health s disability support services must be better coordinated and planned in concert with those of other agencies. We can improve the health outcomes of people with disabilities by ensuring that all health services are responsive to people with disabilities and including them in the planning of future health services. Action Role Completion date 6.1 Improve utilisation of primary health care services by people with disabilities. Clinical Services Directorate Public Health Directorate Support providers to deliver services which promote and maintain independence for people with disabilities. Clinical Services Directorate Ensure a more concerted approach in the integration of the Ministry s disability support services with those of other agencies through the Disability Action Team and the Cook Islands National Council for the Disabled. Clinical Services Directorate Public Health Directorate National Council for the disabled 2007 The Cook Islands Health Strategy 19

63 Goal: Encourage healthier lifestyles and safer environments Objective 7: To strengthen mental health services including alcohol, drug, tobacco cessation and gambling cessation services. Mental health services are often one of the last services to be developed and adequately resourced in smaller health systems. The diversity of mental health needs in the community requires a core number of mental health services to meet these needs. The principles of mental health service development include developing services that empower consumers, their families and care givers, building the strengths of a person to support the recovery process and ensuring service delivery is strongly focused in the community. Recent advances in mental health services in the Cook Islands have seen the development of two non governmental mental health services. These agencies have provided essential support services to people with mental health issues. However, a comprehensive mental health strategy is required to ensure that the development of services to meet the mental health needs of the population is undertaken in a comprehensive and systematic manner. Excessive tobacco use and alcohol consumption continues to impact on individuals, families and communities and the increasing participation in gambling activities is impacting on small communities. The emerging and concerning trends in drug use particularly in the young population who are often initially exposed to drug use while overseas requires a future mental health service which can be responsive to these changing health needs. The Cook Islands Health Strategy 20

64 Objective 7: To strengthen mental health services including alcohol, drug, tobacco cessation and gambling cessation services. Action Role Completion date 7.1 Develop and implement a comprehensive mental health, drug and alcohol, tobacco and gambling cessation strategy. 7.2 Establish a Mental Health Unit Clinical Services Directorate Public Health Directorate Clinical Services Directorate Ensure all mental health services are accessible to the population. Public Health Directorate Ensure mental health, alcohol and drug, tobacco and gambling legislation is in place. 7.5 Ensure that schools and health services are smokefree. 7.6 Collect data, monitor and analyse the prevalence of mental illness. Ministry Clinical Services Directorate Public Health Directorate Ministry Public Health Directorate Ministry Statistical Unit The Cook Islands Health Strategy 21

65 Objective 8: To reduce the impact of non communicable diseases and injury with an emphasis on diabetes, cardiovascular disease, respiratory disease, cancer and oral health. Non communicable diseases such as diabetes, cancer, cardiovascular disease, obesity and oral health represent the greatest burden to the health of the community and put pressure on the health system. Diabetes is anticipated to increase in the Cook Islands related primarily to two factors; an aging population and an increasing rate of obesity. For a person with diabetes the harmful effects of diabetes relate to complications from the disease including retinopathy, kidney failure, diabetic foot disease and periodontal disease. Damage to peripheral nerves including diabetic foot disease is responsible for a high percentage of amputations. The most common respiratory illnesses are asthma and chronic obstructive respiratory disease. These admissions can be reduced or prevented with good self management plans and early identification of the development of acute episodes. Cardiovascular disease is the leading cause of mortality in the Cook Islands and attempts will be made to reduce incidence Information on the incidence of cancer in the Cook Islands is contained in the national cancer registry. The statistics indicate an increasing incidence of cancers, in particular the high rate in the 35 to 54 age group. Late presentation leading to poor outcomes is a concern. Early detection and diagnosis of cancer can affect a cure and extend the survival time and quality of life. Deciduous decay rates is one of the worst diseases affecting school children. There is a high decay, missing and filled (dmft) rate for 5 year-olds that is over 6 dmft compared to the World Health Organisation rate which is 3. The edentulous (toothless) rate is high in the older population, particularly the year olds. The burden of non communicable diseases can be reduced and outcomes improved through lifestyle changes such as improving nutrition, increasing physical activity, reducing smoking, better oral health care and ensuring people have access to good primary care and specialist services. Improved injury preventative measures will also enable the reduction in injuries in the population. The Cook Islands Health Strategy 22

66 Objective 8: To reduce the impact of non communicable diseases and injury with an emphasis on diabetes, cardiovascular disease, respiratory disease, cancer and oral health. Action Role Completion date 8.1 Reduce the prevalence of obesity in the population. Public Health Directorate Reduce the incidence and impact of diabetes, cardiovascular disease and respiratory illness in the population. 8.3 Develop a cancer control strategy and enhance the cancer registry. 8.4 Reduce the prevalence of tooth decay in young children and the edentulous rate in adults. Clinical Services Directorate Public Health Directorate Statistical Unit Public Health Directorate Clinical Services Directorate Public Health Directorate Reduce the incidence and impact of injury Public Health Directorate 2008 The Cook Islands Health Strategy 23

67 Objective 9: To reduce the impact of communicable diseases with an emphasis on STIs/HIV/AIDS, vector borne diseases, hepatitis and tuberculosis. The Cook Islands are included in regional programs in partnership with donors for the eradication of several communicable diseases. These include filariasis, tuberculosis, measles, HIV/AIDS and STIs. HIV/AIDS remain a major threat to small Pacific countries and the need to continually educate, reinforce key messages and break down stigma surrounding HIV/AIDS is constant. We currently have positive HIV cases and ongoing vigilance will be required to ensure that the situation does not worsen through targeted programs. Vector borne diseases (especially dengue fever and filariasis) and hepatitis continue to be the major communicable disease challenge. The approach will need to strengthen public health strategies to reduce the incidence and spread of these diseases. The recent SARs epidemic and the emerging bird flu epidemic and influenza pandemic reinforces the view that the Cook Islands is a member of the global community and global health issues impact on the health of the community. Dengue fever in particular is a risk to the economy with the potential impact of reducing the tourism trade with repeated outbreaks. The approach to all these issues is a combination of population engagement, education and responsiveness to rapidly emerging threats. The Cook Islands Health Strategy 24

68 Objective 9: To reduce the impact of communicable diseases with an emphasis on STIs/HIV/AIDs, Vector borne diseases, hepatitis and tuberculosis. Action Role Completion date 9.1 Complete and implement a public health strategy for communicable diseases 9.2 Ensure the Ministry of Health is in a state of readiness to respond to emerging epidemics and disasters locally, regionally and globally. 9.3 Maintain low HIV/AIDS infection rate 9.4 Reduce the incidence of STIs 9.5 Reduce the incidence of vector borne diseases Clinical Services Directorate Public Health Directorate Ministry Clinical Services Directorate Public Health Directorate Public Health Directorate Clinical Services Directorate Public Health Directorate Public Health Directorate Reduce the incidence of hepatitis. Public Health Directorate Eradicate Filariasis Public Health Directorate 2009 The Cook Islands Health Strategy 25

69 Objective 10: To improve environmental health focusing on food safety, safe water, clean air, sanitation and waste management. The health of the environment has an immediate effect on the health of the population. The key issues are food safety, access to safe water, including drinking water and water in the lagoons and rivers, improved sanitation for all communities, and access to a safe waste disposal system. The Ministry of Health s role in these areas is to ensure compliance to standards and monitoring the quality of the environment. Fish poisoning has been identified as an emerging health issue with increasing hospital admissions as well as asbestos particularly in building materials throughout the Cook Islands. Action Role Completion date 10.1 Facilitating and enforcing the maintenance of a healthy environment by working in partnership with other agencies Improve access to safe water for all communities Facilitate the enforcement of food safety legislation 10.4 Facilitate the enforcement of sewerage regulations to ensure 100% compliance with sanitation standards by Improve access to safe waste disposal systems for all communities Assess the impact of fish poisoning Public Health Directorate Ministry of Environment services Public Health Directorate Ministry of works Public Health Directorate Public Health Directorate Ministry of Works Public Health Directorate Ministry of Works Statistical Unit Public Health Directorate The Cook Islands Health Strategy 26

70 Goal: Support community development Objective 11: To support families and communities to lead healthier lives The key to improved health outcomes is to have healthier families and communities, where families and communities take responsibility for their own health. They will be provided information and advice to support them in maintaining better health. Family violence impacts significantly on communities leading to poorer health outcomes for families and communities. Action Role Completion date 11.1 Develop a comprehensive public health plan. Public Health Directorate Improve access for families to strengthening family and parenting programs Support the increase of positive role models within the Ministry of Health and in Society Ensure public health activities are integrated into daily life. 3.5 Strengthen counseling and support services for family violence. Public Health Directorate 2009 Ministry 2009 Public Health Directorate 2010 Clinical Services Directorate Public Health Directorate Punanga tauturu The Cook Islands Health Strategy 27

71 Strengthened infrastructure and health systems The Cook Islands Health Strategy 28

72 Objective 12: To strengthen the infrastructure of the health system to ensure it has sufficient capacity to meet the health needs of the population The infrastructure is the foundation which supports a quality health service. It embraces: - facilities to meet the needs of the community; - information systems which provide data, enhance communication between health workers and provide access to information for patients; - quality systems to provide confidence for the population that services meet standards and benchmarks; - research to ensure that future health needs and interventions are being met and are effective; and - effective communication networks within the health sector as well as with external agencies and the community - working partnerships with civil society, NGOs, the private sector, the community at large and overseas institutions. Underpinning all these is the need for a sustainable financing model, prudent financial management systems and a legislative framework which supports the work of the sector. The Cook Islands Health Strategy 29

73 Objective 12: To strengthen the infrastructure of the health system to ensure it has sufficient capacity to meet the health needs of the population Action Role Completion date 12.1 Develop a facilities development plan including maintenance and asset replacement by Complete the implementation of the electronic patient record and management system by Review and develop the financial management system. Ministry 2007 Clinical Services Directorate 2008 Ministry Improve the medical referral system Develop a quality system for monitoring and conduct audits Strengthen communication networks and support effective engagement with communities and external agencies 12.7 Seek greater participation by private sector, civil society and NGOs in the health sector 12.8 Investigate options for sustainable health financing for the future Review the legislative framework for health legislation and, where necessary, ensure new legislation is in place. Ministry Clinical Services Directorate Ministry Clinical Services Directorate Public Health Directorate Ministry Ministry Ministry Ministry of Finance and Economic management Ministry The Cook Islands Health Strategy 30

74 Objective 13: To enhance human resources and research capacity. Workforce development is very complex and challenging as we continue to train, retain and sustain the personnel in maintaining quality health services. The ongoing migration of skilled health workers coupled with an aging workforce is also a challenge for the provision of health services. The health workforce must meet the expectations and needs of the people through evidence-based practices. The Ministry of Health has 303 employees comprising: Ministry of Health Staff Clinical Medical Officers 28 Nursing 116 X-Ray 4 Laboratory 8 Pharmacy 6 Physiotherapy 2 Domestic 17 Drivers/Security/Orderlies 13 Groundsman 12 ICT 2 Kitchen 9 Statistics 4 Theatre Assistant 2 Dental Dental Therapists 4 Dental Officers 10 Dental Technicians 2 Public Health Public Health Inspectors 20 Public Health Nurses 18 Receptionists 9 Administration officers 3 Finance officers 4 Policy 10 TOTAL MOH STAFF 303 The Cook Islands Health Strategy 31

75 Objective 13: To enhance human resources and research capacity Action Role Completion date 13.1 Complete and implement the Ministry of Health s workforce plan Implement the National Health Research Strategy. Ministry 2007 Ministry 2007 The Cook Islands Health Strategy 32

76 Acknowledgements I extend sincere appreciation to the many individuals and groups who contributed their time and knowledge in ensuring that this long awaited National Health Strategy truly reflects the vision and convictions of our people in relation to the direction of services in the health sector over the next five to ten years. They include: the members of the Health Sector Working Group of the National Development Task Force working through the Office of the Prime Minister s Policy Coordination Unit in 2003; the members of that Task Force and staff of that Unit; the participants at the 2003 National Development Forum; the participants at the 2004 Health Advance workshop especially those from Civil Society, NGOs and our private sector; and the participants at the 2005 Strategy Consultations. We are grateful for the contribution from our colleagues in other government agencies in particular thank the contributions of the Ministry of Finance and Economic management (MFEM) through its Statistics Office and Policy/Planning Unit, and the Ministry of Internal Affairs through its dedicated Unit working with those with Disabilities. We have also been most fortunate in securing the assistance of Cook Islands doctors residing in New Zealand in formulating this Strategy: Dr Aumea Herman, Dr Francis Agnew, Dr Joseph Williams and Mrs Metua Faasisila. To Debbie Sorensen of Sorensen and Associates in New Zealand and Dr Kiki Maoate who contributed so much to this Strategy, we are most grateful. To the staff, the Directors, clinical staff and senior officers, thank you for the sharing of expertise and generous contributions to the strategy. Finally, we are grateful for the guidance and leadership of the Minister of Health and Deputy Prime Minister, the Hon Dr Terepai Maoate, which was invaluable in the final form of this Strategy. We look forward to working together with everyone in the Cook Islands as well as our friends and partners from overseas in realising our vision of Healthier Cook Islanders achieving their aspirations. Vaine Teokotai SECRETARY OF HEALTH The Cook Islands Health Strategy 33

77 Guiding principles The Cook Islands Health Strategy is guided by the principles of the National Sustainable Development Plan Sustainable Development Is A National Responsibility For All Cook Islanders means that all people of the Cook Islands have a responsibility to ensure that the three pillars of sustainable development economic growth, social cohesion and environmental protection are given balanced treatment to guide the future development of the Cook Islands 2. Democratic Principles, Basic Human Rights, Respect for Cultural, Religious and Ethnic Diversity And The Rule Of Law means that every Cook Islander has fundamental rights, which should be respected 3. Equitable Economic Development And Universal Access To Basic Health And Education And Environmental Sustainability Are Essential Prerequisites For Poverty Alleviation, Social Harmony And National Security means that only when every Cook Islander has an equal opportunity to benefit from economic development, basic public services, and environment sustainability, can we expect to live a peaceful existence free of hardship, conflict and instability 4. Special Needs of the Outer Islands and Disadvantaged Groups Are Recognised means that special consideration is necessary to address the development needs of the outer islands and disadvantaged groups 5. National Development That Reflect Appropriate Regional And International Commitments means that development should respond to the needs and aspirations of all people of the Cook Islands, while at the same time, be mindful of commitments that have been made by the Government at the regional and international levels 6. Good Governance Promoted Through Participatory Decision-Making Process At All Levels Involving Key Stakeholders, Including Community, Non-Government Organizations, and Government Agencies means that decisions made, and actions taken, by all levels of Government and community are transparent and accountable 7. Coordinated And Harmonized Access To, And Effective Use Of, National Resources And Development Partner Support From Bilateral, Multilateral Development Partners And Regional Organizations means that national resources and development assistance are efficiently and effectively used 8. International And Regional Foreign Relationships And Partnerships Must Be Based On Mutual Respect In The Interest Of The Cook Islands means that relationships with other nations are based, first and foremost, on what s in the best interest of the Cook Islands The Cook Islands Health Strategy 34

78 Glossary DMFT HIV/AIDS GDP MDGs NGOs Northern Group Southern Group SARS STIs WHO Decayed, Missing and Filled Teeth Human Immuno Deficiency Virus / Acquired Immune Deficiency Syndrome Gross Domestic Product Millennium Development Goals Non Governmental Organisations Islands in the northern part of the Cook Islands which are all atolls namely: Manihiki, Nassau, Palmerston, Penrhyn, Pukapuka, Rakahanga and Suwarrow Islands in the southern part of the Cook Islands which vary in structure from volcanic islands to raised atolls namely: Aitutaki, Atiu, Mangaia, Manuae, Mauke, Mitiaro, Rarotonga and Takutea Severe Acute Respiratory Syndrome Sexually Transmitted Infections World Health Organisation The Cook Islands Health Strategy 35

79 COOK ISLANDS PATIENT REFERRAL POLICY August th October 2010 doc.

80 CONTENTS INTRODUCTION... 3 VISION... 3 OBJECTIVES... 4 SCOPE... 5 ELIGIBILITY CRITERIA... 6 Special Criteria apply to the following patients:... 6 Alcohol related crashes or incidents... 6 Emergency and/or Critical Patient transfers... 7 POLICY COVER... 8 REFERRAL PROCESS... 9 Patient Referral Committee:... 9 Medical and/or Nurse Escorts... 9 Referring Officer:... 9 Accepting Officer:... 9 Medical Officer:... 9 Activation of Patient Referral Process Activation of Repatriation ASSOCIATED DOCUMENTS APPENDICES DOMESTIC PATIENT REFERRAL FORM - HOSPITAL INTERNATIONAL PATIENT REFFERRAL FORM INTERNATIONAL PATIENT REFERRAL CONSENT FORM INTERNATIONAL PATIENT REFERRAL CONSENT FORM INTERNATIONAL PATIENT REFERRAL CONSENT FORM INTERNATIONAL PATIENT REFERRAL CONSENT FORM AIR NEW ZEALAND MEDA FORMS (AIRNZ MEDA) REPATRIATION FORM PATIENT REFERRAL CHECKLIST INFORMATION FPR PATIENTS REFERRED TO RAROTONGA HOSPITAL FOR MEDICAL REASONS INFORMATION FOR PATIENTS REFERRED TO NEW ZEALAND FOR MEDICAL REASONS Page 2 of th October 2010 doc.

81 INTRODUCTION The vision of Te Marae Ora Ministry of Health Cook Islands is for all Cook Islanders to live healthier lives and achieve their aspirations, though the provision of accessible and affordable health care of the highest quality, by and for all in order to improve the health status of the people of the Cook Islands. The Cook Islands health care system (public and private) has provided a range of primary, secondary, and tertiary health services for Cook Islanders for many years, some of these provided by visiting specialists. The referral of patients within the Cook Islands as well as New Zealand, has developed to a level where Cook Islanders are able to access an almost complete range of medical and surgical services. There are increasing numbers of patients presenting with chronic diseases and complications from cardiovascular disease, diabetes, cancer, renal failure, stroke, as well as multiple injuries from road traffic crashes, the majority of which are alcohol related. These represent a myriad of ailments requiring tertiary level services that the Cook Islands health system currently cannot viably provide in-country. The referral system to New Zealand therefore is an important conduit to meet these needs. This Patient Referral Policy sets the direction for the future enhancement of this system, increased efficiency and access to quality, safe, seamless and sustainable services, and improved population health outcomes. VISION All Cook Islanders enjoying the highest standards of health and well-being through the use of a patient referral system which provides equitable and timely access to primary, secondary and/or tertiary health care services in the Cook Islands and to New Zealand. Page 3 of th October 2010 doc.

82 OBJECTIVES 1. Comprehensive, high quality, and responsive patient referral system a. Establish clear terms of reference for the functions of the Patient Referral Committee b. Periodically update clinical guidelines, eligibility criteria and standard forms for referring patients within the Cook Islands and to New Zealand c. Promote and coordinate the development and dissemination of information and resources through various media. d. Maintain quality patient referral services with a continuous improvement focus. This will be achieved through regular clinical audits, patient satisfaction surveys, monitoring of clinical indicators and health outcome measures. Page 4 of th October 2010 doc.

83 SCOPE This Policy applies to All USERS who are identified and managed through the Ministry of Health Cook Islands health system or through registered private general practitioners in the Cook Islands. Category Description Notes Fees charged to Patient Resident Cook Islanders Non-Cook Islanders that hold Permanent Residency status Non-Cook Islanders who are married to a Cook Islander OR have given birth to a baby from a Cook Island partner, and have resided in the Cook Islands for more than one year Cook Islanders returning to the Cook Islands who have EITHER:secured permanent employment OR completed studies or work experience with Cook Islands government support OR lived in the Cook Islands for longer than six months consecutively Cook Islanders residing overseas All Visitors to the Cook Islands including the following: Tourists Short term consultants Contract workers Any other person that does not fit into Category 1or 2 i No charge No charge* i, ii No charge* iii iii, iv iii, iv iii, iv No charge* Full* charge Full* charge Full * charge Note: Patients referred for treatment overseas require a current passport All health service users when registering for Health services must provide their Passport. i Must show Permanent Residency Certificate ii Must show Marriage Certificate OR Baby s Birth Certificate iii Must show Proof of permanent employment OR Proof of study and work experience from the respective Cook Islands based agency/ministry iv Must show Proof of health insurance Note: Cook Islands Permanent Residents or Non-Cook Islanders who are not New Zealand citizens/permanent Residents DO NOT qualify for free health services in New Zealand. In such cases the full health service costs, including accommodation and living expenses in New Zealand will be met by the patient or their family. Category 1 Patient Referral process funded by the Ministry of Health. ALL referrals that are ALCOHOL RELATED are charged treatment costs(as set out in User Charges Policy and fifty percent (50%) of travel costs. Category 2 & 3 Health/Travel Insurance required Page 5 of th October 2010 doc.

84 ELIGIBILITY CRITERIA The Patient is considered for referral to Rarotonga or New Zealand for secondary and/or tertiary care provided the following conditions are met: 1. The individual has been identified and managed through the Cook Islands Ministry of Health, health care system. 2. The Patient Referral Committee concludes that the patient cannot be managed successfully on their island of residence and will benefit from further secondary or tertiary health care services. Special Criteria apply to the following patients: Patients <16 years and >70 years: Return air and/or sea fare for the patient plus one accompanying family escort. Patients years: Return air and/or sea fare for the patient only. Stretcher Cases: Three seats plus one seat for patient only (4 seats). Patients with Chronic disability Return air and/or sea passage for the patient plus one accompanying family escort. Cook Island Permanent Residents (non New Zealand citizens) Cook Island permanent residents who are not New Zealand citizens qualify for patient transfers, however they do not qualify for free access to the New Zealand public health system. Full health care costs, including accommodation and living expenses in New Zealand will be met by the patient and/or their family. Alcohol related crashes or incidents 1. Fifty percent (50%) of referral costs incurred for patients involved in alcohol related accidents or incidents are charged to the Patient and/or their next of kin. Costs include: a. Return airfares b. Airline stretcher costs c. New Zealand Ambulance costs d. Medical and/or Nurse escort airfares (including patient family escorts) e. Medical and/or Nurse per diems * Patients also pay service costs set out in the User Charges Policy. 2. If the Patient was not directly responsible for the crash or incident then this becomes a civil case. The Ministry of Health will request a letter from the Referring Medical Officer and/or Nurse addressed to the Patient Referral Committee to confirm the patient transfer is alcohol related. Copies of the letter will be distributed to the following recipients: Page 6 of th October 2010 doc.

85 a. Director of Clinical Services, Director Hospital Health Services, Secretary of Health and the Director of Funding and Planning b. Cook Islands Police department in Rarotonga and the island from which the patient is referred c. Office of Crown Law The intent is to indicate the Ministry s intention to seek reimbursement from the offender through the civil court for fifty percent (50%) of the costs of the alcohol related crash or incident. Costs include 1.a to 1.e. above. Emergency and/or Critical Patient transfers 1. All Emergency and/or critical patient transfers must have an accompanying Medical and/or Nurse escort. In critical cases, more than one Medical Officer may be required to transfer the patient. 2. Where the fifty percent (50%) cost of Air Ambulance transfers is to be covered by the patient or next of kin, the Ministry may facilitate arrangements for the transfer. Page 7 of th October 2010 doc.

86 POLICY COVER Patient Referral Policy cover 1. Costs covered under this policy, based on all eligibility and/or special criteria being met are: a. Patient return airfare/sea fare costs, including stretcher costs (where applicable) b. Patient family escort return airfare/seafare costs (within eligibility criteria) c. Medical escort airfares costs and per diems (where applicable) d. Rarotonga and New Zealand Ambulance costs e. Health care services costs at the Rarotonga Hospital for the Patient only 2. All Patients involved in alcohol related crashes and incidents are required to pay fifty percent (50%) of these costs Note that the Ministry will source the most economical airfares/seafare for travel. Patients and/or their next of kin cover 1. Costs for accommodation, transport, meals and incidental expenses on Rarotonga and in New Zealand 2. The cost of Passports and/or Visa, including departure tax for themselves 3. Rarotonga Hospital charges based on the Rarotonga Hospital User Charges Schedule 4. All Patients involved in alcohol related crashes and incidents are required to pay fifty percent (50%) of costs 5. Patients involved in alcohol related crashes or incidences inflicted upon them will not be required to pay for services, instead fifty percent (50%) of costs will be charged to the instigator of the incident. Page 8 of th October 2010 doc.

87 REFERRAL PROCESS Patient Referral Committee: 1. Core Membership i. Referring Officer ii. Accepting Officer iii. Medical Officer Rarotonga Hospital iv. Director of Clinical Services 2. Addendum to membership i. Health specialists visiting the Cook Islands ii. Air New Zealand Doctor Medical and/or Nurse Escorts 1. Qualified medical or nursing escort staff will be required from time to time as recommended by the Referring Officer in consultation and with the approval of the Patient Referral Committee. 2. All medical or nursing escorts must hold current annual practising certificates and advanced cardiac life support certificates. 3. All medical or nursing escorts must provide safe and appropriate heath care services required for patients during the transfer. 4. Once the medical and/or nursing escort has completed full handover to the Accepting Officer, he/she must return to their place of work on the first available flight, taking appropriate account of health and safety requirements. 5. Per diems payable for medical and/or nursing escorts are $50 per day for national referrals and $150 per day for international referrals. Per diems cover accommodation, transport, meal and incidental costs. Referring Officer: The Referring Officer will be the lead health provider of the island/ service which can include a medical officer, nurse practitioner or nurse on the Outer Islands or the medical officer in Rarotonga. For instance, the surgeon for referral of a patient requiring surgical services. Accepting Officer: The Accepting officer will be the lead health provider of the specialist service in Rarotonga or New Zealand who must be a medical officer with specialist qualification or skills and knowledge in the particular clinical area. Medical Officer: The Medical officer will be a practising health provider in Rarotonga Hospital who must be a senior medical officer who has a specialist qualification or specialist skills and knowledge in another clinical area. Page 9 of th October 2010 doc.

88 Activation of Patient Referral Process 1. Patient Referral process is as follows: i. Referring Officer consults with the Accepting Officer and presents the history, clinical findings, diagnosis and reason for referral ii. Accepting Officer consults with the Director of Clinical Services iii. Director of Clinical Services consults with members of the Patient Referral Committee to justify activation of referral, based on confirmation from Accepting Officer and/or appointment letter, escort requirements and payment options iv. Committee members activate and sign off on referral process with final approval from Secretary of Health Special circumstances for URGENT referrals include oral approval being obtained from an Accepting Officer or their representative and the Secretary of Health, with written approval being obtained as soon as possible afterwards. 1. Administrative process is as follows: i. Referring Officer i. Completes correct Patient Referral form ii. Organises signing of Patient Consent form iii. Completes airline Medical fitness for air travel (MEDA) form iv. Prepares referral letter to Accepting Officer/Service ii. Patient Referral Coordinator i. Coordinates travel arrangements, including ambulance services, and documentation (passport/visa) for Patient and/or Escort ii. Sends completed Patient Referral form to Secretary of Health for final approval iii. Monitors and maintains database of all patient referrals iv. Gives patient the Patient Information leaflet. iii. Finance Officer i. Activates payment of airfares and escort allowances upon receipt of completed and authorised Patient Referral form Special circumstances for URGENT referrals include oral approval being obtained at short notice, with the written approval process being obtained in retrospect, as soon as possible afterwards from the Secretary of Health. Page 10 of th October 2010 doc.

89 Activation of Repatriation 1. Patient Repatriation process is as follows: i. Accepting Officer provides discharge summary or medical clearance to Patient/Next of Kin and Patient Referral Coordinator at Rarotonga Hospital ii. Patient Referral Coordinator obtains initial approved Patient Referral form and ensures patient meets policy criteria for repatriation iii. Patient Referral Coordinator completes the Patient Repatriation form 1. Administrative process is as follows: iv. Director Clinical Services & Director Hospital Health Services i. Approve Patient Repatriation form upon receipt of letter of medical clearance and initial Patient Referral form v. Patient Referral Coordinator i. Coordinates travel arrangements and documentation (passport/visa) for Patient and/or Escort ii. Facilitates signing of Medical fitness for air travel (MEDA) form by Director of Clinical Services iii. Contacts Patient/Next of Kin to confirm travel arrangements iv. Sends Patient Repatriation form to Finance for payment vi. Finance Officer i. Activates payment of airfares upon receipt of completed and authorised Patient Repatriation form Deceased Patients 1. Should the patient die during the patient referral, the Ministry of Health will fund the cost of returning the deceased back to their home island by way of cargo only (freight of human remains). 2. If the patient continues to remain in Rarotonga or New Zealand for more than 3 months after being discharged or being given their medical clearance, the Ministry of Health shall cease to be responsible for the patient s return airfare or freight of human remains to their island of residence. 3. A copy of the Death Certificate and the Airway bill must be presented to the Ministry of Health, Patient Referral Coordinator at Rarotonga Hospital, prior to the release of payment for freight of human remains. Patient Self Referrals Patients who travel to Rarotonga or New Zealand to seek further secondary and/or tertiary health care, independent of the Ministry of Health Patient Referral system can seek reimbursement of the cheapest economy travel costs from the Ministry of Health in the following circumstances where all the following criteria have been met: 1. Patients and/or their next of kin must provide evidence of their Cook Islands citizenship and residency for more than 6 months and/or Permanent Residence Certificate, within one month of returning to their island of residence. Page 11 of th October 2010 doc.

90 2. The Ministry of Health receives letters of support for reimbursement from the Referring Officer and the Director of Clinical Services. 3. The Patient Referral Committee concludes that the patient could not have been managed successfully on their island of residence or at Rarotonga Hospital. 4. The patient has not previously been reimbursed travel costs for the same disease or medical condition. Change in patient management 1. If a patient declines health care services and advice provided by the nominated Accepting Officer, after arrival in Rarotonga and/or New Zealand, all further health care costs including return airfares for the Patient and/or family escort, will be met by the patient and/or next of kin. 2. If a patient declines further secondary and/or tertiary health care services through the Patient Referral system, the Patient and/or next of kin must reimburse the Ministry of Health the full cost for all related expenses. Follow up health care services 1. Patients that require a first follow up clinic review and/or treatment following the initial referral will have transfer costs met where they meet the following criteria: a. The Ministry of Health receives a confirmed appointment from the Accepting Officer b. The Ministry of Health receives letters of support from the Referring Officer and the Director of Clinical Services. c. The Patient Referral Committee concludes that the patient must be referred. 2. Patients that require further clinical review and/or treatment services after the first clinical review will have to meet their travel and health care costs. Discharge from health care services 1. Upon receipt of a written clearance and/or discharge summary of a patient by the Accepting Officer, the patient must return to their island of residence within 3 months. 2. If the patient continues to remain in Rarotonga or New Zealand for more than 3 months, the Ministry of Health shall cease to be responsible for the patient s return airfare to their island of residence. 3. Patients who are not discharged and/or haven t received medical clearance and choose to travel back to Rarotonga or island of residence must meet the costs of their travel. Should they fall ill for the same medical condition, the Ministry of Health will not be liable for their transfer costs. The Ministry will only be liable for their final repatriation upon receipt of a discharge summary or medical clearance from the Accepting Officer as highlighted at point #1. Page 12 of th October 2010 doc.

91 ASSOCIATED DOCUMENTS Ministry of Health Act Cook Islands Public Health Act 2004 Cook Islands Ministry of Health Strategy Cook Islands National Sustainable Development Plan Page 13 of th October 2010 doc.

92 APPENDICES 1. DOMESTIC PATIENT REFERRAL FORM - HOSPITAL Date:. Patient s Name:.. Date of Birth: Age:. Sex: Male/Female Island: Reason for Referral to Rarotonga Hospital: Referral Confirmed by Telephone/Fax/ to Rarotonga Hospital and accepted by: Accompanying Family:.. (Permitted only by child under 16 years) Is Medical or Nurse Escort Required? YES/ NO. If Yes, Name of Escort:. TRANSFER DETAILS; Please circle Routine flight transfer: Yes/No CHARTER: Yes/No Flight Diversion: Yes/No Stretcher Required: Yes/No Ambulance Required: Yes/No Own Transport: Yes/No IS THIS ALCOHOL RELATED REFERRAL? YES/NO If Yes, Has the Police been informed? Yes/No NAME OF POLICE OFFICER: If this case is referred under the Specialist Health Programme,Please indicate:.. Referred by:.. Date: Resident Medical Officer Outer Islands Travel Details: This must be completed for all patient referrals and faxed to Administration Office on ( or Air Rarotonga Ticket No:. (One way travel only) Date of Issue:. Patient Ticket No:. (One way travel only) Date of Issue:. Family Ticket No:. (One way travel only) Date of Issue:. Medical/Nursing Escort Page 14 of th October 2010 doc.

93 2. INTERNATIONAL PATIENT REFFERRAL FORM Date:... Patient s Name:.. Male / Female Passport Name Age.. Residence:.. Patient s Doctor:. Home Island:.. Departure Date:. Diagnosis:.. Reason for Referral: Referral Confirmed by Telephone / Fax / to: Hospital. Services: Consultant:... Appointment / Admission Date:. Duration:. Accompanying family:. (Permitted only for children under 16 years) Passport Name Is Medical or Nurse Escort Required? Yes / No. If Yes, Name of Escort:... TRANSFER DETAILS: Please circle Seating: Regular Seating Passenger Other: Business Stretcher Required: Yes / No Ambulance Required: Yes / No Own Transport: Yes / No Contact address in NZ: Phone No: IS THIS ALCOHOL RELATED REFERRAL? PATIENT REFERRAL COMMITTEE Yes / No Director of Clinical Services Referring Team Leader Medical Officer: Signature:.. Signature: Signature:. Page 15 of th October 2010 doc.

94 INTERNATIONAL PATIENT REFERRAL CONSENT FORM NO:1 I,, otherwise referred to as the Referral Patient, do hereby confirm and agree that in the event that I refuse and/or change my mind on arrival in New Zealand for the said purpose will reimburse to the Ministry of Health, no later than 90 days after my departure, all related expenses pertaining to my transfer to Auckaland. All related expenses to include airfares, stretcher fees, ambulance fees, medical escort airfares and medical escort allowance as applicable. Further note that if I continue to remain in New Zealand for more than three months upon receipt of a written clear and/or discharge by the managing specialist s, then the Ministry of Health will cease to be responsible for my return airfare to Rarotonga. Signed: Patient/Family Member/Next of Kin Date: Signed: Director of Clinical Services Date: Signed: Director of Hospital Health Services Date: In the event that the consent form cannot be signed as in the case of a minor and/or by the patient, this form must be signed by a parent and/or nominated next of kin and/or guardian of the minor and/or patient. MOHH/2009/2

95 INTERNATIONAL PATIENT REFERRAL ALCOHOL RELATED ACCIDENTS CONSENT FORM-NO:2 I,, the immediate family member (next of kin), sign on behalf of, otherwise referred to as the Referral Patient and /or the person responsible for the accident, do hereby confirm and agree to pay the Ministry of Health: Air New Zealand Charges Stretcher Fees(for Patient) X2 Medical Escorts return airfares R X2 Escort Fees $300 Ambulance Fees(NZ) Oxygen SUBTOTAL Complete Total Other Charges Hospital HDU care Alcohol related (Raro) Ambulance Fees(Raro) Pick up and transfer to airport Hospital Professional service charges including xray,laboratory and consultation SUBTOTAL I, further confirm that I will reimburse to the Ministry of Health all such costs incurred in full within 90 days following departure. Failure to fully recover costs will result in the Ministry of Health seeking legal action for claims as such. Please note that this consent form does not wave any possible avenue that the patient and/or his/her family may pursue against the person responsible for the accident. Signed: Date: Patient/Next of Kin/Person responsible for accident Signed: Director of Clinical Services Date: Signed: Director of Hospital Health Services Date: INTERNATIONAL PATIENT REFERRAL MOHH/2009/2

96 REFERRAL FOR COOK ISLANDS PERMANENT RESIDENTS RESIDENT IN THE COOK ISLANDS, DOES NOT HAVE NEW ZEALAND CITIZENSHIP AND IS A HOLDER OF A FOREIGN PASSPORT CONSENT FORM-NO:3 This form must be completed for all patients who have been recommended for referral to New Zealand at any of the public hospitals in Auckland namely, Auckland Hospital, Greenlane Hospital, Middlemore Hospital or Auckland Starship for further diagnosis/management and treatment. The Ministry of Health will only assist with the payment of return economy airfares and shall schedule appointments with the consulting specialist at any of the public hospitals in Auckland. The Ministry of Health will not meet any further related hospital costs borne as a result of this referral. All costs must be met by the patient. I,, otherwise referred to as a Referral Patient, do hereby confirm and agree that in the even that I refuse and/ or change my mind on arrival to New Zealand for the said purpose will reimburse to the Ministry of Health, no later than 90 days after my departure, all related expenses pertaining to my transfer to Auckland. All related expenses to include airfares, stretcher fees, ambulance fees, medical escort airfares and medical escort allowance as applicable. Signed: Patient/Family Member/Next of Kin Date: Signed: Director of Clinical Services Date: Signed: Director of Hospital Health Services Date: MOHH/2009/2

97 INTERNATIONAL PATIENT REFERRAL PRIVATE REFERRALS CONSENT FORM-NO:4 This form must be completed for all patients who wish to be referred to New Zealand for private consultations. This include consulting specialists at any of the public hospitals in Auckland namely, Auckaland Hospital, Greenlane Hospital, Middlemore Hospital or Auckland Starship and other private hospitals in Auckland for private and further management. The Ministry of Health will only asist and schedule appointments with the consulting specialist at any of the public hospitals in Auckland and will not meet any related costs borne as a result of this private referral. All costs must be met by the patient. I,, otherwise referred to as a private patient, that require further management and treatment of my condition in New Zealand and do hereby confirm that the Ministry of Health will not be liable to meet any cost and/or expenses incurred as a result of my request for overseas referral as a private patient. Signed: Patient/Family Member/Next of Kin Date: Signed: Director of Clinical Services Date: Signed: Director of Hospital Health Services Date: In the event that the consent form cannot be signed as in the case of a minor and/or by the patient, this form must be signed by a parent and/or nominated next of kin and/or guardian of the minor and/or patient. MOHH/2009/2

98 Medical Fitness for Air Travel (MEDA) - July 2009 PLEASE PRINT IN BLOCK CAPITALS Flight Details Your Travel Agent will complete this. Air New Zealand Booking Reference: NAME: AGE: DAYTIME TELEPHONE: ( ) Flight No: NZ Date: From: To: Flight No: NZ Date: From: To: Flight No: NZ Date: From: To: Flight No: NZ Date: From: To: Are you travelling with: (please circle): A companion? A doctor? A nurse? Their Name: Their Air New Zealand Booking Reference : Medical Details Your Doctor will help complete this. DIAGNOSIS OR CONDITION DESCRIPTION : SEVERITY Mild Moderate Severe Date of Injury/Illness/Surgery (if applicable): Date of Discharge from Hospital (if applicable): Services Requested Your Doctor can help with this. Tick (3) as required. Aisle Seat Seat Near Toilet Quadriplegic torso harness Wheelchair to the aircraft steps (can manage steps if required) Wheelchair to the aircraft door (cannot manage steps) Wheelchair to the aircraft seat (cannot walk from door to seat) Note: Ambulance arrangements to/from airports are passenger/escort responsibility. Oxygen 2 litres per minute by Nasal Prongs needs to be AVAILABLE THROUGHOUT THE FLIGHT. Passenger is able to use a PULSE DELIVERY oxygen concentrator Yes No (extra charge applies for oxygen supply - see note page 2) Note: Other flowrates available by special arrangement Stretcher Air New Zealand International Services Only. Oxygen Bottles to drive ventilator must be escorted by Qualified Doctor/Nurse Power Supply to drive incubator with all necessary equipment for in-flight care. (See Page 2) Other Requests: PLEASE NOTE: Flight attendants can not provide assistance with heavy lifting, eating, personal hygiene, ostomy devices or administering medication. Passengers needing help with these need to be accompanied by someone who can assist. DOCTOR S CERTIFICATE AIR NEW ZEALAND LIMITED acknowledges that in providing the requested/attached MEDA information the medical practitioner concerned is providing an opinion to the best of his/her knowledge and assessment of the subject and that the final decision as to whether to accept the subject for carriage on its services rests with Air New Zealand Limited alone. I have read the considerations overleaf and on the notes attached to this form. In my opinion this person is safe to undertake the proposed flight, is not contagious, and is not likely to effect the safety or well-being of other passengers. I agree that the services requested above are appropriate in the circumstances. This passenger is able to take care of his/her own meals, transfers, personal hygiene, administering medication and other needs in flight. (or escorted by someone who can assist with these needs). Additional Comments: Doctor s Name: Signed: Date: Qualification / Speciality: Doctor s Address: Contact Phone Number: Address: PLEASE FAX THIS PAGE ONLY TO AIR NEW ZEALAND CARINA Services : (+64 9) OR TO medaclearance@airnz.co.nz Office Use Only:

99 Medical Fitness for Air Travel (MEDA) Please complete this form if you have any of the following: a. An injury, illness or medical condition that could cause a significant problem for you or others in flight. Examples include active heart disease, severe mobility problems, and psychiatric problems. b. A medical condition that may be made worse by the flight itself Examples include significant lung disease, ear and sinus problems, and recent major surgery. c. An infectious disease Any illness that could be contagious at the time of travel, particularly chickenpox, tuberculosis, measles, mumps. d. A requirement for special medical equipment Equipment requiring power supply (such as nebulisers, syringe pumps, CPAP units) must be approved at least two weeks in advance by Air New Zealand for safety reasons. Battery powered devices may be used in flight (except take-off and landing) if they have self-contained batteries, and are no larger than standard cabin baggage items. Maximum cabin baggage dimensions are; International Pacific Class 1 bag not exceeding the following dimensions: 55cm (22in) + 23cm (9in) + 40cm (14in); 5kg (11 lbs) maximum weight. First/Business Class 2 bags combined dimensions not exceeding 115cm (45in); Total 7kg (16 lbs) Oxygen The aircraft oxygen supplies are for emergency use only and not for planned use. However, oxygen is available for medical reasons with adequate notice (usually four days) and is normally supplied by the use of an "Airsep Lifestyle" oxygen concentrator on international flights. For domestic New Zealand flights Air New Zealand will refer you to an authorised provider who can supply the required oxygen directly to you. You will be responsible for operating the equipment and following any safety instructions.. Your doctor can advise on whether oxygen will be necessary in flight, but if you are breathless on the ground or use home oxygen it is likely to be required. Your own oxygen bottles may be carried but will need to be packaged and transported per Dangerous Goods carriage regulations. While Air New Zealand will make every effort to have oxygen available on the flight that you request it may not be possible to fulfil the request. In these instances Air New Zealand reserves the right to request that you travel on a flight where oxygen can be supplied. Please note that Air New Zealand will only supply oxygen in flight. If oxygen is required on the ground (including during transit) it is the passengers responsibility to arrange supply. Stretchers (Air New Zealand International Services Only) PLEASE COMPLETE PAGE 4 AS WELL A stretcher can be provided at extra cost for patients travelling with appropriately qualified and equipped nursing or medical escorts. Ventilators (Air New Zealand International Services Only) PLEASE COMPLETE PAGE 4 AS WELL Any passenger requiring a ventilator will need to have the ventilator and assorted equipment approved for use on board the aircraft. Incubators (Air New Zealand International Services Only) PLEASE COMPLETE PAGE 4 AS WELL Power supply for Air New Zealand approved and modified baby incubators is available to medical teams transporting babies. Please contact Air New Zealand at the earliest opportunity to ensure suitability. There is no need to complete this for: Uncomplicated Pregnancy unless after 36 weeks and a flight duration time of more than 5 hours. Mobility problems requiring only a wheelchair to the aircraft door. NOTES TO THE DOCTOR. All information on this form is treated in strict confidence, used only to facilitate medical clearance and special handling arrangements, and is necessary to ensure that your patient and other passengers are carried safely and efficiently. Please consider the following factors: 1. Reduced atmospheric pressure most airlines cruise at an equivalent cabin altitude of feet. This reduced pressure produces two main effects: GAS EXPANSION At normal cruising cabin altitudes, gas expands by 20-35%. This is important for the middle ear, the sinus, and for any trapped gas present such as in the lungs, gut, thorax, or eyes. REDUCED OXYGEN TENSION At 8000 ft, alveolar oxygen pressure for a healthy individual is reduced from a normal 103mmHg to 64mmHg. Peripheral oxygen saturation is reduced from 97% to 93%. Sea level equivalent can be restored by as little as 10% added oxygen (2 litres per minute by mask). Passengers with Pa02 below 60mmHg at sea level are likely to be worse at altitude and should breathe continuous oxygen. Pa mmHg may require oxygen if distressed. 2. Other effects: low humidity, motion and turbulence, immobility and confinement. p a g e 2

100 3. Inflight care: Passengers need to be able to manage their own inflight care including meals, personal hygiene and administering medication, or travel with a companion who can flight attendants cannot assist with these tasks. They are able to assist a wheelchair-bound passenger in getting to the toilet door. For safety reasons, they are not able to lift passengers. 4. For the sake of other passengers, any passenger with a contagious disease in the active stage should not travel. Guidance notes for specific conditions can be found on page ❸. For further advice call Air New Zealand Medical phone Notes on Specific Conditions Allergies: We are not able to provide a meal free of a specific food allergen. You may bring your own food (subject to the quarantine requirements at your destination), but we are not able to refrigerate, store, or warm it for you. If you have a life threatening food allergy which may require treatment in-flight, you should discuss with your doctor what medication to bring with you. If you need injections, you must be able to administer them yourself or travel with a companion who can do this. Asthma: This is rarely a problem in-flight: however please ensure you carry your medication in your cabin baggage. If you need a nebuliser we recommend a battery powered one; however, inhalers with a spacer device are usually just as effective; please discuss with your doctor. All our International flights carry an oxygen driven nebuliser for emergency use, NOT ROUTINE requirements. Deep Vein Thrombosis (DVT): Prolonged immobility can increase the chance of blood clots in the legs (DVT or Deep Vein Thrombosis). Those with a previous or family history of DVT (or Pulmonary Embolism) should seek advice from their doctor before flying. Other risk factors include older age, blood clotting tendencies, pregnancy, oestrogen therapy (including oral contraceptives), certain cancers and heart conditions, lower limb injuries and recent major surgery. Customers with any of these risk factors are also advised to contact their doctor before travel to discuss measures such as compression stockings or drug therapy. Ear and Eye Problems: You should not fly with a current middle ear infection (otitis media) or within two weeks after surgery to the inner ear. (Please check with your surgeon). Following eye surgery which involved leaving gas in the eye, you need to have this form completed by your eye surgeon. Fractures: Complete this form for all new long bone fractures (72 hours or less) and for full leg casts. Plasters should be split for fresh leg injuries which could swell inside the cast (especially the first 72 hours) on a long flight. Passenger should receive instruction on method of loosening the plaster cast in the event of the leg swelling causing pain or disturbance to circulation. Extra leg room for leg elevation is not possible in economy class, however an aisle seat can be reserved, please state whether the injury is left or right. If you have a fractured jaw which is wired closed, you must have a way of releasing the wires in an emergency. Heart Disease: A form is required only for recent or unstable heart failure, arrhythmias or recent heart attacks. For the first few weeks following a heart attack, a medical escort will usually be required. Following heart surgery, check with your surgeon whether a form is required. Lung Disease: If you have lung disease which prevents you walking more than 100 metres on the flat, or has required you to use oxygen in hospital or at home (or in-flight previously), please ask your doctor to complete the form describing the severity of your problem. The aircraft oxygen is for emergency use only, but extra oxygen can be made available with adequate notice (usually four days). Your own oxygen cylinders cannot be used but may be carried subject to certain conditions and prior arrangement; please ask your travel agent to assist with this. Mental Stress: Flying can be stressful for many people, particularly the elderly and those with specific phobias. Please check with your doctor, but a form is required only where the ability to cope with flight is in question. Physical Disabilities: There is no need for this form if you simply require a wheelchair; your travel agent can indicate this on your reservation. Longhaul aircraft have on-board wheelchairs, and seats with moveable armrests. For safety reasons the upper deck of the Boeing 747 is only available to those who can manage stairs unassisted. An upper torso harness should be requested for passengers who have difficulty sitting upright in an aircraft seat. Note: Civil Aviation Rules require all passengers to be able to use the aircraft seat with the seatback in the upright position. Pregnancy: For travel beyond 36 weeks of pregnancy on journeys of 5 hours or more, and for any complicated or multiple pregnancy, the form is required. Ask your doctor or midwife to indicate the risk of early labour or complications. Psychiatric Problems: Passengers with unstable psychiatric problems which could pose a hazard to other passengers will normally require a doctor or nurse escort. In particular passengers treated with sedation will need to be escorted. Special Meals: Special meals for religious, ethnic, or dietary reasons can be arranged through your travel agent or the website without using this form, on selected flights. If you have a food allergy please see the section on allergies above. Terminal Illness: Passengers in the advanced stages of terminal illness will normally require a medical or nursing escort. p a g e 3

101 SUPPLEMENTARY MEDA FORM PATIENT NAME: Name of Air New Zealand approved Air Ambulance Service Provider Booking Ref: (for stretcher patients only) Contact name: Tel Fax List of all Medical Equipment being carried: Requires aircraft power supply Own power supply but for use during all phases of the flight Items exceeding the dimensions and weights listed on page 2 of this form Small portable electronic devices not being used during take-off or landing If travelling to New Zealand For Medical / Surgical Treatment: Has admission to hospital in New Zealand been arranged? Yes No Which hospital? Name of doctor there Has ambulance been arranged from Auckland airport to the hospital Yes No (Note: Ambulance arrangements to / from airports are passenger / escort responsibility) Is the escort medically or nursing qualified? Yes No Has escort been briefed about case history? Yes No The escort is qualified to undertake the transfer and has all necessary equipment to deal with the patient s needs and any likely complications during the journey. SIGNATURE OF DOCTOR DATE Please fax this page along with page 1 to; Air New Zealand Reservations Control Telephone (64-9) Fax (64-9) p a g e 4

102 8. REPATRIATION FORM Note: to be completed by Patient Referral Coordinator Name of Patient: DOB: Passport Number: Medical Clearance report received from Doctor Yes No Follow-up Appointment Date (if any): Confirmation patient was referred through MOH Patient Referral system Yes No Booking arrangement with airline for repatriation Name of Patient and / or next of kin: Airline: Flight Number: Ticket Reference Number: Date of Travel: Cost ($): Works Order Number Confirmed booking with Patient or next of kin; Date: Repatriation approved by: DHHS/ DCS Name: Sign: QUALITY HEALTH CARE FOR ALL Page 24 of th October 2010 doc.

103 PATIENT REFERRAL CHECK LIST PATIENT S NAME: DATE OF BIRTH:.. NEXT OF KIN/GUARDIAN:. REFERRAL DOCTOR:. HOME ISLAND:. TELEPHONE CONTACT: OFFICIAL USE ONLY INDICATE WHEN DONE RAROTONGA HOSPITAL 1. Referral Form signed by Referral Committee ( ) 2. Is this referral authorized by HOM ( ) 3. Letter of acceptance by Hospital accepting the case ( ) a) Accepting letter attached ( ) b) Acceptance confirmed by telephone/fax/ ( ) 4. Name of Consultant Specialist in Auckland 5. Service Area: Contact Phone no:. 6. Have documents been faxed to the Consulting Specialist in Auckland ( ) 7. Has the patient been informed of the Referral Procedure? ( ) 8. Has the patient completed the Patient Consent Form? ( ) 9. Has the patient been given his complete case documentation? ( ) 10. Has the patient been given the Patient Referral Brochure? ( ) 11. Is this referral, Alcohol Related. Yes/No If Yes, please refer to Crown Law for civil action MOH CENTRAL ADMINISTRATION (UNLESS EMERGENCY CASE) 1. Travel Arrangements confirmed with Airline Carrier a) Stretcher confirmed b) Medical Officer/Nurse Escort confirmed:. c) Flight No:.. Departure Date:.. e) Bookings made by: SECRETARY OF HEALTH 1. Is this referral authorized by the Secretary of Health? Yes/No 2. Family Escort. Is MOH responsible for meeting their airfares? Yes/No Signature of HOM: Date:

104 IMPORTANT CONTACTS in Rarotonga Rarotonga Hospital Telephone: Fax: Rarotonga Health Administration Tupapa P.O.Box 109 Avarua Telephone: Fax: Justice Department Avarua Telephone : Fax: 29610/28610 New Zealand High Commission Avarua Telephone: Fax: Internal Affairs Air Rarotonga Avarua Avarua Telephone: Telephone: Fax: Fax: Information for Patients referred to Rarotonga Hospital for medical reasons Hostels / Telephone Mitiaro: Perhyn: Mangaia: Pukapuka: Mauke: Aitutaki: Atiu - Rakahanga: Your family contact in Rarotonga Name: Address:.. Telephone: Home:.. Cook Islands Ministry of Health P.O. Box 109 Avarua Rarotonga COOK ISLANDS CONTACT DETAILS: Peggy Teiotu Patient Referral Coordinator p.teiotu@health.gov.ck RAROTONGA HOSPITAL Phone: (682) Fax: (682) March 2010

105 1. Travel Itinerary Your travel itinerary will be organised by the Patient Referral Coordinator Peggy Teiotu. She will co-ordinate all aspects of the travel and travel document required for your successful transfer to Rarotonga and she will organize for your return back to your home island. 2. Passport All patients referred to Rarotonga must bring with them their current passport ( in case the patient needs to be referred to New Zealand for further investigation or treatment). If it is expired or lost, then you will be required to apply for an emergency passport to the NZ High Commission in Rarotonga. An emergency passport will cost $350 and will be valid for 1month. You will need to complete an application form, have 2 passport photos, your expired passport ( if not lost), your birth certificate and $ NB: A new copy of birth certificate or marriage certificate from the Justice Dept will cost $15.00 each. Passport photos will cost $ Medical arrangements Your doctor or nurse in charge on your island will make all the necessary arrangements with the doctor on Rarotonga before your transfer. This will also include ensuring that the patient Outer Island Referral Form is completed and faxed through to the Patient Referral Coordinator. 4. Patient Referral Coordinator The Patient Referral Coordinator will make all the necessary arrangements once she receives the Outer Island Referral documents from your doctor or nurse. 5. Medical/family escort All emergency/critical care cases will have an accompanying medical and/or nurse escort. In cases where a patient is medically well to travel on their own the cost for airfare for one family member will be covered by the MoH if the patient is under 16 years of age or over 70 years old. 6. Pick up from Rarotonga Airport The Patient Referral Coordinator will make arrangements for an ambulance to pick the patient from the airport and transport them to the hospital when they arrive in Rarotonga. In some cases the patient can be picked up by a family member and they will not be required to be admitted to the hospital but will be required to be seen by a doctor the next day or at an appointed time. 7. Accommodation It is important that the patient and their family make their own accommodation arrangements in Rarotonga in case they are not admitted to the hospital or for when they are discharge from the hospital. However it is possible in certain circumstances to make arrangements so that the patient can be discharged from the hospital and go straight on a plane to go back to their home island. 8. Contact address in Rarotonga It is necessary to provide a contact person and a contact number in Rarotonga. (See back of page). 9. In patient hospital fees There is a NO FEE charge for all outer islands Cook Islanders or Permanent Residents EXCEPT if the patient is being admitted to Rarotonga Hospital as a result of ALCOHOL RE- LATED INJURIES. 10. Costs incurred as a result of an alcohol related admission In addition to hospital inpatient fees the patient will also be liable for all costs including airfares for themselves as well as for the doctor/nurse escort and the daily per diem for the doctor or nurse. 11. Arrangement for return to home island Once you have completed all treatment and discharged by your doctor please contact the Patient Referral Coordinator to make your bookings for your return home. Please note: Some patients may need to be referred onwards to NZ for further investigations and treatment. Therefore it is important to bring your current passport, birth certificate and marriage certificate with you when you come to Rarotonga. It is important for all to be aware that any reimbursements for airfares or boat fares will not be made unless an Outer Islands Referral Form is completed by the doctors and submitted to the Patient Referral Coordinator. The Vision of the Ministry of Health To provide accessible and affordable health care of the highest quality, by and for all in order to improve the health status of the people of the Cook Islands