Health Expenditure and health outcomes in Pacific Island Countries: What can the data tell us?

Transcription

1 Health Expenditure and health outcomes in Pacific Island Countries: What can the data tell us? Dr Wadan Narsey Visiting Professor Kagoshima University Research Center for Pacific Islands [Lecture to visiting JICA Fellows from the Pacific. 21 Oct. 2011] 1

2 JICA objectives for visit by health professionals From the JICA documentation: objectives of the visit are: To assist medical staff to aim and implement an in-service training program plan Human resource development of community health nurses With comprehensive preventative approach (good nutrition a least cost approach?) Lifestyle-related diseases like diabetes, heart diseases (all affect Life Expectancies) Maternal and child-health issues etc Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

3 Overview of lecture Begin with health issues in MDGs: popular focus internationally. Assess how well each PIC is doing, in comparison to other countries in the Pacific: any regional patterns? other similar developing countries in the world ( good models ) developed countries in the world (ideal long-term targets) International, regional and national data sources Strong linkages of health outcomes to health expenditures to economic growth. What do Household Income and Expenditure Surveys reveal about private health expenditures (and bad health expenditures) by households Hints for policy guidelines for health professionals Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

4 Where do MDGs come from? In September 2000, world leaders - adopted the United Nations Millennium Declaration committing their nations to -a new global partnership to reduce extreme poverty and - setting out a series of time-bound targets - with a deadline of 2015 MD Goals The Millennium Project was commissioned by the United Nations Secretary-General in 2002 to develop a concrete action plan for the world to achieve the MDGs. So UN is good source of data on MDGs as well as what s happening internationally. Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

5 What are the MDGs? (note 1, 4, 5 and 6 are health related, and also 8) Goal 1 Goal 2 Eradicate extreme poverty and hunger Achieve universal primary education Goal 3 Promote gender equality and empower women Goal 4 Goal 5 Goal 6 Goal 7 Goal 8 Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability Develop global partnerships for development. Important one for PICs missing: paid employment. All have sub-targets and indicators within them: google UN MDG : tons of information

6 Data source for Pacific: google PRISM database SPC Regional Data and also National data from the country databases Regional data can be economic indicators: - GDP - trade - CPI etc Regional data can be social: - population - demographic parameters - infant mortality - life expectancy - crime etc Can download data on to spreadsheets and analyse: as I do here. Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

7 eg Most fundamental long-term health indicator: Life Expectancy at Birth LE very crudely but effectively captures the impact of following variable: infant mortalities (<1) child mortalities (1-5) nutrition life style diseases and adult mortality communicable diseases like HIV etc state of public health service private ability to fund medical services Also: civil unrest, wars, and stressful lives Also: DNA and genes of different ethnic groups Also: biological differences between men and women Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

8 * Pacific comparisons: Which countries are doing badly? Doing well? Life Expectancies at Birth New Caledonia N Mariana Islands Wallis and Futuna French Polynesia Guam Cook Islands Samoa American Samoa Niue Tonga Tokelau Palau Fed States of Micronesia Marshall Islands Vanuatu Fiji Islands Tuvalu Solomon Islands Kiribati Nauru Papua New Guinea Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

9 Compare regions and rough ethnic groups: simple averages Trend 1: Melanesian countries not doing well at all. Trend 2: Females live longer than Males (as everywhere else in the world): Trend 3: is there a trend in Female:Male gaps in LE? Life Expectancies (at birth) Male All Female 50 Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct 2011 A Melanesian B Micronesian C Polynesian New Caledonia 9

10 But what about metropolitan political influence? French/US/NZ? Fr > NZ > US > Independent Being independent is not so great for Life Expectancies? Life Expectancies (at birth) Male All Female 50 Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct A Independent B ex-us C NZ D French

11 From lowest to highest Life Expectancy: Independent Countries are in red * Type 1 Type 2 Country LE at birth A Melanesian A Independent Papua New Guinea 54 B Micronesian A Independent Nauru 56 B Micronesian A Independent Kiribati 61 A Melanesian A Independent Solomon Islands 61 C Polynesian A Independent Tuvalu 64 A Melanesian A Independent Fiji Islands 65 A Melanesian A Independent Vanuatu 67 B Micronesian B ex-us Marshall Islands 68 B Micronesian B ex-us Fed States of Microne 68 B Micronesian B ex-us Palau 69 C Polynesian C NZ Tokelau 69 C Polynesian A Independent Tonga 70 C Polynesian C NZ Niue 72 C Polynesian B ex-us American Samoa 72 C Polynesian A Independent Samoa 73 C Polynesian C NZ Cook Islands 73 B Micronesian B ex-us Guam 74 C Polynesian D French French Polynesia 74 C Polynesian D French Wallis and Futuna 74 B Micronesian B ex-us N Mariana Islands 75 D Mixed D French New Caledonia 76 Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

12 eg 2 Infant Mortality Rates (deaths per 1000 births): reds are high Large differences: why? All are islands in the Pacific. Type 1 Type 2 Country IMR A Melanesian A Independent Papua New Guinea 56.7 B Micronesian A Independent Kiribati 52.0 B Micronesian A Independent Nauru 45.8 B Micronesian B ex-us Fed States of Microne 37.5 C Polynesian C NZ Tokelau 31.3 A Melanesian A Independent Vanuatu 25.0 A Melanesian A Independent Solomon Islands 24.3 B Micronesian B ex-us Marshall Islands 21.0 C Polynesian A Independent Samoa 20.4 B Micronesian B ex-us Palau 20.1 C Polynesian A Independent Tonga 19.0 C Polynesian A Independent Tuvalu 17.3 A Melanesian A Independent Fiji Islands 17.0 B Micronesian B ex-us Guam 11.7 C Polynesian C NZ Cook Islands 11.6 C Polynesian B ex-us American Samoa 11.3 C Polynesian C NZ Niue 7.8 D Mixed D French New Caledonia 6.1 C Polynesian D French French Polynesia 5.9 C Polynesian D French Wallis and Futuna 5.2 Dr B Wadan Micronesian Narsey "Health B expenditures ex-us and outcomes N Mariana in PICs". Islands KURCPI 21 Oct

13 Infant Mortality by region/ethnicity (simple averages): Why is Infant Mortality so high for Micronesia and Melanesia? Child mortality patterns very similar (examine on your own). Infant Mortality Rate (deaths per 1000 births) New Caledonia 6 C Polynesian 14 B Micronesian 28 A Melanesian 31 Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

14 Does political control matter?: being Independent not so good? Is there anything to do with funding by metropolitan countries? France, NZ, US? No health expenditure data in PRISM database. Infant Mortality Rate (deaths per 1000 births) D French 6 C NZ 17 B ex-us 18 A Independent Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

15 Dev d countries in blue Pac Is in red. Other Islands in Green China/India in yellow. Interesting stories? Malaysia < US? China < India (& PNG) Trinidad? International comparisons of Infant Mortality? A Japan A Germany A Australia A UK A New Zealand B Malaysia A US C Mauritius C Maldives D Fiji D Vanuatu D Tonga B China D Samoa C Jamaica D Solomons D Tuvalu C Trinidad D Kiribati D PNG B India Infant Mortality (Av ) (Deaths per 1000 births) Jamaica? Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

16 International comparisons and trends of LE over 40 years? Are PICs improving? WB Database Japan LE extremely high and solidly rising (over 80 now) 80 Life Expectancies at Birth ( ) Steady rise in Average for Japan, US, UK, Germany, Aus, NZ; Big Gap with PICs Why are PNG; Solomon Is so low? Japan Dev'ed Av. Tonga Other Islands Samoa Vanuatu Fiji Solomons PNG Clearer picture next slide Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

17 Take away the developed countries: interesting stories Tonga leveled off: why? Fiji rising steeply to 1980s then leveled off (coups?) Healthier migrating? Life Expectancies at Birth ( ) Tonga Other Islands Samoa Vanuatu Fiji Solomons PNG Great improvement for Samoa and Vanuatu, 55 (why diff. from SI/PNG?) 50 Solomon Is: why the dip? 45 PNG: why the dip? 40 Statistical errors? Or health services? Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

18 Are health outcomes (eg infant mortality) affected by Health Expenditures pc? (curr US$) (Av ): Low values for PICs US way out: big controversies over Health Care spending there. But change the axis and exclude developed countries. Look only at the others. A United States A Germany A Australia A United A Japan A New Zealand B Malaysia B China B India C Trinidad C Maldives C Mauritius C Jamaica D Tuvalu D Samoa D Kiribati D Fiji D Tonga D Vanuatu D Solomons D PNG Health Exp. pc Cur.US$ (Av ) Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

19 Compare PICs with other Islands in the world Pacific countries In red: Other islands: green. Jamaica lower: civil war Tuvalu: so high? Lows for PNG and SI: both are resource rich countries. Why is Fiji worse than Samoa and Kiribati? A United States A Germany A Australia A United A Japan A NZ C Trinidad C Maldives C Mauritius B Malaysia D Tuvalu C Jamaica D Samoa D Kiribati D Fiji D Tonga B China D Vanuatu D Solomons B India D PNG Health Exp. pc (curent US$) (Av ) Why is resource-rich PNG so low? Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

20 But PICs already spend high proportions of their GDP on Health More than other islands Public Health Exp. as % GDP (Av ) Be impossible to increase govt health expenditures more without reducing other areas like education infrastructure etc Real limitation: GDP of country and GDP per capita. D Kiribati D Tuvalu A Germany A New Zealand A United States A United Kingdom C Maldives A Australia D Samoa D Solomons D Tonga D Vanuatu D PNG D Fiji C Trinidad C Jamaica C Mauritius B China B Malaysia B India

21 Basic problem: PICs (in red) have very low incomes (GDP pc) MDCs Other Is Pics & China/India A Japan A United States A United A Germany A Australia A New Zealand C Trinidad B Malaysia C Mauritius C Jamaica C Maldives D Fiji D Tonga B China D Samoa D Vanuatu D Solomons D Kiribati B India D PNG GDP pc (Const. 2000$US) Average Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

22 Compare PICs with other islands: GDP pc PICs much lower incomes per capita than the other Islands in the world like Mauritius etc GDP pc (Average ) (Const. 2000$US) MDCs Other Is PICs Why are PICs GDP pc so low? A Japan A United States A United A Germany A Australia A New Zealand C Trinidad B Malaysia C Mauritius C Jamaica C Maldives D Fiji D Tonga B China D Samoa D Vanuatu D Solomons D Kiribati B India D PNG

23 Note very strong blinks between Health Expenditure and Total Government Expenditure and Gross Domestic Product Government Health Expenditure usually steady % (5% to 8%) of Total Govt. Exp. Total Government Expenditure usually some steady % of GDP (25% to 30%) Private Health Expenditure usually steady % of household incomes. i.e the level of Total Health Expenditure (public and private) depends on Total GDP of the country Which depends on how economy has been growing over the long term: compound interest rates are very very powerful. PICs have not done well wrt long term economic growth. PICs could have been in the same situation today as Mauritius, Maldives, Malaysia, wrt health expenditure had our economies grown at the same rate as theirs. Remember: growth over 40 years is roughly our working life-time!

24 Trends in Gross Domestic Product pc for islands around the world fascinating stories Strange graph for Trinidad (red line): political mess for so many years. GDP pc (Const 2000US$) C Trinidad B China B India B Malaysia C Jamaica C Maldives C Mauritius D Fiji D Kiribati D PNG D Samoa D Solomons D Tonga D Vanuatu

25 Focus on other islands in the world: top 4 lines/countries almost same as PICs 40 years ago Jamaica (red): tragic path for last 20 years: political unrest Malaysia (blue), Mauritius green), Maldives (grey): great growth and progress.

26 Focus on PICs: China s phenomenal growth: huge development lesson for the whole world. Fiji wasted years. Tonga leveled off. Why? Samoa flat for years, then recent good growth (until tsunami) Solomon Is: wasted yrs PNG: Wasted years Kiribati: wasted years (but, like Tuvalu, few resources) GDP pc (Const 2000US$) B China D Fiji D Tonga D Samoa D Vanuatu D Solomons D Kiribati D PNG

27 PIC average growth rates are very poor: compare with Mauritius Given resources, Pacific growth rates should easily be above 3% and even above 6%. But Mauritius growth rate also slowing down (still higher than PICs) 9 GDP Growth Rates (5 year moving averages) 6 Mauritius 3 Pacific Aver. 0 Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

28 Why are Pacific growth rates so poor? Needs to be > 3% pa Political instability: eg Papua New Guinea PNG extremely rich country: yet long periods of below 3% growth rate. But recent discoveries of huge deposits of Liquid Natural Gas and Minerals: huge growth potential for next ten years. 9 PNG: GDP Growth Rates (5 year moving averages) Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

29 Political instability also in Solomon Islands: going backwards for years Paradox of resource rich country- timber, minerals, fisheries. But internal civil war some ten years ago; wasted years with negative economic growth. Australian soldiers (RAMSI) now peace-keepers. If RAMSI leaves? Solomon Is: GDP Growth Rates (5 year moving averages) Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

30 Fiji: political instability: military coups in 1987, 2000, and 2006 Fiji s economy slowly going down since the 1987 military coup. Zero economic growth between 2006 and now. No end in sight for Fiji s troubles: the problems continue. i.e. GDP not high ie. Govt Revenues and Exp. not high i.e Health Expenditure pc not high 9 6 Fiji GDP Growth Rates (5 year moving averages) Both public expenditure AND 3 Private expenditure. 0 Dr Wadan Narsey "Health expenditures and outcomes in PICs". KURCPI 21 Oct

31 Private Health Exp. as % of GDP: Pacific values are low. Compared to other islands room to expand private expenditure on Health: but only if household incomes are able to grow. Even India and China have higher proportions than PICs. Tuvalu extremely low. Private Health Exp. as % of GDP (Av ) C Maldives C Mauritius B India C Trinidad B China A Australia B Malaysia A Germany C Jamaica A New Zealand D Kiribati D Tonga D Samoa D Fiji D Vanuatu D PNG D Solomons D Tuvalu

32 What about Health Expenditures at Household Level? Aggregate data at national levels can be very misleading: need data at household level Very few PICs have done national household surveys on Health. BUT nearly all have done Household Income and Expenditure Surveys which have lots of data on health and medical expenditures And on the consumption of bad health items such as tobacco and alcohol As well as detailed data on food consumption- which can give great hints on nutrition patterns in the country, and likely trends of life-style diseases like diabetes, heart disease and strokes. Some countries (like Fiji) have already done two HIES: so can get a time trend for the first time for those PICs Others (like Vanuatu and Solomon Is are about to do their second HIESs.

33 Why is the HIES so useful at the national level? These HIES are NOT your normal academic study of some small village or town or area. These HIES may be small samples of about 5% in Fiji and Solomon Is (or very high 26% in Tuvalu) But scientifically random and representative of the whole country, urban and rural areas. Although high income people do not respond eg Chinese households in SI or Vanuatu But these small samples are extremely accurate about the whole country. These HIES are unexplored gold mines of information: by rural/urban, districts, islands, ethnic communities, kinds of households, sources of income, etc etc: Can enable policy makers to really target their development efforts around the country according to objective assessments of need if done properly, reduces national political conflicts about where development funds should go: huge problem in PICs; major cause of civil war unrest in SI, PNG, Fiji, Tonga etc.

34 Fiji HIES solid and fascinating Fiji did HIES in and one in Good surveys. Unfortunately, military coup of 2006 came right in the middle of these two HIES, so what was happening in-between is difficult to know, except one knows that net results In Fiji all the data indicates that things were improving between and 2006 after which things deteriorated. Still plenty of fascinating information. On all kinds of stuff- I will talk about today. Can do very similar analyses for most PICs which have done such HIES including Kiribati, Tonga, Samoa etc.

35 Fiji: Private Health Expenditure is only 24% of Total Health Expenditure Total Private HH Exp ($m) Govt Health Exp. ($m) Total Health ($m) Private HH share % This includes Health Insurance. Govt Health expenditure data can be got from Budget documents- also gives break-downs of Govt. expenditure on medicines etc i.e Tax-payers are paying for some 76% of Health Expenditure in Fiji- whatever they provide: nurses, doctors, medicines, etc. And to whoever these public services go to: usually focused on urban people.

36 Where does the private HH expenditure go? Fiji HIES , Perc. Composition % Ch. Prescribed Medicine Other Pharm.Products Private Medical services Hospitalisation Health insurance Total Roughly a third to prescribed medicine Roughly a third to health insurance Roughly 30% to private medical services. Very low expenditure on hospitalisation: fees less than the food eaten by patient! Note the changes from to : why the reductions? Why the increase in proportion going to Health Insurance? GPs have been complaining that private patients are not seeing them. Symptom of?

37 But aggregate picture for the country can be misleading Must look at per capita values (taking account of population growth) Must disaggregate by Rural and Urban: huge disparities in Pacific Must disaggregate by poorest and richest ranked by Household Income per capita Here rural and urban population divided separately into quintiles where Q1 Bottom 20% of the rural or urban population (taken separately) Q2 Next 20% Q3 Middle 20% Q4 Next 20% Q5 Is top 20%. Fiji data is very good for this kind of analysis

38 Household Health Expenditure pc: are rural people too cash-poor? 80% of rural people spend very little on health: too poor In Urban areas: the bottom 40% are definitely poor, and possibly up to 60%. Only top 40% of urban people spend reasonable amounts on health. Total Health Expenditure pc ( ) RQ 1 RQ 2 RQ 3 RQ 4 RQ 5 Urban Rural

39 Clear that for rural people, Govt. Health services are critical In all PICs Govts tend to spend largest amount of money in urban areas- in urban hospitals or Urban Health Centres (where govt. doctors and nurses want to go to) In all PICs the hardest to get health services to are the scattered rural households. Where govt. doctors and nurses do not want to go to. So what do rural people do when they get sick in Fiji, Solomons, Vanuatu, PNG? Bush medicine; traditional medicine; or they just suffer; And many die prematurely. Would be a very interesting exercise for all PICs to look at Life Expectancies, Infant Mortality etc, disaggregated by - rural/urban - income levels.

40 For MDG monitoring: need changes over time Perc. Change in Health Exp.pc ( to ) Nominal Real Rural Urban FIJI 0-30 Nominal change is % change in dollar value. Real change adjusts for inflation. You might be tempted to conclude?: Real adjusted Health Exp. pc has declined for rural areas (nominal and real) declined for Fiji as a whole (in real terms by -30%)_ but improved for urban areas (67% nominally, 12% in real terms)?

41 But not all in urban areas have spent more: by quintiles: following picture 60 Real Change in Health Exp. pc (by quintiles) (Changes between 2002 and 2008) RQ 1 RQ 2 RQ 3 RQ 4 RQ 5 Urban Rural All rural households (green) have seen significant reductions in health expenditure per capita (negative changes- below the 0 line) But even in urban areas, the bottom 60% of the population have seen decreases. Quintile 4 : small increase. Only real increase has occurred for the richest 20% in Urban Fiji.

42 Solomon Islands 86 % live in Rural areas. Reporting on their MDGs Infant Mortality Rate 96 (1989) 66 Child Mortality Rate 36 (stast. error) 73 Maternal mortality HIES captured 59% of GDP (Fiji approx. 80%) Health GDP per person: $107 pa.

43 . From SI HIES 2006 Household Exp. pc HIES 2006 (SI$) Honiara Prov.Urban Rural SI Medical/Health Alcohol/Tobacco Education Can see the great differences between Honiara, Provincial Urban and Rural SI. But look at how little is spent on health compared to the amounts spent on alcohol and tobacco, which are usually very under-reported anyway. Could it be that only the rich are spending all this money on alcohol and tobacco and not the poor?

44 Differentiating between Honiara and the Rest, by Quintiles Similar trend to Fiji 120 Medical/Health Expenditure pc pa ($SI) Honiara Rural 0 RQ1 RQ2 RQ3 RQ4 RQ5 Quite clear that most of Rural SI (perhaps as much as 60%) not spending much at all on Health and Medical expenses. And even in Honiara, only the top 40% do.

45 Alcohol and Tobacco Expenditure pc: Solomon Islands 800 Alcohol/Tobacco pc 600 Honiara 400 Rural RQ1 RQ2 RQ3 RQ4 RQ5

46 Much higher on Funafuti Health Exp pc: Tuvalu (Funafuti and Outer Islands Than on Outer Islands Health and Medical pc pa (A$) But upper income in Outer Islands do spend more Funafuti Outer Is F RQI1 RQI2 RQI3 RQI4 RQI5

47 Alcohol and Tobacco Exp. pc: Tuvalu Very interesting shape of the graphs: more pronounced on Funafuti than on Outer Islands Why are poorest people spending more than middile income people? Hint to Ministry of Health officials where to mount their education campaigns for the reduction of alcohol and tobacco abuse? 350 Alcohol and Tobacco Exp. pc pa ($): Tuvalu 300 Funafuti Outer RQI1 RQI2 RQI3 RQI4 RQI5

48 G Also for Tuvalu: ratio of alcohol/tobacco to health exp. Ratio Alcohol and Tobacco: Health RQI1 RQI2 RQI3 RQI4 RQI5 Grand Total Funafuti Outer Is As elsewhere; people spending miles more on alcohol and tobacco than on health and medical needs.

49 Some good news from Fiji: with two HIES: time trend Perc. of households with some expenditure on narcotics: tobacco and alcohol. Perc. of HH consuming some narcotic % Ch. Alcohol Tobacco Yaqona Any of abov Does this data indicate that Ministry of Health Campaigns are working? Or is it just impact of economic down-turn? Interesting research question for MoH? One hint: check how consumption is changing at different income levels

50 Changes in perc. of HH with some narcotics consumption (by quintiles) While nationally, there were some 12% less households with some consumption of alcohol, yaqona and tobacco. Only small 5% decrease at lowest quintile. The decreases were higher at the higher income levels: ie reducing income not likely be part of the explanation. Perc. of HH With Some narcotic % Ch. IQ IQ IQ IQ IQ FIJI Fiji personnel: have a look at my FIBoS Report on the HIES (should be launched within the next few week): more interesting tit-bits: eg how Indo-Fijians have extremely high levels of alcohol abuse; and now apparently consuming more kava than indigenous Fijians.

51 More good news: ratio of Narcotics Exp.: Health and Medical Exp. in Fiji Ratio Alc/Tob/Yaqona: Health and Medical: Fiji 3 2 Rural 1 Urban 0 RQ 1 RQ 2 RQ 3 RQ 4 RQ 5 Ratios are low: below 1 is good. Good news for urban hh, especially at upper incomes: declining ratio

52 Tuvalu: Perc. of HH with some Alcohol and Tobacco consumption RQI1 RQI2 RQI3 RQI4 RQI5 All Funafuti Outer Is Extremely high ratios compated to Fiji; Higher in Outer Islands. Look at the very high proportion (74%) at the lowest quintile in Funafuti. 80 Perc. of HH with some Alcohol and Tobacco: Tuvalu Funafuti Outer Is RQI1 RQI2 RQI3 RQI4 RQI5

53 Solomon Is: Perc. of HH with Some Alcohol/Tobacco consumption RQ1 RQ2 RQ3 RQ4 RQ5 All Honiara Rural High percentages: usual income trend 60 Perc. of HH with some Alcohol/Tobacco 50 Honiara Rural RQ1 RQ2 RQ3 RQ4 RQ5

54 Far more analysis possible: With all HIES in all PICs. Important to implement surveys accurately. Suggest 2 initiatives for you when you go back to your countries: A Ask your Bureaus of Statistics to examine what the HIES in your country can tell you about health issues and what might be the policy implications. B See if future HIES can be modified in some simple ways to obtain vital data, at the national level, which MoH does not currently have.

55 Thank you Questions and comments Then break for morning tea.