Investments for health looks at all critical inputs necessary to effectively deliver health care and public health. These include financing, human resources, health technologies and infrastructure. Investment in health is, therefore, an investment in the broader economy. “Investment for health and wellbeing is a driver and an enabler of sustainable development and vice versa, and it empowers people to achieve the highest attainable standard of health for all”54.
The COVID-19 pandemic brought to light just how critical these inputs are to the daily operations of the health system. Resources were diverted into national COVID response very often at the expense of other services and functions.
HCW absenteeism due to COVID-19 exposure, staff redeployment to new isolation and treatment facilities, and demands from the expanded COVID-19 testing and dedicated ‘fever clinics’ highlighted the importance of an adequate, trained and resilient workforce. Restrictions in international air travel, depreciation of the Seychelles rupee, and in-country lock-downs in source countries severely compromised the procurement of medicines and medical products.
The successful implementation of the health agenda 2022-2026 is dependent on actions to strengthen each health system building block, outlined next.
Human Resources for Health
The COVID-19 pandemic has further highlighted the importance of sufficient numbers of adequately trained motivated HCWs, in dealing with existing and emerging health challenges. The national vision for health, expressed in the National Health Policy, can only be achieved with an adequate resilient workforce equipped with knowledge and skills to take on these challenges.
Effective human resources (HR) management strategies are crucial to achieving better outcomes in health56. Local HR Management capacity is rudimentary, focusing principally on administrative functions around ‘hiring, paying and firing’. The Human Resources Division requires much capacity building to deliver on all core HR functions. Some key areas of deficiency are staff welfare and occupational health and safety. The sector has yet to define national HR norms and standards, affecting projection and planning and better deployment of available human resources. There is a lack of quality data to inform decision making and planning.
Outstanding issues in HRH
Health Workforce Production
The Seychelles health system is heavily dependent on foreign health workers. Fifty-seven per cent of all health professionals are expatriates and 64% are trained abroad57. The health sector faces intense competition from other sectors in attracting the best minds, especially for the local training programmes. The NIHSS Access Programme, designed to help meet admission requirements, has contributed positively to increasing enrolment. More effort is required to engage secondary school students at an early stage to increase interest in careers in health and social fields. The health sector remains dependent on foreign training for key occupational cadres. There is a need to bring uniformity to training by selecting key institutions for the different cadres. Mechanisms for access to in-service training is also inadequately defined and communicated.
Recruitment and Deployment
There is no clear policy on recruitment, especially for foreign HCW. Unnecessary bureaucracy delays the employment of identified personnel. Allocative inefficiencies are often reflected in highly trained staff with critical skills not working in the areas for which they have received training.
Succession Planning
Key positions in the sector remain unfilled due to poor succession planning. Managers sometimes do not adequately recognize and nurture future leaders in health, affecting succession planning.
Remuneration, Incentives and Rewards
Staff awareness on remuneration, appraisal and promotion policies and norms is low. Where Schemes of Service are available, these are not readily available and accessible to staff. Appraisal systems are not adequately tailored to actual work and do not sufficiently reflect performance. More continuous mechanisms for feedback on performance is lacking. Incentives are considered from a monetary perspective only.
Collection, Analysis and Use of HR Data
The sector does not systematically collect, analyse and use HR data to guide training, recruitment, deployment of staff. Available data is fragmented, mostly paper-based and inaccessible to decision makers. The National Health Workforce Accounts (NHWA) has been introduced to facilitate the standardization of a health workforce information system in order to improve data quality58. This reflects a step in the right direction for evidence-informed HRH planning, but more work is required towards institutionalisation of the process.
Staff Wellbeing
HCWs are under considerable strain. The COVID pandemic has stretched resources thin. HCWs have been redeployed to areas in need, in some instances with little or no training and little consideration of effects on their mental health and wellbeing. HCWs feel unappreciated within their organisation and are often left alone to deal with occupational and personal crises. Burnout, although not systematically measured, is a reality. An unknown number of HCWs abuse drugs and alcohol. However, the subject remains taboo, and subsequently, help is not accessed.
Priority Areas in HRH
- Develop a national Human Resources Strategic Plan.
- Empower professional councils to become more effective regulators.
- Make careers in health more attractive.
- Enable HR to deliver on all core HR Functions.
- Provide support and guidance for career planning.
- Care for the carers.
- Improve HR data collection, analysis and use for decision making.
Healthcare Financing
Health financing involves the mobilisation and equitable distribution of funds to meet the health needs of individuals and communities. This means ensuring that no one endures financial hardship as a result of accessing essential health care.
The government has always been and remains the principal investor in health. Total Government Health Expenditure was SCR 887 million in 2018, representing 11.2% of total government expenditure, below the 15% target countries committed to in the Abuja Declaration. Total Health Expenditure (THE) as a percentage of nominal GDP increased from 3.8% in 2014 to 5.6% in 2018. The major cost drivers are health care goods and services (54.5%) and compensation of employees (38.8%).
Outstanding issues in Health Financing
Sustainability of the current financing model
Health expenditure is increasing and will continue to rise due to several factors, including the increasing incidence of NCDs, obesity, and the shift towards an ageing population. New technologies are expensive, and inflate costs especially when there is overutilization to satisfy rising client expectations.
The right to health enshrined in the Constitution obligates the state to provide for free primary health care in all its institutions. However, the current palette of services includes dental care, secondary and tertiary health care, which is not sustainable in the long run.
Spending is skewed towards curative care, especially specialised care
In 2018, 47.4% of CHE went towards curative care and 22% towards preventive care. Consecutive NHA reports have shown a small increase in expenditure on preventive care, from 17.7% in 2016 to 19.4% in 201759.
Challenges with PPBB
Performance-Based Budgeting (PPBB) refers to ‘any budget that represents information on what agencies have done, or expect to do, with the money provided to them’60. In other words, PPBB is ‘the systematic use of performance information to inform budget decisions, either as a direct input to budget allocation decisions or as contextual information to inform budget planning, and to instil greater transparency and accountability throughout the budget process, by providing information to legislators and the public on the purposes of spending and the results achieved’.
However, the introduction of PPBB has not brought expected improvements in results. Managers are not sufficiently engaged in the budgeting process. The abolition of cost centres with the introduction of the PPBB system has left health managers in the dark regarding available funds for the projects they are expected to implement efficiently.
Lack of cost (-benefit) awareness
There is a lack of cost awareness among service providers and service users. The notion of free healthcare may nudge users to undervalue the cost of the care they receive. Greater cost awareness will help guide cost-conscious clinical and administrative decision making and ultimately improve costefficiency of health services.
Weak revenue collection systems in the public health sector
Health being free at the point of use, the system is not traditionally geared towards revenue collection. There are no SOPs and guidelines to guide revenue collection from those not eligible for free services (expatriate workers, tourists) nor established mechanisms to minimize risk of diversion of funds and embezzlement. Some service areas are more vulnerable to corrupt practices than others.
There are not enough cashiers, especially at the Seychelles Hospital and outside regular working hours. Most facilities are not equipped for cash less transactions. There is no centralized billing system. Very often, HCWs do not know who is eligible for free services and who is not.
Priority Areas in Health Finance
- Make PPBB work for the sector.
- Address inefficiencies in health care management and delivery.
- Improve revenue collection.
- Ensure sustainability of health care financing.
- Increase spending on preventive and promotive care.
Health Infrastructure
A Masterplan for the development of Hospitals in Seychelles was developed. It is a comprehensive infrastructure plan for the Seychelles Hospital and its annexes and the three smaller hospitals at Anse Royale, Baie Ste. Anne and La Digue. The project did not include primary health care facilities and has not been implemented to date. Infrastructure development and maintenance is not well-coordinated and is not necessarily based on needs.
Outstanding issues in Infrastructure
- Internal capacity to manage big projects is weak.
- The sector does not have an infrastructure maintenance plan.
- Some facilities are no longer fit for purpose.
- Need for additional Intensive Care beds.
- Need for purpose-build dedicated Isolation infrastructure.
- Facilities are not disabled-friendly.
- Fire, flooding, chemical, biological and radiological risks need to be addressed.
Priority Areas in Infrastructure
- Needs-based infrastructure planning
- Infrastructure maintenance
- Addressing fire and other risks
- Renovate, upgrade or replace infrastructure no longer fit for purpose
- Disability-friendly facilities
Health Technologies
Health technology is the application of organised knowledge and skills in the form of medicines, medical devices, vaccines, procedures, and systems developed to solve a health problem and improve quality of life (WHO).
Outstanding issues in Health Technologies
- Lack of regulatory framework for health technologies
- Stock outs of medicines and commodities
- The sector does not have a list of essential technologies
- The Procurement Unit does not involve service providers in prioritisation exercises
- Service maintenance contracts are not always clear on roles, responsibilities and scope
- The digitalisation of stock management is not complete.
Priority Areas in Health Technologies
- Strengthen procurement and stock management capacity
- Digitalise Stock management
- Engage Service providers in procurement processes
- Improve service maintenance contracts
- Ensure donated equipment, medicines or supplies align with MOH standards and needs.
Information Technology
Information Technology (IT) presents unprecedented opportunities for innovation in health care delivery. As these technologies become more accessible to broader sections of the population, the health sector needs to take advantage of these technologies to improve health outcomes.
Electronic Health (eHealth) is the delivery of health care using modern electronic information and communication technologies when health care providers and patients are not directly in contact, and their interaction is mediated by electronic means.
Mobile health (mHealth) is a subset of eHealth, defined as medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices (WHO).
Outstanding Issues in IT
The sector has not capitalised on the wide availability of mobile phones (193,672 mobile phones and 89,896 mobile broadband subscribers in 201961) to engage with service users. Different units have created WhatsApp groups for discussions and sharing of information; however, the sector has yet to exploit the full potential of these technologies. The MoH has introduced different telemedicine projects over the years, but none proved to be sustainable.
Priority Areas in IT
- Support for new health care delivery models – appointment systems, reminders, treatment adherence support, health education, health promotion, self-management supports.
- Provide health professionals with point of care access to information – guidelines, standards, decision-making tools.
- Facilitate data collection – routine reporting, surveys, monitoring.
- Institutionalise eLearning and CPD.
- Utilise Telemedicine to improve access to services, including in crises.
SD5 General Objectives
To ensure effective, efficient and sustainable investment in the building blocks of the health system.
Human Resources for Health
The sector shall develop a national Human Resources for Health Strategy to guide the production, recruitment, deployment, retention and remuneration of health care workers. Emphasis will be on support for HCW throughout their career, from induction and mentorship programmes to staff welfare programmes. MoH will strengthen the capacity of the human resources unit to deliver on all HR functions.
Health Finance
The sector will seek to improve efficiency in health care by raising cost awareness, conducting costbenefit analyses of key services (including outsourced services), and redirecting funding to more costeffective upstream interventions delivered through preventive and primary care.
The sector will also conduct a review of ‘low-value care’ – care that provides little or no benefit, may cause harm, or yields marginal benefits, at disproportionately high cost. MoH will explore alternative financing sources such as national insurance funds, social enterprising, accessing global, regional and bilateral supports, and public-private partnerships in evidence-based health service delivery to ensure health sustainability.
Infrastructure
The health sector will elaborate a comprehensive infrastructure development and management plan to address resilience in the face of climate change, disability access to facilities, fire and other risks, and address the challenges of inadequate safe and secure storage for supplies. The plans will ensure that new buildings are more fit-for-purpose, and outdated facilities are gradually brought up to standard. The proposed centralisation of infrastructure development will benefit the health sector, which lacks the internal capacity to develop and follow through with major infrastructure projects.
Health Technologies
The sector will develop an Essential List of Health Products, that similar to the Essential List of Medicines, aligned with the agreed package of care and services. Both the Essential List of Health Products and the Essential List of Medicines will serve as advocacy tools for resource mobilisation and prioritisation, ensuring that facilities have access to those medicines and commodities required for their scope of health care services. The tools will also guide donations, ensuring alignment with health system needs and standards. The sector will introduce mechanisms for the introduction of new health products and technologies and revise the procurement process to avoid stock-outs.
Information Technology
As health care workers and the population become more technology proficient and technologies become more affordable, the sector will look for opportunities to introduce IT solutions across the spectrum of activities, including to:
- Promote e-learning: Online-learning platforms with the capacity to track CPD activities, push targeted content towards specific groups and upload local content will be developed.
- Provide remote consultations (telemedicine), which can significantly reduce the cost of providing many decentralised specialist services.
- Support new health service delivery models: Patients will receive reminders and prompts. They will be encouraged to monitor specific parameters at home and relay this information to their service providers, who will provide the appropriate response.
These platforms can also be used for health promotion and health education.
SD5 Specific Objectives
View the Invest for Results: Specific Objectives
54 Dyakova, Mariana, Hamelmann, Christoph, Bellis, Mark A., Besnier, Elodie, Grey, Charlotte N.B.et al. (2017) . Investment for health and well-being: a review of the social return on investment from public health policies to support implementing the Sustainable Development Goals by building on Health 2020. World Health Organization. Regional Office for Europe. https://apps.who.int/iris/handle/10665/326301
56 Kabene, S.M., Orchard, C., Howard, J.M. et al. The importance of human resources management in health care: a global context. Hum Resour Health 4, 20 (2006). https://doi.org/10.1186/1478-4491-4-20
57 Health Workforce Situation in Seychelles: Insights from baseline National Health Workforce Accounts, MOH, 2021
58 Understanding National Health Workforce Accounts, WHO 2017
59 National Health Accounts (NHA), 2016-202017 Report
60 OECD Best Practices for Performance Budgeting, Public Governance Committee Working Party of Senior Budget Officials. November 23, 2018. Online at: https://one.oecd.org/document/GOV/PGC/SBO(2018)7/en/pdf
61 Seychelles in Figures, 2020 Edition, NBS, Seychelles