REVIEW REPORT on Tokelau’s Clinical Health Services and Patient Referrals Scheme Prepared by: Tracie Mafile’o, Sunia Foliaki, Tanya Koro, Helen Leslie*, Michelle Redman- MacLaren, Caryn West, Matthew Roskrudge November 2019 *Helen Leslie contributed to the review report as a review team member up until July 2019 Table of Contents LIST OF FIGURES ..............................................................................................................................................III LIST OF TABLES ...............................................................................................................................................III ACRONYMS .................................................................................................................................................... IV GLOSSARY ...................................................................................................................................................... IV ACKNOWLEDGEMENTS ................................................................................................................................... V EXECUTIVE SUMMARY ................................................................................................................................... VI PURPOSE .............................................................................................................................................................. VI APPROACH ............................................................................................................................................................ VII FINDINGS AND RECOMMENDATIONS .......................................................................................................................... VII CLINICAL HEALTH SERVICES ..................................................................................................................................... VIII HEALTH FINANCING ................................................................................................................................................. X NON-COMMUNICABLE DISEASES (NCDS) .................................................................................................................... XI TOKELAU PATIENT REFERRAL SCHEME (TPRS) .............................................................................................................. XI IMPLEMENTATION OF THE REVIEW ............................................................................................................................. XII PURPOSE OF THE REVIEW ................................................................................................................................ 1 HEALTH FROM A TOKELAU PERSPECTIVE ......................................................................................................... 1 TOKELAU ENVIRONMENT .......................................................................................................................................... 2 POPULATION AND GOVERNANCE ................................................................................................................................ 2 SPIRITUALITY AND BELIEFS ......................................................................................................................................... 3 WORLDVIEW .......................................................................................................................................................... 4 SOCIAL SYSTEMS...................................................................................................................................................... 4 HEALTH STATUS ...................................................................................................................................................... 4 THE WAY THE REVIEW WAS DONE ................................................................................................................... 5 DATA COLLECTION ................................................................................................................................................... 5 Documentary analysis .................................................................................................................................... 7 Interviews ....................................................................................................................................................... 7 Systems Assessment Tool (SAT) with Health Professionals ............................................................................ 8 Community Workshops .................................................................................................................................. 8 ANALYSIS AND REPORTING ........................................................................................................................................ 9 LIMITATIONS OF THE REVIEW ..................................................................................................................................... 9 APPROACH AND STRUCTURE OF THE REPORT................................................................................................ 10 THE FINDINGS OF THE REVIEW ...................................................................................................................... 11 CLINICAL HEALTH SERVICES: AN EXPERIENCE .............................................................................................................. 11 OVERVIEW OF FINDINGS FROM THE SYSTEMS ASSESSMENT TOOL ................................................................................... 11 1. DELIVERY SYSTEM DESIGN .............................................................................................................................. 13 Team structure, function and clinical leadership ......................................................................................... 13 Appointments and scheduling ...................................................................................................................... 20 Care planning, follow up and continuity of care .......................................................................................... 20 Client access and cultural competence ........................................................................................................ 21 Physical infrastructure – facilities, medical equipment and pharmaceuticals ............................................. 22 2. INFORMATION SYSTEMS AND DECISION SUPPORT ............................................................................................... 25 3. SELF-MANAGEMENT SUPPORT ......................................................................................................................... 27 4. LINKS WITH COMMUNITY, HEALTH SERVICES AND OTHER SERVICES ........................................................................ 28 5. ORGANISATIONAL INFLUENCE AND INTEGRATION ................................................................................................ 29 Organisational commitment ........................................................................................................................ 29 Quality improvement strategies .................................................................................................................. 31 i Integration of health system components ................................................................................................... 32 6. HEALTH FINANCING ...................................................................................................................................... 32 Funding required to deliver adequate levels of health service ..................................................................... 32 Budget impact of the growing incidence of NCDs ........................................................................................ 36 7. NON COMMUNICABLE DISEASES (NCDS) .......................................................................................................... 38 TOKELAU PATIENT REFERRAL SCHEME: AN EXPERIENCE ................................................................................................ 40 8. TPRS RELEVANCE ......................................................................................................................................... 41 9. TPRS EFFECTIVENESS .................................................................................................................................... 43 10. TPRS EFFICIENCY ..................................................................................................................................... 48 The TPRS Expenditure Picture ...................................................................................................................... 49 A pragmatic approach to TPRS efficiency .................................................................................................... 52 11. TPRS IMPACT AND SUSTAINABILITY ............................................................................................................. 53 IMPLEMENTING THE REPORT ......................................................................................................................... 54 REFERENCES CITED AND DOCUMENTS REVIEWED ......................................................................................... 55 APPENDICES..................................................................................................................................................