Health systems in developing countries suffer from significant resource deficits. In these countries patients have difficulty accessing too few doctors at hospitals and clinics that in many cases are dispersed across a large and challenging terrain.
This is especially true in the Solomon Islands, a country comprising more than 900 islands separated by large areas of open seas, as well as volcanic mountains. One of the most difficult ingredients for a establishing a functional health system for a developing country like Solomon Islands is having an adequate supply of properly trained healthcare workers, especially doctors and nurses. Overcoming insufficient human resources for health is largely a question of supply and demand: Are enough doctors and nurse specialists being trained to provide universal access to healthcare and is the country’s Ministry of Health able to support their career development? Demand can come from staffing needs within the country’s health system as well as the pressures of endemic health challenges the public faces, but it also comes from external sources. The poaching of doctors and nurses from Solomon Islands and other Pacific Island Countries by United States Department of Interior-funded health systems in American Samoa has contributed to health care workforce shortages.
Assembling an adequate health workforce takes time and is an expensive process, with costs of up to $50,000 to educate one doctor at the Fiji National University School of Medicine or at Papua New Guinea’s Medical School. Student spaces at both of these institutions are limited, as these medical schools have historically educated doctors for all 14 Pacific Island Nations. This has made it impossible for a developing country like Solomon Islands to strengthen its healthcare workforce without a large budget. However, thanks to Cuba’s Health Assistance Program the Solomon Islands is poised to set in motion a healthcare worker expansion that if handled properly could change the way health is delivered to its 600,000 residents.
In 2007, the Solomon Islands and many other Pacific Island countries established a health assistance program with Cuba. In Solomon Islands, this included the immediate deployment of eight Cuban medical doctors to the country and the establishment of a medical education program whereby young adults from Solomon Islands study medicine in Cuba. This is easy for Cuba to do as it has too many doctors. Cuba’s physician density is the highest in the world: 67 doctors for every 10,000 people. Its community-based health system is responsible for delivering primary care and preventive services to a well-defined population cluster. This care includes visits to a patient’s residence. It is a low technology system that is high on cost saving prevention and a natural fit for the developing health systems of the Pacific Region.
Solomon Islands is one of the least developed countries in the Pacific Region. In 2013, the GDP per capita for the country was $1953, with the majority of people living at subsistence levels. The prevalence of diabetes is 1 in 4 people and other chronic diseases such as cancer are straining the health system under the best of circumstances. In an area already prone to natural disasters like cyclones, earthquakes, heavy rains and floods, infectious disease outbreaks like dengue in 2013, measles in 2014, and emerging chikungkunya in 2015, on top of endemic malaria and tuberculosis, have pushed the Solomon Island health system literally to the brink of disaster. The health care system is overseen by the Ministry of Health and Medical Services and extends over 12 hospitals located on eight different islands with hundreds of kilometers between them. Rural village care is provided by just over 340 area health clinics and outpost clinics staffed by nurses and aides. There are currently two fully trained doctors for every 10,000 people in Solomon Islands, with most doctors working in Honiara, the capital. To put this workforce in perspective, in the United States the doctor-to-population density is 24 doctors to 10,000 people and in Australia it is 39 to 10,000. In Solomon Islands, people living on the more remote outer islands die just trying to get to where medical help is available.
Training in Cuba
Since the 1960s, Cuba has been assisting with global health development largely through south-to-south collaborations in Africa and the Americas. It has educated more than 800 medical doctors from Sub-Saharan Africa alone. In addition, Cuban Medical Brigades have been deployed to natural disasters such as the earthquakes in Chile and Haiti as well as the recent Ebola virus outbreak in Central Africa.
In 2007, Solomon Islands jumped into the Cuban Health Education Program feet first, sending 100 of its best and brightest students to Havana to obtain a medical degree over a five-year period. The agreement was developed and signed by the Ministry of Foreign Affairs with virtually no input from the Ministry of Health and Medical Services. Since the first cadre of students left for Cuba in 2008 there have been numerous discussions about what to do with them once they complete their studies. While these students were learning Spanish in order to learn medicine, Solomon Islands development partners washed their hands of the matter. In November 2014, the first 22 new doctors arrived home amid a great deal of concern about how to assess their knowledge and how to train them. At present these young doctors are doing core rotations at the National Referral Hospital (NRH) on Guadalcanal as part of a transitional six months. This is a trial period for them and a chance for the Ministry of Health to ascertain the extent of their medical knowledge before they are appointed to a two-year internship. The current plan is for the Ministry of Health to certify their medical degrees, thereby “trapping” them to work only in Solomon Islands. Provisions for salary budget increases and training curriculum are currently being developed.
While recently working with the World Health Organization in Honiara, I had the opportunity to interact directly with six of these newly repatriated Solomon Island doctors. They were on the surgical service at the National Referral Hospital. They were well dressed, polite, formal and above all eager to be the doctors they trained to be. They are admittedly a bit hesitant when asked questions about their patients and this on first blush could be misinterpreted as representing a lack of knowledge. After some time with them it became clear these young doctors are undergoing two significant transitions. The first transition is unique to this cadre of new doctors: translating the medicine they learned in Spanish back into English. The second is a transition every new doctor makes: translating book knowledge into clinical care or “thinking on the fly.” When asked their opinions on differential diagnoses and care algorithms an astute observer could imagine them flipping through language databanks and medical lists before giving an answer. This hesitancy does not reflect a lack of knowledge, simply a processing delay something even Apple’s Siri has to do.
The Ministry of Health and Medical Services in Solomon Islands now faces a test. With the right postgraduate medical training, these 22 students can begin to change the face of health care in Solomon Islands, and could the three additional waves of new doctors soon to follow. Depending on how they are trained, they could either achieve and perhaps even surpass their potential or they could flounder and become well-educated taxi drivers in Honiara. This is where the cooperative support of all development partners in Solomon Islands could make a huge difference with minimal investment. There is an urgent need for a two-year health development partnership that works with the country’s fully trained physicians as well as the Cuban-educated Solomon Island doctors. The entire health system needs to be taught how to teach, while putting in place an educational curriculum that focuses on community-based health and prevention training that is unique to Solomon Islands. All of the expensive components of this type of program are already in place: the consultant physicians in Surgery, Pediatrics, Medicine, Obstetrics and Gynecology, Emergency Medicine and Radiology as well as a number of general provincial doctors. The new doctors are educated and willing to return to the islands they grew up on. It is simply a matter of assisting the Ministry of Health to put in place the glue that will pull the system together; that is a partnership program that creates a hybrid of in-country “train-the-trainer” education as well as a custom graduate medical education program. In-country training sessions mixed with distance learning using the Internet can keep costs down while helping Solomon Islands address its endemic health threats as well as new threats the country can expect in the future. It could also have the real potential to decrease dependence on outside aid, especially when it comes to pandemic and disaster preparedness.
Foreign Assistance Bargain
A Solomon Island Health System Education Partnership must not be seen as a “hand out.” It is a “hand clasp” that is a foreign assistance bargain. At a cost of less than $1 million for two years it could assure universal health access for the people of Solomon Islands. With increased U.S. interest in the Pacific Region, and stronger than ever ties with Australia and New Zealand, a multilateral partnership for health education with Solomon Islands Ministry of Health and Medical Services could prove to be a true game changer in many ways. The Obama administration has softened its Cold War stance on Cuba and along with New Zealand’s recent cooperative agreement to support Cuban medical assistance in the Pacific Islands an historic multinational cooperation that includes Cuba could begin with health development in the Pacific Region. A coalition of health development partners including the United States, Australia, New Zealand and the European Union could complement Cuba’s health education program in Solomon Islands and other Pacific Island counties. Without this type of Health System Education Partnership it would be a terrible waste to squander the medical education of these young and enthusiastic doctors in a country with crippling medical challenges from multiple threats.
Eileen Natuzzi, MD, MS, FACS is a public health surgeon and director of surgical education for the Solomon Islands Living Memorial Program, an educational partnership between health providers in the U.S., Australia and Solomon Islands.