The problem with Health...

Saturday April 01, 2017 Written by Published in Health

With health spending in the news recently, a CI News reader has contributed this feature which highlights deficiencies in the national health budget. The writer, who is well qualified to comment on this issue, has asked not to be named. He says Health spending is currently $10 million below recommended minimum


Prominent New Zealand-based surgeon Dr George Ngaei has labelled the Cook Islands health budget of 3.4 percent (or $13 million) of Gross Domestic Product (GDP) a disgrace. By its own admission, the Cook Islands Government spending on health should be around 6 percent of GDP or $23 million. So why the massive mismatch?

Health minister Nandi Glassie, interviewed on Radio New Zealand, agrees that the Cook Islands health budget is well below the World Health Organization (WHO) requirement of around 5 per cent of GDP.

Glassie told RNZ journalist Jo O'Brien: “It’s the best that can be expected within budget constraints… 3.4 percent is equivalent to about 13 million dollars in the Cook Islands. Given the situation in the Cook Islands that is all we can run by at this stage.”

According to the Minister, the Cook Islands government should be spending an additional $7 million on Healthcare to match WHO requirements. Meanwhile, the Health ministry, in its 2015/6 Budget Plan, sets a goal of 6 per cent of GDP by 2016. On this basis, government needs to be spending an additional $10 million a year on Health.

While the Health minister blames “budget constraints”, his claims are contradicted by his colleague, Finance minister Mark Brown, who has announced a large budget surplus. This is confirmed in the December 2016 Cook Islands Half Year Economic and Fiscal Update which estimates a net operating balance or budget surplus of 62.3 million in 2016/17.

This serious government under-spend on Health places the Cook Islands at Number 16 in the World Atlas Table of Countries with the Lowest Health Expenditures Relative to GDP Worldwide. This ranks us narrowly above the African Congo (3.2 per cent), below Ethiopia (3.8 per cent) and equal to Syria at 3.4 percent. According to the World Bank, it also places us far behind Pacific neighbours such as Kiribati (8.3 per cent); Marshall Islands (14.4 per cent); New Zealand (9.1 per cent); Samoa (6.5 per cent); and Tuvalu (16.4 per cent).

As Table 2 shows, government funding on health remains much lower than government spending on tourism. In 2016/7, estimated government support to the tourism industry, (including the Air New Zealand underwrite), will be $19.4 million. On the other hand, Health spending has been on a downward spiral since 2010, and in the current year will be $5.3 million less than government spending on tourism.

In his Radio New Zealand interview, the Health minister said, “We need to have more money to have doctors on some of the outer islands but the reality for the Cook Islands is that we have people migrating to New Zealand and to Australia. We have an issue with depopulation. Therefore, if people are sick in the outer islands it's easier for the Ministry of Health to fly them to Rarotonga.”

According to Health ministry reports, the major causes of death in the Cook Islands over the period 2012 -2015 were circulatory system diseases (hypertension, stroke and diseases associated with the heart).

This, and the continuing challenge of providing medicines to the outer islands, raises questions about the effectiveness of air evacuation as the primary medical recourse for people scattered over 1,800,000 square kilometres of ocean.

The Health ministry’s Budget Plan for 2015/16 identifies “Restricted Access to the Pa Enua (Tokerau) in Emergency situations” as “High in Likelihood.” This contradicts the minister’s argument that “it’s easier to fly them to Rarotonga” that pay for a resident doctor.

For those who have died in remote locations without ever seeing a doctor (as in several recent cases) death certificates are now issued by Nurse Practitioners. According to the Royal Australasian College of Surgeons, “The issuing of a death certificate requires the practitioner to exercise powers of advanced diagnostic reasoning ... “

The reporting of a death has implications for statistics on mortality and prevalence of fatal conditions; and needs to be accurate. The training of medical practitioners is more extensive and diverse in this regard, particularly where the medical condition is complex ....”

It is not known if current training provides nurses and nurse practitioners with the advanced diagnostic reasoning needed for determining causes of death, particularly in complex cases. It also raises questions about the validity of Ministry of Health data on outer islands morbidity and mortality.

Around 237 Pa Enua patients are flown to Rarotonga on referral each year. Of these, 195 are from the southern group and 42 from the north.

This adds up to a significant amount of money, with a single emergency charter to the northern group costing around $26,000.

This money would go a long way to paying for resident doctors on each island, assuming the government were actually short of money.

In summary,

(1) The Cook Islands government is, by its own admission, failing to match minimum spending levels on health recommended by the World Health Organization by $7 million a year, placing it 16th lowest in the world for expenditure on health care relative to GDP;

(2) The Cook Islands government is failing to match the level of health care spending it set for itself in the Cook Islands Health Strategy 2012 – 2016 by as much as $10 million a year;

(3) The Cook Islands government prioritises spending on tourism over spending on health care, and will spend an estimated $5.3 million more on tourism than healthcare in the current financial year;

(4) The Health minister agrees that the outer islands need resident doctors but says he cannot find the money because of “budget constraints”; the Finance minister says the government has more money than it can spend; the December 2016 MFEM Half Year Economic and Fiscal Update estimates a ‘net operating balance’ or budget surplus of $62.3 million in 2016/17;

(5) Perhaps as much as $400,000 a year is being spent on bringing people from the outer islands to Rarotonga in the absence of doctors on their islands. This money could go a long way to paying for resident doctors in each of the Pa Enua;

(6) Isolated nurses or Nurse Practitioners are being asked to do what the government is failing to do: provide quality medical care in what the ministry acknowledges is a challenging environment, “with a 24hr/7days a week on-call and little relief, little contact with other medical or nursing colleagues and limited opportunities for continuing professional development.”

While Health secretary Elizabeth Iro, a nurse herself, maintains that Nurse Practitioners can effectively replace doctors in the Pa Enua.

WHO technical officer Erica Reeve, commenting on the Mangaia situation for Radio New Zealand, said: “nurses can't be trained up to cover all emergencies and it's not necessarily the capacity, it's also the technology that they have available to them, the tools and the access to particular medicines. And you can't expect them to cover to the degree a doctor would be able to."

So where does that leave the Pa Enua? The Health ministry, in its Strategic Plan (page 13) states that the ministry, “will facilitate and ensure equality of opportunity and equal rights for all our people including access to…health care….including the most vulnerable and marginalised groups.”

The ministry admits in its 2015/6 Budget Plan that, with the current underfunding, it “does not meet the aspirations of Te Marae Ora, or the population in general with regard to the desired level and quality of health service provision.”

It warns of the dangers of “Stagnation of progress made with delivery of quality service to the Pa Enua,” if funding levels are not increased.

Yet there is more than enough money in the Treasury to allow the ministry to provide better health outcomes to all our citizens.

The absence of doctors and dentists is deeply felt in the Pa Enua and could decide the next election, with 14 seats held by outer island constituencies.

It is an issue of exclusion and discrimination that could undercut traditional CIP/Demo divisions in northern and southern group electorates and deliver Rarotonga a government dominated by the outer islands.

The recent election in the US shows the impact of a sudden political awakening among those ‘left behind’.

It will be interesting to see how long it takes before that same awakening reaches our outer islands.

Having a blast on Raro

IT IS hard not to have fun on Rarotonga, but most things will cost you a reasonable (or unreasonable) amount of cash from your wallet, or bucks on to your credit card.

Here is a little tip that will give you an absolute buzz – and you do not have to reach into your back pocket at all.

Don’t tell anyone I told you this, but it is the Jetblast and is found at each end of the international airport in Rarotonga.

Because space is fairly limited on the island roads are very close to the tarmac.

The most popular vantage point is on the coast at the seawall. There you can wait as large airliners head in over the ocean and land, or take off, closer than any other international airport in the world.

When the big jets come in to land directly over your head you swear you could reach up and touch them.

If the airliner is taking off from the seawall-end the Jetblast is powerful, but because you are sunk down from the level of the tarmac the buzz is not the full-on experience.

If you want a really amazing “OMG I wanna do that again now” thrill, head down to the inland road end of the runway.

All that sits between you and the massive engines of modern airliners is a wire fence and – unsurprisingly – that doesn’t afford much protection.

To get the best adrenalin rush you need to be directly in line with the engines.

The close-up sight of a big airliner turning is amazing and as the air starts to heat up around you and the throttle is pushed forward you begin to wonder if this really is the place to be.


But, trust me, by that stage it is too late for flight, so to speak, and so you just have to hang on to the fence as the jet gushes out hot air at a phenomenal rate. You can lessen the impact of the force - all you need to do is duck down to ground level.

Just as you think your Jetblast experience can’t get any noisier or windier – it does. That’s when you wonder “have I made a very big mistake?”

But, before you can silently answer that, it’s all over and the plane has rumbled down the tarmac and into the air.

One Kiwi woman who was scared of trying the Jetblast was absolutely thrilled that she did try it in the end. The look on her face was one of both surprise and elation.

And above all, it is free.

Here are some words of warning though.

Take off expensive glasses and don’t wear a hat -as they will end up 60 metres away in grass so long it will take you a week to find them. That is if you are really lucky.

And gals, it’s best not to wear short skirts or flimsy tops – unless you are an exhibitionist. They will fly up.

            - Richard Moore

Richard Moore is the owner and editor of online tourism magazine

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