National Health Strategic Plan

2022-2026
Ministry of Health, Seychelles
January 2022

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 The National Health Strategic Plan 2022-2026

This is a publication of the Ministry of Health, Seychelles.

This document is licensed under a Creative Commons Attribution-Non-commercial-No Derivatives 4.0

International License (https://creativecommons.org/licenses/by/4.0/).

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from doing anything the license permits.

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Executive Summary
The National Health Strategic Plan (NHSP) 2022-2026 has been developed at a time when Seychelles,
like the rest of the world, is confronting an ongoing COVID-19 pandemic. A new direction in health is
now imperative, as we strive to protect pre-pandemic health gains, address past pervasive non –
achievements and recover from the pandemic stronger.

The NHSP was developed using a participatory approach engaging stakeholders within and beyond the
Ministry of Health (MoH). A review of the implementation of the NHSP 2016-2020 showed that there
was progress in the last five years, in particular: MoH offered a wider range of specialist services;
primary health care services are well integrated with medical, oral health and rehabilitative services
offered under one roof in regional centers. A new health facility, the Family Hospital was inaugurated in
2017; a record number of Seychellois doctors joined the MoH; and key health policies and Acts were
developed and implemented. The country has made progress towards protecting and improving
Universal Health Coverage (UHC) as reflected by the increasing UHC index (77.6)

However, despite notable progress, an analysis of the current situation of the health of the population
and health systems revealed urgent issues that have to be addressed in the next five years and beyond.

The health profile of the nation, shows some worrying trends, in particular, there is disproportionate
number of deaths every year among young men and the previous NHSP’s target for life expectancy (LE)
of men was not reached and premature mortality from non-communicable diseases (NCD) remains
unacceptably high. Among risk factors for health, there is an alarming rise in obesity among school
children. There was an important change in the pattern of cause of death in 2021 with COVID-19 related
deaths being the second leading cause of mortality.

Analysis of the health system, the organization of people, entities and resources, that deliver services
and safeguard health, revealed several weaknesses and gaps.

Health is complex and the ‘production’ of good health requires resources, the need for which will
increase as the population ages and the country deals with new health threats like pandemics and
climate change. The country spent 3% to 5% of GDP on health prior to the COVID-19 pandemic, while
this is relatively high compared to other African countries, it is well below the OCED average of 8.8%.
The country has invested in human resources for health, however, there is still reliance on expatriates
for clinical care and there is a lack human capacity for health economics, disease surveillance, health
regulation, data governance and monitoring and evaluation.

While it is true that the sector lacks some critical inputs, it is also true that it does not always succeed to
transform inputs into results. The service delivery model has remained rigid over many years and digital
technology is not used adequately to improve services. Monitoring and evaluation is patchy and
available health data is not sufficiently mined and used to improve health and efficiency.

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Health gains that took years and efforts to secure can be quickly eroded. The COVID-19 pandemic has
adversely affected the health and wellbeing of the population, as well as all the building blocks of the
health system.

The NHSP 2022-2026 commits to the national vision for health - the “attainment, by all people living in
Seychelles, of the highest level of physical, social, mental and spiritual health and living in harmony
with nature”. The achievement NHSP of goals requires bold and innovative actions. Over the next five
years, the health sector has to do three key things:

 Protect health gains secured so far.

 Fix what did not work in the past.
 Identify and implement solutions for new health challenges.

The new NHSP is a comprehensive document outlining the health sector’s goals and strategic directions
(SDs).The goals are coherent with national, regional and global commitments.

 Increase life expectancy and healthy life expectancy.

 Achieve and sustain all dimensions of UHC.
 Prepare, prevent, detect early and respond to all health emergencies.
 Promote healthy populations.

To achieve NHSP goals, MoH needs to implement new interventions and also transform the way it was
implementing some old interventions; this is captured through six SDs.

SD1 Strengthen Leadership, Governance and Administration: Promote a culture of hard work and
accountability, ensure entities transform resources into results, build partnership and successfully steer
the sector to achieve goals.

SD2 Protect and Improve Universal Health Coverage: Provide people of all ages and all health needs
with health services. Transform primary health care. Use a proactive approach to prevention, work on
achieving all dimensions of quality care.

SD3 Address Health Security: Identify outbreaks and other health threats. Improve crisis response and
protect the health of the population.

SD4 Promote Healthy Populations: In collaboration with other sectors, support the creation of
conducive environment to support well-being, healthy living, reduce risk factors for health and address
social ills. Strengthen community health systems.

SD5 Invest in Health: Ensure appropriate resources are available and efficiently used. Financial
resources should be commensurate with expected results, human capacity for health is reviewed and
strengthened.

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SD6 Improve Data for Impact: Increase the availability, quality, value and use of timely and accurate
strategic health information.

Successful implementation of the objectives of the NHSP requires leaders and health workers to
demonstrate conviction, commitment and hard work as well meaningful engagement and participation
of the population.

While there is unity of purpose and collective ownership of the NHSP goals, entities within the sector
have been assigned clear roles and responsibilities and MoH will ensure the necessary structures and
processes are in place for monitoring and reporting on progress in line with the Results-Based
Management Framework and will make sure appropriate remedial actions are implemented when
needed.

The NHSP has been developed during a pandemic and there are several known and unforeseen risks
that can thwart successful implementation; mitigation strategies have been developed to counter key
known risks.

Health is a societal resource and asset, but also a product of development. A complex array of
interlinked factors outside the purview of MoH influence health and well-being. MoH will redouble its
efforts to provide health care, however, good health is the product of effective policy across all parts of
government. MoH will build new platforms for health in all policies, for partnership, collaboration and
joint actions, to promote good health and well-being.

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Acknowledgements
The National Health Strategic Plan 2022-2026 was developed with the combined efforts and support of
several people.

The Steering Committee: Agnes Chetty (Lead), Susan Fock Tave, Geralda Didon, Sanjeev Pugazhendhi,
Juddy Jean-Baptiste, Joel Edmond, Doreen Zelia, Shannon Surman

Technical Working Group 1: Agnes Chetty (Lead), Sylvie Pool, Cynthia Noshir, Melina Amedee,
Stephanie Charlette, Gylian Mein, Michelle Fred, Louine Morel, Shannon Surman, Doreen Zelia

Technical Working Group 2: Sanjeev Pugazhendhi (Lead), Ashwin Sakharia, Joel Edmond, Ituen-Umanah
William, Annia Rousseau, Stephanie Belmont, Shannon Surman

Technical Working Group 3: Juddy Jean-Baptiste (Lead), Winnie Low-Wah, Sabrina Mousbe, Gina
Michel, Patricia Rene, Bharathi Viswanathan, Gaynor Mangroo, Merna Amade, Andrew Richard, Julita
William, Vereine Louis-Marie, Morison Julie, Bertrand Louis-Marie

Technical Working Group 4: Susan Fock-Tave (Lead), Sanjeev Pugazhendhi, Agnes Chetty, Juddy-Jean-
Baptiste, Doreen Zelia.

Reviewers: Bernard Valentin, Agnes Chetty, Susan Fock Tave, Sylvie Pool, Beryl Camille, Emelyn Shroff,
Conrad Shamlaye and Sanjeev Pugazhendhi (all from health sector), and Julius Joubert (from
Department of Economic planning).

We express our heartfelt gratitude to the WHO-AFRO regional office and WHO Country Office for
Seychelles, for reviewing this document as well.

Photographs: kindly contributed by Conrad Shamlaye.

We would also like to express our thanks to all those who participated in the various consultative
meetings. Your positive contributions have helped to forge the way for the next five years.

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Foreword
The sight of Seychelles Government remains firmly riveted on the attainment of the health sustainable
development goals through lasting universal health coverage, and ensuring that no one is denied the
opportunities to enjoy the fortunes of good health.

The 2022-2026 National Health Strategic Plan intends to build on the health gains of the Seychellois
nation while at the same time addressing the shortcomings and failures of the health system so that,
above all, people are able to live healthy and fulfilling lifestyles. There is no doubt that the level of
investment needed to keep the Seychellois nation healthy will bring about numerous social and
economic returns.

Primary health care is the foundation for better health, for this is where most of the primary prevention
and early detection of diseases take place. It must therefore become stronger and more prominent on
the health agenda. The Government vows to quickly introduce and assiduously drive structures and
processes that will bring the desired outcomes in primary health care and beyond.

Now more than ever before, the Government understands that an All-of-Government and All-of-Society
approach is a prerequisite to address adequately the challenges of poor nutrition, substance abuse and
sedentary lifestyles common in all segments of the population. The stomping effects of such lifestyles on
the nation’s health and purse are so direct, devastating and deadly that we must all leverage every
effort needed to reverse the trend. Health in all policies is the answer.

It is unfortunate that for many, the Ministry of Health’s focus is perceived to be ill-health and diseases.
This is often reinforced by the manner in which services are organised and national measures of health
expressed in the form of rates of diseases. It is incumbent upon health professionals, whether operating
in clinical services, health promotion or heath policy-making, to change this disease-oriented outlook on
health, to better communicate the value of good health and to engage with others in the pursuit of
wellbeing. The edification of utilitarian public health policies that seek to do the greatest good for the
greatest number of people and favour prevention over cure, need not only good will and shrewdness,
but also experience and knowledge in equal measure.

I thank the team who has worked so diligently to put together this National Health Strategic Plan. I thank
every single person who contributed time and ideas to crown this so very important opus and those who
will now be at the forefront of the implementation fray.

The work begins anew.

Peggy Vidot
Minister for Health

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Table of Contents
Executive Summary....................................................................................................................................... II

Acknowledgements....................................................................................................................................... V

Foreword...................................................................................................................................................... VI

Tables and Figures ....................................................................................................................................... IX

List of Acronyms ........................................................................................................................................... XI

1 Introduction ............................................................................................................................................... 1

1.1 Background to the National Health Strategic Plan (NHSP) ................................................................. 1

1.2 Overview of the Existing Policy Foundations ...................................................................................... 2

1.3 Overview of Seychelles Efforts to Achieve the Sustainable Development Goals ............................... 2

1.4 Rationale for the NHSP 2022-2026 ..................................................................................................... 3

1.5 NHSP Development Process ............................................................................................................... 3

2 Review of implementation of NHSP 2016-2020 ........................................................................................ 6

2.1 Achievement of NHSP 2016-2020 Goals ............................................................................................. 6

2.2 Review of 2016-2020 Strategic Priorities............................................................................................ 6

2.3 Stakeholders’ perspectives ................................................................................................................. 8

3 Situation Analysis ..................................................................................................................................... 11

3.1 The Seychelles Context ..................................................................................................................... 11

3.2 Health Status ..................................................................................................................................... 16

3.3 State of Health System ...................................................................................................................... 29

3.4 Identified Priorities ........................................................................................................................... 33

4 Strategic Agenda for 2022-2026 .............................................................................................................. 36

4.1 Vision, Mission, Goals ....................................................................................................................... 36

4.2 The NHSP 2022-2026 Framework ..................................................................................................... 37

SD1: Strengthen Governance, Leadership and Administration .............................................................. 40

SD2 Protect and Improve UHC ................................................................................................................ 47

SD3: Address Health Security.................................................................................................................. 55

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 SD4 Promote Healthy Populations.......................................................................................................... 60

SD5 Invest for Results ............................................................................................................................. 69

SD6 Improve Data for Impact ................................................................................................................. 85

5 Implementation Arrangements ............................................................................................................... 91

5.1 Roles and Responsibilities ................................................................................................................. 91

5.2 Implementation Risks and Assumptions ........................................................................................... 99

6 Monitoring and Evaluation .................................................................................................................... 105

6.1 Monitoring Achievement of Goals and Targets .............................................................................. 105

6.2 Data Needs ...................................................................................................................................... 106

6.3 Data Sources ................................................................................................................................... 107

6.4 Data Architecture ............................................................................................................................ 108

6.5 Indicators ........................................................................................................................................ 109

List of Annexes .......................................................................................................................................... 119

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Tables and Figures
Figures

Figure 1 Review of Health System Issues - Fishbone diagram (TWG 1)........................................................ 7

Figure 2 Population Trends 2016-2020, Seychelles .................................................................................... 11
Figure 3 Seychelles' Socioeconomic Environment ...................................................................................... 13
Figure 4 Contribution of each MPI indicator to National MPI, Q3 2019. ................................................... 14
Figure 5 Comparison of top 10 causes of death in 2009 and 2019, all ages combined. ............................ 16
Figure 6 Estimated prevalence of Hypertension, Diabetes, and Obesity, with projections to 2030 .......... 17
Figure 7 Cancer incidence and cancer-related deaths, 2013-19, with extrapolations to 2030 .................. 17
Figure 8 Life Expectancy at Birth, by gender, 1980-2020. .......................................................................... 19
Figure 9 Leading causes of Death in Seychelles, 2016-2020....................................................................... 20
Figure 10 Registered deaths by month, Jan-Sep 2020 and 2021, compared to 5y Average (2015-19) ..... 22
Figure 11 Suspected Dengue cases, by week; from week 52 of 2015 to week 16 of 2020. ....................... 23
Figure 12 Newly detected cases of HIV infection by year, 2014-2020. ...................................................... 24
Figure 13 AIDS-related Mortality, 2014-2020. ............................................................................................ 24
Figure 14 Prevalence of Obesity and Overweight in Girls, 1998-2019. ...................................................... 26
Figure 15 Prevalence of Overweight and Obesity in Boys, 1998 to 2019. .................................................. 27
Figure 16 Share of Current Health Expenditure (CHE) spent on Preventive Care, 2014-2018. .................. 30
Figure 17 NHSP 2022-2026 Framework ...................................................................................................... 38
Figure 18 Social (Environmental and Economic) Determinants of Health (SDH). ...................................... 60
Figure 19 Causal pathways linking poor SDHs with risk factors and later disease. .................................... 61
Figure 20 Framework describing how change impacts global public health. ............................................. 63
Figure 21 Health Finance inputs and pathways to production of Health interventions ............................ 69
Figure 22 Monitoring and Evaluation Conceptual Framework ................................................................. 106
Figure 23 Data Architecture ...................................................................................................................... 108

Tables
Table 1 External Stakeholders engaged in NHSP 2022-2026 Development process .................................... 4

Table 2 Progress towards Main Goals of NHSP 2016-2020 .......................................................................... 6

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Table 3 Projected Population of Seychelles, 2021 to 2050......................................................................... 12

Table 4 Maternal and Infant Deaths, 2019-2020. ....................................................................................... 18

Table 5 Life Expectancy at Birth (Years), 2016-2020. ................................................................................. 19

Table 6 Top five causes of Death, Seychelles, Q1-3, 2019-2021. ............................................................... 21

Table 7 Registered Live births to Teenage girls, 2015-2020. ...................................................................... 25

Table 8 Spending on Health, 2014-2020. .................................................................................................... 29

Table 9 Identified priorities to improve Health System and Health Status, by building blocks. ................ 33

Table 10 NHSP Framework: Strategic Directives with Key Objectives........................................................ 39

Table 11 SD1 Strengthen Leadership, Governance and Administration: Specific Objectives .................... 43

Table 12 SD2 Protect and Improve UHC: Specific Objectives ..................................................................... 50

Table 13 SD3 Address Health Security: Specific Objectives ........................................................................ 58

Table 14 SD4 Promote Healthy Populations: Specific Objectives ............................................................... 66

Table 15 SD5 Invest for Results: Specific Objectives................................................................................... 78

Table 16 SD6 Improve Data for Impact: Specific Objectives....................................................................... 87

Table 17 NHSP Roles and Responsibilities at senior levels of Government. .............................................. 92

Table 18 Roles and Responsibilities of Non-Health Stakeholders. ............................................................. 93

Table 19 MoH and Entities' Roles and Responsibilities in implementation of NHSP 2022-2026. .............. 94

Table 20 Lead Responsibility for Implementation of Strategic Directions of NHSP 2022-2026. ................ 98

Table 21 Anticipated Risks and proposed Mitigation Strategies .............................................................. 102

Table 22 Data Sources............................................................................................................................... 107

Table 23 Indicator Matrix: Inputs ............................................................................................................. 110

Table 24 Indicator Matrix: Outputs........................................................................................................... 111

Table 25 Indicator Matrix: Service Coverage ............................................................................................ 112

Table 26 Indicator Matrix: Health Risk Factors ......................................................................................... 114

Table 27 Indicator Matrix: Health Status .................................................................................................. 115

Table 28 Indicator Matrix: Health Security ............................................................................................... 117

Boxes
Box 1 Definition of Universal Health Coverage (UHC) ................................................................................ 47

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List of Acronyms
Acronym Full form Acronym Full form
A&E Accident & Emergency IHME Institute for Health Metrics and
AIDS Acquired Immunodeficiency Evaluation
Syndrome IHR International Health Regulations
ANC Antenatal Care IMR Infant Mortality Rate
APR Annual Health Sector Performance IPC Infection Prevention and Control
Report IT Information Technology
ART Antiretroviral Therapy KPIs Key Performance Indicators
ASFF Alliance of Solidarity for the Family LE Life Expectancy
AU African Union LoTC Long Term Care
CDCU Communicable Diseases Control M&E Monitoring and Evaluation
Unit MDAs Ministries, Departments and
CEHS Centre for Environmental Health Agencies
Services mHealth Mobile Health
CIC Consultant in Charge MoEdu Ministry of Education
CPD Continuous Professional MFTIEP Ministry of Finance, Trade,
Development Investment and Economic Planning
CRD Chronic Respiratory Diseases MoH Ministry of Health
CVD Cardiovascular Diseases MPI Multidimensional Poverty Index
DALY Disability Adjusted Life-Years NBS National Bureau Statistics
DSRU Disease Surveillance and Response NCDs Non-Communicable Diseases
Unit NDS National Development Strategy
eHealth Electronic Health NEET Not in Employment, Education or
eHIS Electronic Health Information Training
System NGO Non-Governmental Organisation
EPI Expanded Programme on NHA National Health Accounts
Immunization NHSP National Health Strategic Plan
GBV Gender-Based Violence NHWA National Health Workforce
GDP Gross Domestic Product Accounts
GLASS Global Antimicrobial Resistance NIC Nurse in Charge
Surveillance System NIHSS National Institute of Health and
HALE Health-Adjusted Life Expectancy Social Studies
HASO HIV/AIDS Support Organization NM Nurse Manager
HBV Hepatitis B Virus NSP National Strategic Planning
HCA Health Care Agency OECD Organisation for Economic
HCV Hepatitis C Virus Cooperation and Development
HCW Heath Care Workers PBM Performance-Based Management
HDI Human Development Index PDA Personal Digital Assistants
HIA Health Impact Assessment PHA Public Health Authority
HiAP Health in All Policies PHC Primary Health Care
HIV Human Immunodeficiency Virus PHEOC Public Health Emergency
HRH Human Resources for Health Operations Centre

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 Acronym Full form Acronym Full Form
PLHIV People Living with HIV SD Strategic Direction
PM&E Performance Monitoring and SDG Sustainable Development Goals
Evaluation SOP Standard Operating Procedure
PMO Principal Medical Officer SOW Statement of Work
PMS Performance Management System STI Sexually Transmitted Diseases
PNO Principal Nursing Officer TA Technical Assistance
PPBB Programme Performance Based TFR Total Fertility Rate
Budgeting TGHE Total Government Health
PWID People Who Inject Drugs Expenditure
PWUD People Who Use Drugs THE Total Health Expenditure
QI Quality Improvement TOP Termination of Pregnancy
QoC Quality of Care ToR Terms of Reference
RBM Results Based Management TWG Technical Working Group
RMNCAH Reproductive, Maternal, New-born, UHC Universal Health Coverage
Child and Adolescent Health UN United Nations
RTA Road Traffic Accidents UNAIDS Joint United Nations Program on
SIDS Small Islands Developing States HIV/AIDS
SAMOA SIDS Accelerated Modalities of VNR Voluntary National Review
Action WASH Water Sanitation and Hygiene
SARA Service Availability and Readiness WHA World Health Assembly
Assessment WHO World Health Organisation
YLL Years of Life Lived

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Chapter 1

Introduction

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1 Introduction
1.1 Background to the National Health Strategic Plan
The origins of the current Seychelles Public Health System date back to the late seventies, to the
years immediately following the 1976 independence. The country had inherited a rudimentary
health system and it was imperative to develop one that would respond to the needs and aspirations
of the young Seychellois nation. Inspired by the global Health for All movement1, Seychelles
embraced the primary health care approach promoted by WHO as of 1978. In the early years, the
focus was on improving geographic and financial access to care, by developing a network of primary
healthcare centres, free at point-of-use. At the same time, secondary care, based primarily at and
around the Seychelles Hospital (then Victoria Hospital) expanded at a steady pace. Through
sustained political commitment and investment in the health sector, the government managed over
the years to improve health outcomes - infant mortality rates dropped from 43.2 in 19772 to 11.6 in
20203, life expectancy at birth increased from 69.5 years in 19804 to 77.3 years in 2020.

The right of the citizens to health care, the state's obligation to make health care available to all its
citizens and the emphasis on individual responsibility for one’s health are anchored in Article 29 of
the 1993 Constitution of the Third Republic.

The period 1993 to date has seen drastic changes in the socio-political and health landscape. An
increasingly more educated and health literate population, a widely travelled population, freedom
of expression, access to health information via widely available internet and social media, the rapid
expansion of the private health sector and the introduction of new health technologies have
resulted in a vocal population with very high expectations on the quality of health care services.

The health system has not always been able to meet or manage these expectations. The mismatch
between expectation and level of satisfaction of the population with the health care services they
received prompted the government to set up a Health Task Force in 2013 to cast a critical look at the
health sector and propose a way forward to improve health service delivery and health outcomes.
The Health Task Force presented its findings and recommendations in the Health Task Force Report
2013, which laid the foundations for the “modernisation” of the health sector and led to the
development of the Seychelles National Health Policy 2015. The “modernisation process” bestowed
leadership and oversight role to the Ministry of Health, delegating health service delivery and
regulatory functions to statutory entities under its portfolio. The first National Health Strategic Plan
(NHSP) of the “modernisation era” took effect in 2016, for the five years to 2020.

1
Mahler, Halfdan "The meaning of health for all by the year 2000"." World Health Forum. Vol. 2. 1981.
2
Population and Vital statistics mid-year estimates 2015, NBS, Seychelles
3
Annual Performance Review 2020, MoH
4
Population and Vital Statistics December 2016, NBS, Seychelles

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1.2 Overview of the Existing Policy Foundations
Human health and sustainable development are inextricably linked. Health strategies therefore must
be consistent with national and global agendas for sustainable development.

Seychelles’ long-term vision for sustainable and equitable development, ‘Vision 2033’, is based on six
key pillars: Good Governance; People at the Centre of Development; Social Cohesion; Innovative
Economy; Economic Transformation and Environmental Sustainability; and Resilience. The National
Development Strategy (NDS) 2019-2023 is the first of three strategic plans to achieve Vision 2033.

The NDS goal for health, anchored in Pillar 2, is ‘the attainment of the highest level of health and
well-being’. This goal is well-aligned with Goal 3 of the Sustainable Development Framework5 and
Goal 3 of the African Union (AU)’s ‘Agenda 2063: The Africa We Want’6. Two broad strategic
priorities for the health goal are firstly, to pursue effective health protection, promote
empowerment and personal and societal responsibility for holistic health, and secondly, to build a
high-quality integrated healthcare system with a focus on people-centred care.

This NHSP is also aligned to the National Health Policy formulated in 20157, which places health and
well-being at the centre of national development, both as a beneficiary of and contributor to
socioeconomic development. It reaffirms the right to health enshrined in the Constitution and
emphasises individual responsibility in health matters. Together with other Small Island Developing
States (SIDS), Seychelles, in 2014, was a signatory to the SAMOA (SIDS Accelerated Modalities of
Action) Pathway8 for sustainable development, which articulates the sustainable development
pathways and aspirations for SIDS for the next ten years.

Seychelles has endorsed various other commitments, including World Health Assembly resolutions,
the UN General Assembly Political Declaration on Non-Communicable Diseases9, and the UNAIDS
Getting to Zero declaration10. This NHSP will take into account these commitments as well as targets
set out in various national policies and strategic plans (Annex 1: List of National Health
Commitments).

1.3 Overview of Seychelles Efforts to Achieve the Sustainable

Development Goals
In 2017, Seychelles had an SDG index11 of 67 compared to 85 for Singapore and 71 for Mauritius. The
country developed a baseline SDG report in 2019 based on local specificity and available data and
submitted a Voluntary National Review (VNR) in 2020. Although Seychelles has achieved most of
targets for four SDGs, namely SDG 4 Quality Education; SDG 10 Reduced Inequalities; SDG 11

5
https://www.un.org/sustainabledevelopment/development-agenda/
6
https://au.int/en/agenda2063/overview
7
Seychelles National Health Policy, MoH 2015
8
https://sustainabledevelopment.un.org/samoapathway.html
9
https://digitallibrary.un.org/record/710899/?ln=en
10
https://www.unaids.org/sites/default/files/sub_landing/files/JC2034_UNAIDS_Strategy_en.pdf
11
https://vizhub.healthdata.org/sdg/

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Sustainable Cities and Communities, and SDG 12 Responsible Consumption and Production, there is
still room for improvement. The country is well on track to meet the other SDGs. Seychelles progress
on the SDGs is summarised in Annex 2: Seychelles Progress on SDGs.

While displaying areas of progress towards achieving the SDGs, the Voluntary National Review has
also highlighted gaps and weaknesses that may impede further progress on the goals12. It is,
therefore, necessary to identify alternative and innovative financing mechanisms to implement and
monitor development projects. Weak intergovernmental and stakeholder coordination results in
lack of synergy and coherence in policy planning. Improved coordination will not only contribute
towards better harmonisation of policies but also identify areas of duplication. Reporting on the
SDGs has identified data collection, utilisation, and dissemination gaps – required data are often
unavailable, while available data often lack disaggregation and granularity.

1.4 Rationale for the NHSP 2022-2026

In 2020 with all attention being on the response to the COVID-19 pandemic, the Ministry of Health
(MoH) extended the lifespan of the NHSP 2016-2020 to 2021.

The COVID-19 crisis has negatively affected all the building blocks of the health system, as well as
jobs, livelihood, and the economy as a whole. This NHSP process has reviewed the strategic priorities
in the context of the current health landscape and socioeconomic situation. A thorough analysis of
the implementation of the current NHSP provided insight into achieved targets, remaining gaps and
challenges as well as some of the root causes for persistent failures.

The NHSP 2022-2026 gives direction, sets milestones, and proposes goals to guide the nation and
the health sector during the next five years.

1.5 NHSP Development Process

Strategic planning is a core component of the Results-Based Management (RBM) Framework
advocated by the successive Governments of Seychelles. The development process for this NHSP,
therefore, is closely aligned to national guidelines.

The development of the NHSP under the leadership of the MoH Secretariat, started with wide
consultations within the MoH and its statutory entities, the private health sector, health-related civil
society organisations (CSOs), and partner Ministries, Departments and Agencies (MDAs) – see Annex
3: List of in-person Consultations.

The NHSP Steering Committee constituted different technical working groups to review the
implementation of the NHSP 2016–2020, conduct a situation analysis and identify priorities for the
next five years, assess perspectives of leadership, service providers and beneficiaries on health and

12
VNR 2020, Republic of Seychelles, Economic Planning Department, Ministry of Finance, Trade, Investment
and Economic Planning

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draft and validate the strategic plan. The tasks and objectives of each technical working group are
outlined in Annex 4: Tasks and Objectives of the TWGs.

The Technical Working Groups (TWGs) worked in parallel to provide a comprehensive overview of
the state of the sector and identify emerging priorities. The Steering Committee presented the work
of the TWGs to leadership and senior management for discussion through a series of workshops. The
aim of the workshops was to build consensus on strategic priorities for the next five years.

From the outcomes of the workshops, the Steering Committee formulated the broad strategic
directives with key interventions and milestones. Further consultations and workshops followed
with different target groups (from primary care, secondary and specialised care, programmes,
support services and the inner islands) leading to a zero draft. The draft was shared with reviewers
including the Department of Economic Planning and the World Health Organization country and
regional offices for their inputs.

The Steering Committee engaged non-MoH and non-health stakeholders in the NHSP development
process (Table 1).

Table 1 External Stakeholders engaged in NHSP 2022-2026 Development process

Lead Process Stage Non-MoH/Non-Health Stakeholders

TWG 2 Situation Analysis (Health Private health sector, including Seychelles Private
System) Clinics Association

TWG 3 Perspectives of service  Seychelles Medical Services

providers (Non MOH  Seychelles Prison Services
facilities) and beneficiaries  SDF Medical Centre
 Private Physiotherapists
 STC Clinic

TWG 4 Drafting the NHSP  Department of Economic Planning

 External Reviewers

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Chapter 2

Review of implementation of
NHSP 2016-2020

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2 Review of implementation of NHSP
2016-2020
2.1 Achievement of NHSP 2016-2020 Goals
The TWG1 reviewed the implementation of NHSP 2016-2020 strategic investment priorities,
achievement of set targets and identified unfinished agendas. Progress has been uneven, with
certain goals achieved fully, others partially, and still others with little-to-no progress. Table 2
outlines progress across the main goals of the NHSP 2016-2020.

Table 2 Progress towards Main Goals of NHSP 2016-2020

Goals Indicator Baseline 2020 Results End-term
(2015) Target

Increased expectation of LE/Years M: 72 M: 72.7 M: 74

life at birth F: 78 F: 82 F: 80
Both: 77.3

Reduced incidence, Mortality (30-70 60.32% 59% <40%

prevalence and mortality years) from NCDs (as
associated with priority % of all deaths)
non-communicable and
AIDS -related deaths 15 10 <0.2513
communicable diseases
(per 100,000 pop.)

Deaths from RTAs (% 1.8% 1.6% <1%

of all deaths)

Increased level of Surveys Patient SARA 2017 No Target

satisfaction of people and Satisfaction (Increased
health professionals with Survey 2013 satisfaction for
existing health services (16 areas 11 of 16 areas)
assessed)

Improved overall Surveys No Baseline Not Measured No Target

wellbeing of all people in
Seychelles

2.2 Review of 2016-2020 Strategic Priorities

The NHSP 2016-2020 set the following strategic investment priorities:

1. Strengthening integrated health care

13
Target not clearly defined in NHSP 2016-2020.

6|Page
 2. Promoting and protecting health
3. Human resources for health
4. Sustainable financing for health
5. Research and innovation
6. Partnership and cooperation
7. Governance and leadership

A review of the strategic priorities showed mixed results. While some specific objectives have been
achieved, important gaps remain (see Annex 5: Strategic Investment Priorities).

Root cause analysis to evaluate the pillars of the health system (Figure 1) revealed the following

Figure 1 Review of Health System Issues - Fishbone diagram (TWG 1)

7|Page
The TWG identified the following as lessons learnt:

 The NHSP 2016-2020 was not widely disseminated and communicated to stakeholders
within and beyond MoH – the majority of health workers did not understand /know that
their routine work should be contributing to the achievement of sector goals and targets.
 A lack of ownership of specific targets and objectives – good and poor results were not
owned by one particular entity/unit/person.
 A disconnect between the NHSP set targets/objectives and what was done in practice (the
NHSP did not guide the development of budgets, work plans, disease-specific strategic plans
etc.).
 Absence of a formal monitoring and evaluation framework prevented
 There was no accountability framework across all levels of the health system.
 The work of PHA, in particular, on emergency preparedness and response was not well
included in the NHSP plans and targets
 A mid-term review was not conducted to assess progress made
 The ‘quality of care’ indicators were not monitored.
 The annual performance reports (APR), which report on sector core indicators and targets,
were not disseminated, discussed and used to guide implementation of remedial actions.

2.3 Stakeholders’ perspectives

The task of TWG3 was to capture the perspectives of various stakeholders on health-related matters.
The group consulted with MoH leadership, which included chairpersons of entity boards and chief
executives and also with clinical and non-clinical staff, professional councils, allied health
professionals, the private health sector and beneficiaries.

Knowledge of NHSP 2016-2020

Knowledge of the NHSP 2016-2020 was evident among leaders, some of whom participated in that
strategic plan’s development process. Among clinical staff, many had limited knowledge of the
NHSP. For others with more understanding of the NHSP, alignment of NHSP to operational plans was
limited. NIHSS and NAC are guided by their specific strategic plans with some coherence with the
NHSP. Although there is a good working relationship between the MoH and the private health
facilities, many private health providers had insufficient knowledge of the NHSP. The same applies
for beneficiaries, however, some health-related associations have a good understanding of the
NHSP, which guides their area of work.

Achievement of NHSP 2016-2020 Goals and Objectives

Health leaders acknowledged some progress in the last five years; however, some felt they could
have achieved more with more resources and effective coordination among entities. Some health
care workers felt that lack of proper communication, accountability and commitment have led to

8|Page
inconsistent quality of care and hindered the achievement of set targets. Some nurse managers did
not see the value of PPBB and felt that it did not help achieve sector goals.

Key considerations for New NHSP (2022-2026)

 New NHSP must be disseminated widely for buy-in.
 Human resource units needed to be more proactive than just transactional. Additionally,
more should be done during the next five years to improve staff welfare and remuneration.
 More targeted capacity building is needed to strengthen the skills of all health workers.
 Establish formal M&E in the health sector (public and private).
 Fully implement eHIS.
 There is a need to strengthen the referral system between different levels of health facilities,
including private ones.
 Remove communication barriers (doctors who do not speak local languages).
 Improve health infrastructure.

9|Page
 Chapter 3

Situation Analysis

10 | P a g e
3 Situation Analysis
3.1 The Seychelles Context
The estimated mid-year population of Seychelles was 99,202 in 2021, representing an annual growth
rate of 0.7% over the 2020 estimates. The annual number of registered live births in Seychelles has
remained between 1600 and 1700 in the last five years (Figure 2).

The crude birth rate continued to decrease from 17.4 per thousand population in 2016 to 15.8 in
2020, while the crude death rate was seven per thousand population in 202014. The population is
projected to reach 108,000 in 2045 after which it is forecast to decrease (Table 3)15.

Figure 2 Population Trends 2016-2020, Seychelles

3000 98462 100000
97625
96762 98000
2500 95843
94677 96000
94000
No of Births/Deaths

2000

Populations
1645 1651 1650 1605 92000
1554
1500 90000
88000
1000 818 795
747 748
668
86000
84000
500
82000
0 80000
2016 2017 2018 2019 2020

Number of registered live births Number of registered deaths Mid-Year population estimates

Source: National Bureau of Statistics (NBS), Seychelles

14
Mid-Year Population Estimates 2021, National Bureau of Statistics Seychelles
15
Seychelles in Figures, 2020 Edition, National Bureau of Statistics, Seychelles

11 | P a g e
Table 3 Projected Population of Seychelles, 2021 to 2050
Projected pop. (in 1000s) 2021 2030 2035 2040 2045 2050

Male 50.4 52.9 53.3 53.4 53.3 52.9

Female 48.8 51.9 53.0 54.1 54.7 54.8

Total 99.2 104.8 106.3 107.5 108.0 107.7

Source: National Bureau of Statistics (NBS), Seychelles

The percentage of the population, aged 65 years and above, increased from 9.6% in 2017 to 12.0% in
2021. This percentage is expected to reach 13.1% in 2030 and 21.3 % in 2050. This gradual shift
towards an ageing population will increase the demand for health and social care.

Like all other SIDS, Seychelles faces numerous challenges due to its small population size, small
landmass and remote geographical location. Most of what is consumed come from external markets,
due to Seychelles’ narrow resource base and local manufacturing capacity. The country relies on a
service-based economy, namely tourism and, in recent years, financial services. There is limited
scope for diversification of the economy, and the country remains vulnerable to global economic
shocks.

Seychelles’ vulnerability was laid bare by the COVID- 19 pandemic with worldwide travel restrictions
severely affecting the local tourism industry and causing massive depreciation of the Seychelles
rupee against all international currencies, a resultant increase in the cost of living and an increase of
the national debt burden.

As a small island state, Seychelles is also vulnerable to climatic phenomena, especially those
associated with rising global temperatures, extreme weather events and rising sea levels. Over
eighty per cent of economically productive activity are in low-lying coastal areas, with increased
vulnerability to coastal erosion and flooding. The socioeconomic environment in which the MoH is
developing a new national health strategic plan is outlined in Figure 3.

12 | P a g e
Figure 3 Seychelles' Socioeconomic Environment

The country enjoys political stability. Multi-party democracy was re-introduced in 1993. The general
elections held in 2020 ushered in a new administration in a peaceful transition of power. Seychelles
is ranked 67th out of 189 countries in the 2020 Human Development Index, scoring 0.796, one place
behind Mauritius16. The country attained high-income status in 2015.

However, there is significant inequality in the distribution of wealth, as evidenced by 2013 report of
the NBS17, which estimated the Gini index, at 45.9%. The report further revealed a poverty rate of
39.3% based on the national poverty line of USD 15.22 (in 2013 Purchasing Power Parity USD) per
person per day. However, the VNR of 2020 shows there is progress towards improving inequalities. A
World Bank and National Bureau of Statistics study reported by the National Bureau of Statistics in
February 2021 found that about 25 percent of Seychelles' population is living below the poverty line,
which is SCR 4,376 ($206) per month per adult.

The Multidimensional Poverty Index (MPI) adopts a broader approach to poverty measurement,
looking beyond traditional monetary measures. "In the third quarter of 2019, the poverty incidence
(H) was 11.88%, and the average intensity (A) was 33.26%. The Multidimensional Poverty Index
(MPI), which is the product of H and A (H*A) was 0.040"18.

The study looked at four dimensions of poverty, namely Living standards, Health, Education and
Employment. The largest contributor to poverty was deprivation in the highest level of education
attained, i.e., at least one member of the household did not complete secondary education. Other

16
Human Development Report 2020,The Next Frontier: Human Development and the Anthropocene, 2020 -
UNDP
17
Poverty and Inequality Estimates – 2013, NBS
18
Multidimensional Poverty Index Report 2019, NBS

13 | P a g e
major contributors were Youth Not in Employment, Education or Training (NEET) and informal
employment.

Figure 4 shows the contributions of each indicator towards multidimensional poverty in Seychelles.
The MPI measures reflect the poor state of some of the social determinants of health, which are the
root causes of ill health, influencing risk factors, health-seeking behaviours and health outcomes.

Figure 4 Contribution of each MPI indicator to National MPI, Q3 2019.

Source: Data sourced from Multidimensional Poverty Index, 2019. NBS, May 2020.

Since 2006, the country has been experiencing an increase in the use of illicit drugs, including heroin.
It is estimated that people who use heroin represented 4.6% the total population of Seychelles in
2016. The estimated number of people who inject drugs increased by 28.3% from 2011 to 2016,
from 1,671 to 2,144 (representing 2.3% of the total population in 2016)19.

19
Benjamin Vel. Seychelles Biological and Behavioural Surveillance Of Heroin Users 2017: Round One
Final Report APDAR. February 2018. http://www.apdar.com/wp-content/uploads/2018/05/IBBS-HU-FINAL-
REPORT-2017-Version-8-21-03-2018-1.pdf

14 | P a g e
The combination of widespread substance abuse, harmful use of alcohol and poverty is fertile
ground for all forms of social ills, including gender-based violence (GBV) and child abuse - 57% of
women report having experienced GBV at least once in their lifetime20. Most incidents of GBV,
including intimate partner rape, occur in the home. There was significant association between
alcohol consumption and intimate partner violence.

There was a decrease in most categories of crimes reported to the police between 2019 and 202021.
As at 31st March 2021, the total prison population was 292 (295 per 100 000 pop.), of which 7%
were female, and 16% pre-trial detainees22. This is a significant decrease in the rate from 837 per
100 000 population in 2016, just before the enactment of the Misuse of Drugs Act 2016, which
promotes treatment and rehabilitation for people dependent on drugs.

Despite the high HDI score, challenges remain in addressing some social determinants of health.
These social ills may erode health gains and compromise the achievement of the objectives of this
strategic plan.

20
Peace begins @ home Gender Based Violence (GBV) National Baseline Study in Seychelles - Preliminary
findings
21
Crime Justice and Security Statistics, Q2-2021, National bureau of Statistics
22
https://www.prisonstudies.org/country/seychelles

15 | P a g e
3.2 Health Status
3.2.1 Mortality
Seychelles started to undergo the epidemiologic transition to chronic diseases more than three
decades ago23. Until the end of 2019, non-communicable diseases (NCDs) were the most significant
health burden (Figure 5).

Figure 5 Comparison of top 10 causes of death in 2009 and 2019, all ages combined.

Source: Institute for Health Metrics and Evaluation (IHME) Seychelles profile.

Despite the transition to chronic diseases, communicable diseases like HIV/AIDS, dengue and
leptospirosis remain public health concerns and since 2020, COVID-19 is contributing significantly to
morbidity and mortality.

After detecting the first case of COVID-19 in March 2020, the country experienced community
transmission by the end of December 2020, and by September 2021, 21,470 cases had been
reported24.

Projected burden of disease from key NCDs

From available routine data and survey estimates, the key NCDs of hypertension, diabetes and
cancer, and the associated major risk factor for all three (poor nutrition, sedentary lifestyle and
substance abuse), all show a steady and increasing trend. Extrapolating these trends can provide
rough estimates of the projected disease burden in the coming years.

23
Pascal Bovet for the Investigators of the Seychelles Heart Study. The epidemiologic transition to chronic
diseases in developing countries: Cardiovascular mortality, morbidity, and risk factors in Seychelles (Indian
Ocean). Soz Präventivmed 40, 35–43 (1995). https://doi.org/10.1007/BF01615660
24
Annual Health Sector Performance Reports 2020.

16 | P a g e
Figure 6 Estimated prevalence of Hypertension, Diabetes, and Obesity, with projections to 2030
Estimated prevalence of Hypertension (HTN), Diabetes (DM), and Obesity in
population aged 25-64, with extrapolations to year 2030.
30000 25735
25000
25169
20000 19170
16743
15000
8266
10000
5000 5544

0
1989 1994 1999 2004 2009 2014 2019 2024 2029

HTN HTN_Projection DM
DM_Projection Obesity Obesity_Projection

Source: Seychelles Heart Study series (I-IV), UPCCD.

Figure 7 Cancer incidence and cancer-related deaths, 2013-19, with extrapolations to 2030
500 459
450
396
400
350
298
300
250 202
174 184
200
150
100 151
119
50
0
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Incidence Forecasted_Incidence Deaths Forecasted_Deaths

Source: Seychelles Cancer Registry, 2020

The incidence of cancer is expected to almost double within the next decade, with over 450 cases
and 200 deaths per year by 2030 (see Figure 7). In comparison, the prevalence of hypertension,
diabetes and obesity is estimated to increase by 34%, 49% and 52%, respectively, by 2030, over 2013
estimates (see Figure 6).

This prediction has serious implications for life expectancy, population health and wellbeing, impacts
on economy and society, provision of health services, and health sector planning. Noting that these
conditions have downstream costly complications – namely heart disease and kidney disease – there
is a domino effect on their true burden on the health system.

17 | P a g e
The potential benefits of strong investment in preventive and promotive health services, creating an
environment and society that readily supports healthy living, and revisiting treatment guidelines and
protocols to include newer therapeutics will be significant.

However, it is evident that there will be increased spending on healthcare in the medium term.

Maternal and Child Mortality

The annual number of maternal deaths in Seychelles has varied from zero to three since 1978. The
country did not achieve the NHSP 2016-2020 infant mortality target of <10/1000 live births but has
reached the SDG target. In 2020, the rates for stillbirth, neonatal and perinatal mortality were lower
than the five-year average (see Table 4).

Table 4 Maternal and Infant Deaths, 2019-2020.

SDG Indicator 2019 2020 2016- NHSP 2016-
2020 2020 Targets
Average

3.1.1 Maternal Mortality Ratio/100,000 live 62.3 64.4 61.7 0

births

3.2.2 Neonatal mortality rate/1000 live births 8.7 9.0 10.2 <5

Infant mortality rate/1000 live births 16.8 11.6 14.3 <10

3.2.1 Under-five mortality rate/1000 live 17.4 14.2 16.0 < 12

births

Perinatal mortality rate/1000 total births 8.1 8.3 13.2 No target

Still birth rate/1000 total births 5.0 5.1 8.0 No target

3.2.2 Neonatal mortality rate/1000 live births 8.7 9.0 10.2 <5

Life Expectancy (LE)

There was an increase in life expectancy (LE) at birth for both sexes in 2020 to 77.3 years (Table 5);
this was partially due to decreased deaths due to external causes, following restrictions of
movement due to COVID-19 public health measures. It is likely that this gain has been reversed in
2021.

18 | P a g e
Table 5 Life Expectancy at Birth (Years), 2016-2020.
2016-2020 NHSP 2016-
LE by Sex/y 2016 2017 2018 2019 2020
Average 2020 Target

Male 69.5 70.3 68.5 69.7 72.7 70.1 74

Female 80.8 78.5 77.3 78.4 82.0 79.4 80

Both 74.8 74.3 72.6 73.9 77.3 74.6 No target

In 2020, the LE at birth for women was above the NHSP end-term target of 80 years, while the target
of 74 years for men was not reached25. Despite the increase in LE in 2020, the average LE for the last
five years for both sexes is below the NHSP end-term targets. The average annual death rate for
2016-2020 was less than 10/1,000 population26, and data show that men disproportionately die
young. There remains a wide gap in LE between men and women.

Figure 8 Life Expectancy at Birth, by gender, 1980-2020.

82
80
78
76 Male

74 Female

72 Both

70 5 per. Mov. Avg. (Male)

68 5 per. Mov. Avg. (Female)
66 5 per. Mov. Avg. (Both)
64
62
1980 1985 1990 1995 2000 2005 2010 2015 2020

Figure 8 shows the trend in LE for the past 40 years; women live on average live ten years longer
than men do. There is a difference of approximately 10 years between LE and health-adjusted life
expectancy (HALE)27. LE and HALE are key health indicators, which are highly influenced by the
socioeconomic determinants of health. The gap between LE and HALE has implications for health
services and social care.

25
Ministry of Health, Seychelles: National Health Strategic Plan 2016-2020.
26
Annual Health Sector Performance Report, 2020.
27
Annual Health Sector Performance Report, 2020.

19 | P a g e
Main Causes of Mortality

The leading causes of mortality in Seychelles have remained the same in the last decade (Figure 9),
with the majority of deaths caused by NCDs. Pneumonia in particular, contributes a large proportion
of deaths. Mortality from external causes (injuries, accidents, poisoning, assaults, etc.) accounts for
approximately 6-10% of deaths – 80% of those deaths occur in young men.

Figure 9 Leading causes of Death in Seychelles, 2016-2020.

100%

90% 18% 20% 16% 20%

22%

80% 5%
6% 6% 4%
7% 7% 5%
7% 6%
70%
8% Others
13% 18% 15%
60% 17% Infectious/Parasitic
12%
50% External Causes
17% 19%
18% 20% Respiratory
40% 19%
Neoplasms
30% Circulatory

20% 39% 37%

33% 32% 34%
10%

0%
2016 2017 2018 2019 2020

20 | P a g e
3.2.2 Impact of COVID-19 on Life Expectancy
In 2021, Seychelles experienced a surge in COVID-19 cases from January to July. Registered COVID-
19 related deaths were highest in persons aged 65+ years and those with co-morbidities. COVID-19
related deaths were the second leading cause of death in Q1-Q3 of 2021 (Table 6).

Table 6 Top five causes of Death, Seychelles, Q1-3, 2019-2021.

ICD-10 Mortality Jan-Sep Jan-Sep Jan-Sep
Leading Causes of death
(Condensed codes) 2019 2020 2021

Total Deaths 587 495 718

Diseases of the Circulatory

1064-1071 186 191 209
system

U07.1* COVID-19 related deaths28 - - 180

1026-1047 Neoplasms 111 86 96

Diseases of the Respiratory

1072-1077 98 81 69
system

1095-1103 External causes of mortality 36 26 22

Infectious and parasitic

1001-1025 35 20 17
diseases

Other causes of death 121 91 125

COVID-19 related deaths reported by the Statistics Unit are from registered causes of death by the
Civil Status Office, However, the Public Health Emergency Operations Committee (PHEOC) reported
only 116 deaths during the same period, ‘directly’ caused by COVID-19 through their assessment.

The country also experienced excess deaths, defined as the difference between the observed
numbers of deaths from all causes during a crisis and expected numbers of deaths in the same
period under “normal” circumstances. Figure 10 compares the monthly number of deaths (all-cause
mortality) for January to September 2020 and 2021 with the five-year average, clearly
demonstrating an excess of deaths in 2021.

28
COVID-19 related deaths reported are from registered causes of death by the Civil Status Office, However,
PHEOC reported only 116 deaths during the same period, assessed to be ‘directly’ due to COVID-19.

21 | P a g e
Figure 10 Registered deaths by month, Jan-Sep 2020 and 2021, compared to 5y Average (2015-19)

100

80

60 2020
2021
40 2015-19 Avg.

20

0
Jan Feb Mar Apr (- May Jun Jul Aug Sep
(+11%) (+32%) (+16%) 5%) (+44%) (+67%) (+53%) (+10%) (+20%)

Note: Registered deaths by month, absolute numbers, January to September, for 2015-19 averages, 2020 and
2021. Excess deaths in 2021 expressed in brackets under each month, as % change from 2015-19 average.

Source: Statistics Unit, MoH

3.2.3 Mortality due to NCDs

NCDs include cardiovascular diseases (CVD), neoplasms, diabetes and chronic respiratory diseases
(CRD). The total number of deaths due to NCDs in 2020 was 400 (231 Males, 169 Females),
representing 60% of total deaths. Of these deaths, 245 (61%) were from diseases of the circulatory
system, 128 (32%) from neoplasms, 14 (4%) from diabetes and 13 (3%) from CRD.

There is underreporting of diabetes as an underlying cause of death. The end-term NHSP 2016-2020
target for premature deaths from NCDs was ‘less than 40% of total deaths in the age group 30-70
years’, while the target in the Seychelles Strategy for the Prevention and Control of NCDs is ‘a 25%
relative reduction in the overall mortality from cardiovascular diseases, cancer, diabetes and CRD by
2025’. The probability of dying from any CVD, cancer, CRD between age 30 and 70 years for
Seychelles in 2019 was 21.1%29 (compared with Norway at 8.7% and Mauritius, 23.2%).

Mortality from Neoplasms

A total of 307 (161 Males, 146 Females) new cancer cases were reported in 2020, representing an
increase from the 281 new cases reported in 2019 and also higher than the 222 and 216 new cases
reported in 2018 and 2017, respectively (See APR 2020). Clearly, efforts to address preventable
cancers are urgently needed30.

29
World health statistics 2021: monitoring health for the SDGs, sustainable development goals.
https://reliefweb.int/sites/reliefweb.int/files/resources/whs-2021_20may.pdf
30
WHO, IAEA, IARC – imPACT Review on Cancer Control Capacity and Needs Assessment Report (2019).

22 | P a g e
Mortality from Diabetes

Diabetes and its complications contribute to NCD mortality. Information is under-reported and not
always captured when registering the underlying cause of death. Diabetes is also the leading cause
of end-stage kidney disease, which itself is a significant cause of mortality31.

3.2.4 Mortality from key Communicable Diseases

Among infectious and communicable diseases, pneumonia, leptospirosis, dengue fever, and
HIV/AIDS are the most important in Seychelles. Data on the number of notified cases of leptospirosis
and dengue are not available for most of 2020, and 2021.

Leptospirosis

There were three deaths (all male) due to leptospirosis in 2020, less than the seven and six deaths
reported in 2019 and 2018, respectively. The NHSP end-term target for leptospirosis mortality is a
case fatality rate of <10%. Like in 2019, this was not calculated in 2020, as accurate data for the total
number of cases diagnosed was not available.

Dengue Fever

Dengue fever is a common infectious disease in Seychelles. The country is experiencing a sustained
epidemic starting end of 2015 (Figure 11). In 2020, 185 patients had a discharge diagnosis of dengue
(Male Medical Ward 101; Female Medical Ward 44; Paediatric Ward 40), and dengue fever
accounted for two deaths (one man and one woman).

The case fatality rate for dengue could not be calculated in 2020, as accurate data for the total
number of cases diagnosed was not available, due to interruption of routine disease notification
systems.

Figure 11 Suspected Dengue cases, by week; from week 52 of 2015 to week 16 of 2020.

Source: Disease Surveillance and Response Unit (DSRU).

31
Annual health Sector performance Report, 2020.

23 | P a g e
HIV/AIDS

HIV/AIDS remains an important communicable disease. The number of newly detected HIV cases
(84) decreased in 2020 (Figure 12) compared to previous years but remained above the NHSP end-
term target of 60. Similar the preceding years, the majority (69%) of cases were detected among
men.

Surveillance surveys indicate that Seychelles has a concentrated HIV epidemic among key
populations with the highest prevalence among people who inject drugs (PWIDs); however, the
proportion of people PWID has decreased among annual new cases of HIV detected in the last three
years.

Figure 12 Newly detected cases of HIV infection by year, 2014-2020.

140 120
120 112 109
105
100 91
84
75
80
60
40
20
0
2014 2015 2016 2017 2018 2019 2020

Total Males Females

Source: Communicable Disease Control Unit (CDCU).

AIDS-related mortality decreased in 2019 and 2020, after a spike in 2018 (Figure 13).

Figure 13 AIDS-related Mortality, 2014-2020.

25

20 6

15 9 6 6
Females
4
6 Males
10
17
3
11 12 12
5 10
8
6

0
2014 2015 2016 2017 2018 2019 2020
Source: Communicable Disease Control Unit (CDCU).

24 | P a g e
3.2.5 Other Causes of Mortality

Mortality due Road Traffic Accidents

External causes of mortality are responsible for a significant number of deaths in young men. The
main causes are falls, road traffic accidents (RTA) and drowning. The country has reported seventy-
four deaths from RTA since 2015. The majority of the victims were young men. The death rate from
RTAs [SDG 3.6.1] in 2020 was 11.2/100,000 population. RTAs were responsible for 1.6% of all deaths
in 2020, higher than the NHSP end-term target of less than 1%.

Intentional Self-harm

There was a steady decrease in reported cases of intentional self-harm from 2016 to 2019, but the
numbers increased in 2020 compared to 2019. Of the cases in 2020, 21 were males, and 37 were
females. The NHSP end-term target for intentional self-harm is less than 100 cases, and this target
has consistently been achieved since 201632. Three suicide deaths (all males) were reported in 2020,
giving a suicide rate of 6.1 per 100,000 population [SDG 3.4.2].

3.2.6 Fertility
The total fertility rate (TFR) was 2.29 in 202033. This is above the average replacement fertility34 of
2.05 births per woman35. The number of registered live births to young girls aged 10-19 years was
193 in 2020 (Table 7), representing 12% of total live births.

For the last five years, the birth rate among adolescents aged 15-19 was approximately 60 per
thousand. This figure is above the global average of 42.5 for 2015-2020, and the average for the
European region of 21, but lower than the African region average of 102.

Table 7 Registered Live births to Teenage girls, 2015-2020.

Ages 2015 2016 2017 2018 2019 2020

10-14y 5 3 3 5 9 4

15-19y 187 206 201 212 228 189

32
Refer to Annual Performance Report 2020 for additional information.
33
Population and Vital Statistics, 2021/1. National Bureau of Statistics, 2021.
34
Replacement Fertility rate is the TFR at which a population replaces itself from generation to generation,
assuming no migration.
35
Institute for Health Metrics and Evaluation (IHME). Findings from the Global Burden of Disease Study 2017.
Seattle, WA: IHME, 2018

25 | P a g e
3.2.7 Risk Factors for Health
NCDs have remained the leading cause of death in Seychelles in the last few decades. Several
behavioural risk factors increase the disease burden of both communicable and non-communicable
diseases.

Annual analysis of data from the School Health Programme shows increasing trends in obesity
among school children. From 1998 to 2019, the combined prevalence of overweight and obesity
increased steadily in school children from 13% to 36% in girls and 9% to 28% in boys, respectively
(Figure 14 and Figure 15). In comparison to European countries, overweight or obese among 15-
year-olds was at an average of 19% in 2018 and 16% in 201036.

Figure 14 Prevalence of Obesity and Overweight in Girls, 1998-2019.

40% Girls_Obesity Girls_Overweight

35%

30%

20.80%
17.30%
25%

16.8%
20%

15.3%

17.2%
15.0%
14.4%
14.0%

14.7%
12.9%
13.7%

15%
14.4%

13.7%
13.5%
13.0%

11.4%
12.2%

10%

14.90%

14.80%
9.8%

11.7%
10.8%
10.5%
9.7%

9.6%
8.8%

8.4%

8.4%

5%
6.8%
6.4%

6.4%
5.8%
5.4%
4.9%

4.9%
3.0%

0%

36
OECD/European Union (2020), Health at a Glance: Europe 2020: State of Health in the EU Cycle, OECD
Publishing, Paris, https://doi.org/10.1787/82129230-en.

26 | P a g e
Figure 15 Prevalence of Overweight and Obesity in Boys, 1998 to 2019.
30% Boys_Obesity Boys_Overweight

25%

15.6%
14.3%
20%

14.4%
12.9%
12.3%

13.1%

12.3%
13.0%
15%

12.0%
11.3%
10.9%
9.4%

9.2%
10%
8.3%

7.9%
7.6%

12.5%
12.1%
3.0% 6.3%
2.3% 6.9%

10.6%
9.2%

9.2%

9.0%
8.8%
5%

8.1%
7.4%
6.8%
5.1%

4.9%

4.0%
3.9%

3.9%
3.7%

0%

Note: Measures are made of students in Primary 4 (Avg. age 9.2y), Secondary 1 (Avg. age 12.2) and Secondary
4 (Avg. age 15.1) to estimate above rates of Overweight and Obesity.
Source: Mangroo G, Marie G, Bovet P. School Screening Programme: Update of the prevalence of overweight
and obesity between 1998 and 2019.

Four national NCD surveys37 conducted in 1989, 1994, 2004, and 2013 in the population aged 25-64
years showed the following:

 A marked 25-year downward trend for smoking (due to the strict implementation of national
measures in line with WHO FCTC);
 Slightly downward trends for high blood pressure and high blood cholesterol; and
 Marked upward trends for diabetes and obesity.

The increasing trend in obesity among adults and schoolchildren is a serious public health concern,
increasing the risk of NCDs and severe COVID-19 disease38.

Harmful use of alcohol and use of illicit drugs

Harmful use of alcohol has been a major risk factor for health for many years in Seychelles. In 2016,
the total annual alcohol consumption per capita (persons aged 15 years and more) was the
equivalent of 20 litres of pure alcohol for men and 4 litres for women39. Globally in 2019, the annual
consumption of alcohol was 5.8 litres per capita40.

37
Ministry of Health. National Survey of Non-Communicable Diseases in Seychelles 2013-2014 (Seychelles Heart
Study IV): methods and main findings. Seychelles : 2015.
http://www.who.int/chp/steps/Seychelles_2013_STEPS_Report.pdf
38
Caussy C, Wallet F, Laville M, Disse E. Obesity is Associated with Severe Forms of COVID-19. Obesity (Silver
Spring). 2020 Jul; 28(7):1175. doi: 10.1002/oby.22842.
39
World Health Organization – Non-communicable Diseases (NCD) Country Profiles, 2018.
https://apps.who.int/iris/handle/10665/274512
40
World health statistics 2021: monitoring health for the SDGs, sustainable development goals.
https://reliefweb.int/sites/reliefweb.int/files/resources/whs-2021_20may.pdf

27 | P a g e
An integrated bio-behavioural study conducted in 2016 among heroin users estimated the number
of heroin users to be 4,318 and the number of persons who inject heroin 2,14441. The same study
found an HIV prevalence of 8% and hepatitis C prevalence of 35% among heroin users. The HIV
prevalence among PWID increased from 5.8% in 201142 to 12.7% in 201743.

41
Seychelles Biological and Behavioural Surveillance of Heroin users, 2017. APDAR.
42
Integrated bio-behavioural Study among people who inject drugs, 2011, MoH.
43
Seychelles Biological and Behavioural Surveillance of Heroin users, 2017. APDAR.

28 | P a g e
3.3 State of Health System
3.3.1 Governance and leadership
Based on a review of the health system by a special task force in 2013, the health system was
restructured to separate the service delivery functions, provided by the Health Care Agency (HCA),
from regulatory functions, by the Public Health Authority (PHA), and oversight functions, by the
MoH.

In the practical implementation of the new structure, many areas remain undefined to date, such as
clear reporting lines by entities as well as roles and responsibilities of administrative boards of
entities. Feedback and accountability mechanisms need to improve, and policy and legal frameworks
may require updates to address evolving needs, such as introducing an electronic health information
system.

Since 2020, in response to the COVID-19 pandemic, leadership has operated under an emergency
governance structure that takes into account the functions of different entities within the health
system as well as incorporating the presence of other key national bodies.

In light of the changing health landscape, as well as the continued evolution of the health system, a
review of the effectiveness of the present structure at delivering effective health services is
warranted.

3.3.2 Health Financing

Health services in public health institutions are free at the point of delivery, with the Government
being the principal financier for health services (from tax-based revenues). Spending on health
services has increased steadily in the past decade (Table 8), with a concurrent increase in out-of-
pocket (OOP) spending for health.

Table 8 Spending on Health, 2014-2020.

Total Health Expenditure (THE) 2014 2016 2018 2020

THE as % of total government expenditure 9.7% 9.9% 11% 11%

THE as a % of nominal GDP 3.8% 5.4% 5.6% 5.8%

Source: National Health Account Reports (MoH); National Budget 2020 (Amendment), MFTIEP.

OOP expenditure accounted for an estimated 23.1% of CHE in 2018, compared to 23.8% and 25.3%
in 2017 and 2016, respectively44. This mirrors the rapid expansion of the private health sector
(including complementary health) in recent years.

44
National Health Accounts 2016-202017 and 2018, MoH Seychelles

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The largest share of the budget is allocated to the HCA, with haemodialysis, overseas treatment and
cancer care being major cost drivers in relation to number of patients benefiting from them. The
NHA also shows an increasing trend in spending on preventive care in recent years (see Figure 16).

Figure 16 Share of Current Health Expenditure (CHE) spent on Preventive Care, 2014-2018.

22.0%
19.4%
17.7%
12.2%
11.7%

2014 2015 2016 2017 2018

Source: National Health Accounts series, 2014–2018.

The MoH has fully implemented Programme Performance Based Budgeting (PPBB) framework as
prescribed by the Ministry responsible for Finance. However, this has not brought about expected
improvements in performance. This is likely due to the inflexibility of the PPBB structure, line
managers being unware of budget allocations, and misalignment with actual service delivery.

There is inadequate information on the cost-efficiency of services, which presents challenges in

making cost-conscious policy decisions. Many services have been outsourced over the years without
the necessary additional contract management and monitoring mechanisms in place; this has led to
an apparent cost escalation, as well as multiple complaints; the quality and cost-efficiency of these
services are in question. Weak administration of user fees and delayed payments for produced
supplies and services also present challenges to effective management of health finance.

3.3.3 Infrastructure
MoH owns most of the service delivery infrastructure. However, many facilities are dated and may
not meet ideal requirements for modern standards of care delivery. Many safety risks remain
chronically unaddressed – fire, flood, storm, chemical, biological and radiological. Preventive
maintenance systems are weak, and repairs/replacements often much delayed.

Safe storage space is a major challenge, prompting the need to rent off-site storage space and
leading to storage of medical supplies in clinical areas and along corridors. There is need for
expertise in project management and an infrastructure management plan. The Seychelles Hospital
Masterplan, although conceived at significant cost, is yet to be implemented.

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3.3.4 Commodities
An elaborate essential medicines list supports good treatment access. However, there is no such list
to-date for medical technologies and supplies. Notable challenges include occasional stock-outs of
certain medicines and supplies, and the need for more effective in-country stock-management and
distribution of medicines and supplies. There is a need for more involvement of line managers when
planning any supply cuts to minimise negative impacts on service delivery.

The maintenance and servicing of medical equipment have improved, directly attributable to a more
effective biomedical engineering unit. Maintenance of more advanced equipment (such as MRI
scanners) remains a challenge.

The sector receives many donations of supplies and medicines, but these donations are often not
tailored to needs and/or are not of adequate standard/quality for local use.

3.3.5 Service delivery

The Seychelles public health system is widely accessible geographically, and without financial
barriers to Citizens. It provides decentralised access to emergency services across the main islands,
has elaborate diagnostic capacity, and provides access to an expanded list of medicines and
therapeutic services.

Multiple initiatives, such as patient-centred care and maternal death reviews, have taken root in
recent years, with the aim of improving quality. But the health system does not routinely measure
quality of care. The need for a stronger clinical governance model is evident to improve
accountability and support safe, effective and quality services. The relative neglect of preventive,
promotive and long-term care services, including palliative care, also needs to be addressed.

Referral systems are weak, systems for back-referrals and feedback are lacking and/or require more
streamlining. Language barriers pose another chronic challenge; itself linked to high dependence on
and quick turnover of an immigrant health workforce.

The COVID-19 pandemic has moved public health to the forefront of the health system. The PHA as
the main guarantor of public health, has robust legal frameworks. However, the regulatory wing and
relevant enforcement mechanisms, require further strengthening.

Health programmes focus principally on supporting promotive and/or preventive services. They
access much technical assistance and engage wieldy with external stakeholders. But programme
managers often work alone, and there is poor coordination and cooperation across programmes.

The private health sector is growing rapidly. Communication between MoH and the private sector is
still poor; private-sector regulatory frameworks are weak, with inadequate reporting.

31 | P a g e
3.3.6 Impact of COVID 19 on the health system
COVID-19 has affected the whole country, the health and wellbeing of the population, as well as all
aspects of the health system.

The COVID-19 response has nudged the health system to promote remote-work, and improve
coordination across different departments and service areas. This is reflected in the increased use of
instant messaging platforms for sharing information and coordinating work, electronic platforms for
data management around testing and surveillance, video conferencing systems for meetings, social
media platforms and e-mails for risk communication, etc. There is a renewed emphasis on infection
prevention and control, with more complete guidance, training, monitoring and enforcement.

In addition to direct illness, admissions and deaths, the COVID-19 pandemic has increased the
workload on healthcare workers (HCWs) and imposed a chronic strain on the health system. Most
HCWs were redeployed, and many services were (temporarily) interrupted. The response also
revealed key weaknesses in the health system around data management and effective, timely
communication and coordination.

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3.4 Identified Priorities
Based on the unaddressed agenda (unfinished business) from the implementation of the NHSP 2016-
2020, and the situation analysis, the different TWGs and stakeholders identified the following
priorities for health system and health status (see Table 9).

Table 9 Identified priorities to improve Health System and Health Status, by building blocks.
Health System Key Health System Priorities
Building Block

Leadership and  Adopt a Proactive and long-term approach to sector planning.

Governance  Ensure Participatory decision-making.
 Strengthen HR and financial management capacities.
 Strengthen legal and regulatory frameworks for health.

Human  Improve appraisal systems.

Resources for  Improve staff welfare, retention mechanisms, health and safety.
Health (HRH)  Develop an HRH strategy.

Health Financing  Review revenue generation and user-fees structure.

 Review tender process and performance of outsourced services.
 Improve cost-benefit awareness.

Health  Address fire, flood, storm, chemical, biological and radiological risks,
Infrastructure across the sector.
 Improve preventive maintenance and ensure timely repairs.
 Systematically consider disability access.
 Invest in MoH-owned safe storage space.

Medicines and  Improve stock management and forecasting.

supplies  Develop a Donation policy to guide responsible donations.
 Ensure rational use of medicines and supplies.
 Use a Standardised list of medical equipment.

Health  Adequate IT infrastructure with strong technical support.

Information  Prompt implementation of the eHIS.
systems  Develop data management and research policies.
 Invest in digital solutions for health.
 Establish Central data warehousing.

33 | P a g e
 Health Service  Develop SOPs and clinical guidelines.
Delivery  Establish Quality improvement initiatives; standards of care.
 Strengthen communication and coordination.
 Improve referral and appointment systems.
 Introduce new service/programmes to address existing gaps.
 Strengthen regulatory wing of PHA.
 Consolidate and improve reporting systems.

Private Health  Establish regular communications platform.

Sector  Share and monitor adherence to guidelines, SOPs, regulations.

Health Status Priorities

 Maintain high Life Expectancy (LE) for women.

 Increase LE for men and close gap in LE between men and women.
 Increase healthy life expectancy.
 Continue to improve maternal and child health.
 Decrease morbidity and premature mortality due to NCDs.
 Decrease mortality due to external/accidental causes especially in men.
 Reduce morbidity and mortality due to priority45 infectious diseases.
 Reduce number of cases and mortality due to COVID-19.
 Address risk factors for health (especially obesity in adults and children, harmful use of
alcohol, abuse of drugs).
 Track and improve non-fatal outcomes for priority diseases.
 Prevent, prepare and respond to health emergencies.
 Implement the Health in All Policies (HiAP) approach to address social determinants of
health.

45
Priority diseases include Pneumonia, HIV/AIDS, Dengue and Leptospirosis.

34 | P a g e
 Chapter 4

Strategic Agenda for 2022-2026

35 | P a g e
4 Strategic Agenda for 2022-2026
4.1 Vision, Mission, Goals
As articulated in the National Health Policy 2015, the national vision for health is the “attainment,
by all people living in Seychelles, of the highest level of physical, social, mental and spiritual health
and living in harmony with nature”.

True to this vision, the mission of the sector is “to relentlessly promote, protect and restore health
and quality of life and dignity of all people in Seychelles with the active participation of all
stakeholders, through the creation of an enabling environment for citizens to make an informed
decision about their health”.

The NHSP 2022-2026 is the second strategic plan of the National Health Policy 2015. Like the first
medium-term plan, this NHSP embraces the guiding principles of “Health for, Health by all and
Health in all”.

The goals of this strategic plan are to:

 Increase life expectancy and healthy life expectancy

 Achieve and sustain all dimensions of Universal Health Coverage (UHC)
 Prevent, Prepare for, detect early and respond adequately to all health emergencies
 Promote healthy populations

The NHSP proposes bold changes to maintain and build on health gains for all people in Seychelles
throughout the life-course. It recognises that promoting, protecting and restoring health in the
fragile and unpredictable post-pandemic social and economic situation requires bold and innovative
approaches. It recognises that health gains can be easily eroded; and that renewed and sustained
investment is needed.

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4.2 The NHSP 2022-2026 Framework
This NHSP has six strategic directions represented by the six pillars (see Figure 17):

1. SD1 Strengthen leadership, governance and administration

2. SD2 Protect and improve UHC
3. SD3 Address health security
4. SD4 Promote healthy populations
5. SD5 Invest for results
6. SD6 Improve data for impact

What the sector is planning to achieve is captured under SD2, SD3 and SD4, while critical inputs
required to achieve these results are captured under the other three pillars (SD1, SD5 and SD6). See
Table 10 for an overview of broad objectives.

The NHSP sets out the priorities for each pillar for the next five years. While there is collective
ownership of this five-year plan, the different entities will be responsible for delivering on specific
objectives under these pillars.

37 | P a g e
Figure 17 NHSP 2022-2026 Framework

38 | P a g e
Table 10 NHSP Framework: Strategic Directives with Key Objectives
SD1 Strengthen SD2 Protect & SD3 Address Health SD4 Promote SD5 Invest for SD6 Improve Data
Governance, Leadership Improve UHC Security Healthy Populations Results for Impact
& Administration
General Objective (GO): GO: To protect and GO: To promote and GO: To advocate for a GO: To ensure GO: Build an integrated
To ensure MoH Governance improve UHC throughout protect health security. conducive environment effective, efficient Health Information
and Leadership has the life-course and that supports healthy and sustainable System (HIS), and
appropriate structures and address priority diseases. living, safe & healthy investment in strengthen efforts to
processes necessary to neighbourhoods, and health and the collect, process, report
successfully steer the health improve wellbeing of health system. and use health data.
sector. people.
Specific Objectives (SO): SO: SO: SO: SO: SO:
1.1 Build strong 2.1 Improve health 3.1 Strengthen the One 4.1 Promote healthy 5.1 Human 6.1 Set-up one
governance and services across the Health approach. living for different Resources for integrated HIS
leadership structure life-course and 3.2 Implement the IHR age-groups Health 6.2 Improve data
1.2 Renew stewardship address priority health to prevent, detect 4.2 Address risk factors 5.2 Health governance
function of MoH conditions. and manage for health. Financing 6.3 Enable data use
1.3 Ensure accountability at 2.2 Champion Quality outbreaks 4.3 Revitalise HiAP 5.3 Medicines and 6.4 Implement eHIS
all levels Improvement across 3.3 Implement IDSR 4.4 Promote good Health 6.5 Invest in health
1.4 Implement effective health system 3.4 Strengthen mental health and Technologies data
coordination and 2.3 Improve collaboration regulatory functions address substance 5.4 Infrastructure 6.6 Strengthen
communication with private health of the PHA abuse 5.5 Information research capacity
systems sector and health- 3.5 Improve public 4.5 Promote and Technologies 6.7 Improve health
1.5 Engage the community related NGOs health standards advocate for information
1.6 Build meaningful 2.4 Mitigate risks and and legislation effective public products
relationships mainstream resilience 3.6 Strengthen public health
1.7 Implement RBM across the health health programmes
system
     
Lead Entity: MoH HCA PHA MoH MoH/HCA MoH
- Entity two-year Operational Plans -
- Sector, Entity and Disease-specific Monitoring and Evaluation Plans -

39 | P a g e
SD1 Strengthen Governance, Leadership and Administration
Leaders in health are responsible for developing and implementing national health strategies, setting
health goals and targets for improving health, delivering quality health care services, and monitoring the
population's health. The health sector is also responsible for ensuring that the policies of other sectors
promote and positively impact health.

Governance and leadership is one of the six building blocks of the health system, essential for guiding
the health sector towards achieving its strategic vision. However, governance is generally poorly defined
and may be difficult to operationalise. The WHO definition of governance and leadership includes
“ensuring strategic policy frameworks exist and are combined with effective oversight, coalition-
building, regulation, attention to system-design, and accountability”46.

Good governance is transparent, inclusive and based on a robust system of mutual accountability. MoH
needs solid formal governance structures and processes to lead and engage all health providers and the
community in a shared purpose and vision.

SD1 Outstanding Issues

Governance structure

Since the 2013 reform of the MoH47, functions of the MoH have been assigned to several semi-
autonomous statutory entities with their own governing boards, while the MoH Secretariat, headed by
the Minister, is responsible for political leadership, sector stewardship, accountability and performance
monitoring.

The situation analysis for the development of the current NHSP noted that there had been no review of
the objectives of the 2013 reforms and inadequate clarity around roles, responsibilities and boundaries
of various leadership posts and bodies.

Communication, coordination and collaboration

There are weaknesses with the flow of information within and across entities within MoH and
communication from MoH to other sectors and the private health sector. There is a need for
mechanisms to allow clear and timely communication within MoH and with other sectors and the
community.

46
WHO. https://www.who.int/health-topics/health-systems-governance#tab=tab_1
47
Health Task Force Report, 2013, Strengthening and Modernising Seychelles Health System to Improve Health
Outcomes

40 | P a g e
Accountability

One of the reasons for not achieving desired health outcomes is the lack of accountability in the health
sector. Accountability refers to the act of holding public officials/service providers answerable for
processes and outcomes and imposing appropriate measures if specified outputs and outcomes are not
delivered to the minimum expected standards.

Technical leads develop and submit regular progress reports but do not receive feedback from
leadership. Roles and responsibilities of professional councils and entity leadership about disciplinary
actions are blurred.

To improve health system performance and achieve desired outcomes, there is a need for all in MoH to
be accountable. Formal mechanisms are required to make workers at all levels answerable for
professional conduct and performance, focusing on utilisation of resources, outputs, and results.
Accountability also applies to the private health sector, monitored by the PHA.

Leadership should shape organizational culture.

Policy and Planning

MoH has developed many policies over the years; however, less effort has been made to plan policy
implementation, review progress and its impact. For the next five years, MoH will assess and understand
policy gaps and develop urgently needed policies such as policies on donation and quality of care.
Additionally, mechanisms will be developed to periodically review policy implementation to understand
and report on policy failures and successes. MoH will seek buy-in for an inter-sectoral policy platform, to
advance the HiAP approach.

Partnership

Health is complex, and efforts to promote better health requires using a whole-of-government and
whole-of-society approach by engaging all partners, including the community, private health providers
and other line ministries. The MoH will initiate inter-sectoral interventions to advance the health
agenda, act as a health advocate while engaging the community in health policy formulation, research
and sector monitoring.

MoH’s efforts to promote and protect health can only achieve results when the community is
empowered and actively engaged. Despite some efforts, there are still untapped opportunities to
involve the community and support citizen and patient empowerment to improve health outcomes,
health system performance, and satisfaction with health care.

MoH also works with important global partners, particularly the WHO. MoH, with support from global
partners, will work to advance the national health agenda and also to achieve regional and global
commitments.

41 | P a g e
Results-Based Management (RBM)

The government has approved the rollout of RBM consisting of four pillars: Strategic planning,
Programme Performance Based Budgeting (PPBB), Performance Monitoring and Evaluation (PM&E) and
Performance Management System (PMS).

MoH, like other sectors, needs to establish a performance-driven work culture where accountability for
results is continually strengthened. Lead portfolio institutions have been tasked to establish a portfolio-
level RBM Committee to oversee the implementation of all RBM pillars and ensure harmonization of the
strategic plan with all other pillars of RBM.

The MoH Secretariat will continue to conduct sector monitoring by tracking and reporting on a set of
core indicators annually through the annual health sector performance report; however, sector and
entity M&E frameworks were not developed for the previous NHSP.

SD1 Priority Areas

1. Clarify and strengthen MoH governance structures and processes.

2. Improve communication, coordination and collaboration within and beyond MoH.
3. Ensure accountability at all levels of the health sector (public, private and non-health actors).
4. Develop needed synergistic health policies.
5. Engage the community and build meaningful partnerships.
6. Implement the RBM strategy.
7. Drive the quality in health agenda and mobilise high-level engagement for HiAP.

SD1 General Objective

Ensure that MoH governance and leadership has the appropriate structures and processes necessary to
successfully steer the health sector to:

 Provide strategic vision and guidance

 Ensure accountability, effectiveness and efficiency
 Develop and monitor implementation of synergistic policies
 Foster community engagement and build meaningful partnerships
 Ensure cooperation and policy synergy across public and private sectors and civil society
 Monitor performance and achievement of desired outcomes and goals.

42 | P a g e
SD1 Specific Objectives
Table 11 SD1 Strengthen Leadership, Governance and Administration: Specific Objectives
SD 1: Strengthen Leadership, Governance and Administration

Lead Contributing
Specific Objectives Key Interventions Milestones
Entity Entity
1.1 Build strong Conduct a review of the objectives and implementation of Report of review of 2013 reforms with recommendations MoH PHA; HCA;
governance and 2013 health reforms (Fit for purpose, need for new NIHSS; NAC
leadership governance architecture etc.)
structure Develop a framework for governance defining clear roles and Governance framework developed and disseminated MoH
responsibilities and reporting lines of MoH, entities and
entity boards
Develop key indicators/milestones to monitor governance Indicators developed and monitoring conducted MoH
and leadership functions
Conduct annual assessments and develop reports on health Annual governance report developed and disseminated MoH
governance and leadership
Develop a governance structure for health emergencies with Health Emergency governance structure developed and PHA MoH
clear roles and responsibilities validated
1.2 Renew Conduct a review of existing health policies and policy gaps Policy review report and recommendations MoH
stewardship
function of MoH Formulate strategic policy directions as required (Priorities: Required policies developed and disseminated MoH
quality of care, donation)

Review implementation of key health policies and make Report of review of policy implementation MoH
recommendations
Develop a shared policy platform with key sectors and Policy platform developed and functional MoH
monitor health coherence
Collect and use health intelligence to develop policy briefs Policy briefs developed and disseminated MoH

Continue to strengthen professional councils. Councils strengthened and independent. MoH

Build confidence of HCWs in leadership by ensuring clear All HCWs understand organisational culture and leadership MoH
direction, commitment. actions are consistent with sector vision, values and
strategy.

43 | P a g e
 1.3 Ensure Develop accountability framework to define accountability Health Sector accountability framework developed, and MoH HCA
accountability at requirements at all levels (who is accountable, for what and accountability monitored. PHA
all levels to whom) – leaders, managers, HCWs, councils, entity
boards.
Monitor and report on the implementation of all pillars of Entity and sector RBM committees set up MoH HCA
RBM Annual RBM reports PHA
Develop and disseminate annual health sector performance Annual health sector performance report developed and MoH
reports and follow up on the implementation of remedial disseminated within and beyond MoH
actions as necessary Remedial measures identified, discussed and implemented
by relevant entities
Develop entity annual performance report Annual entity performance reports developed and HCA
disseminated, achievements and failures discussed and PHA
plans for remedial actions developed (HCA, PHA, NAC, NIHSS
NIHSS) MoH
Use progress report as a management tool  New format for progress report developed and used. PHA
 Review format/frequency of progress report  Feedback is given for all reports submitted. HCA
 Review format for feedback and monitor
Develop and disseminate annual Drug Observatory Report  Annual Drug Observatory report developed and MoH
disseminated.
 Follow-up action plan developed and implemented.
Revise scope of work of CIC and nurse managers to include Revised scope of work of CIC and nurse managers HCA
clear roles and responsibilities
1.4 Implement Develop formal coordination mechanisms within and across Formal coordination mechanisms developed by MoH and MoH
effective entities and for actors beyond MoH (circulars, information entities. PHA
coordination and bulletins, leadership blogs, forums, committees, platforms). HCA
communication NIHSS
system Ensure weekly decisions of senior executive committee reach Decisions of the senior executive committee are shared MoH HCA
all health care workers in MoH (and the private sector when every week and as needed. PHA
needed)
Conduct annual coordination meetings with the private  Annual coordination meetings conducted with private HCA
health sector and civil society and bi-annual PHC/Hospital health care providers and NGOs. PHA
coordination meetings  Annual coordination meetings conducted PHC and MoH
hospital services.
Develop and implement effective communication strategies Communication strategies implemented MoH PHA
HCA
1.5 Engage the Include community consultation in the development process Meeting reports of community consultations. MoH PHA
community of all health policies/strategies and understand their values HCA
and preferences

44 | P a g e
 Disseminate and explain key findings from annual Annual meetings on Mahé, Praslin and La Digue MoH
performance report and other important reports to the
community and obtain feedback
Build community leadership for priority health conditions (rf. Community leaders for NCDs and key communicable MoH HCA
SD2 p. 47). diseases identified, trained and supported. PHA
Develop mechanisms to engage vulnerable and key Vulnerable and key populations engaged in the MoH PHA
populations and their advocates in relevant policies and development of programmes and services that target them
programmes
1.6 Build Map key partners and develop a framework to guide the Mapping report of key partners in health MoH
meaningful engagement of local and external partners in health. Framework to guide partnership developed and
partnership disseminated.
Develop a policy to guide donations to MoH. Policy on donation developed, disseminated and used. MoH HCA
PHA
Develop annual reports on grants, TA and donations (on aid Annual reports on donations and aid effectiveness in MoH HCA
effectiveness). health. PHA
Develop brief outlines of key priority projects that are above Project outlines developed. MoH
budget allocation to inform donation requests. PHA
HCA
Define key areas/projects where external technical support Annual TA needs developed jointly by MoH and entities. MoH HCA
(e.g. WHO/UN agencies) is required, at start of each year. PHA
NIHSS
Contribute to the development and monitor implementation WHO biennium plans developed jointly and are in line with MoH HCA
of WHO biennial work plans. national health agenda. PHA
NIHSS

Review, jointly with UN agencies, the mechanisms for Recruitment and engagement of TA from UN agencies are MoH HCA
recruitment and engagement of TA. structured to add value to partnership PHA

1.7 Implement Sensitise managers on RBM and theory of change. Sensitisation workshops conducted. MoH
Results-Based Finalise and disseminate NHSP 2022-2026. NHSP 2022-2026 developed and disseminated. MoH
Management Each entity develops a two-year operational plan Operational plans developed. MoH HCA
(RBM) PHA NIHSS
Set up entity and sector RBM committees with ToRs as RBM committees set up and functioning. MoH PHA
specified by MFTIEP and report to government HCA
Develop sector and entity PM&E frameworks with support PM&E frameworks developed. MoH PHA
from DPA/TA HCA
Develop indicator protocol to monitor core health indicators. Indicator protocol developed. MoH PHA
HCA
Monitor and report on sector and entity core indicators. Annual reports from MoH and entities on core indicators. MoH
PHA

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 HCA
Strengthen M&E capacity with support from government Recruit M&E officers for entities MoH PHA
HCA
Conduct a mid-term review of the NHSP 2022-2026 and Drug-control Master Plan and NHSP mid-term review report MoH
Drug-control Master Plan and recommendations developed and disseminated
1.8 Drive changes Define and agree on purpose and quality goals and assign Quality leads assigned to PHC, in-patient care, specialised MoH
required to leaders services, programmes and in private health sector PHA
improve quality in HCA
health Develop a framework to drive quality in health, and support  Framework on quality in health developed and MoH
and monitor implementation of QI initiatives disseminated. PHA
 Reports QI projects. HCA
Share local best practices within the health sector Best practices identified and shared MoH HCA
PHA
‘Get Boards on board’ – to provide insight, monitor Entity boards to put quality on the agenda PHA MoH
performance and hold managers accountable Set up ‘quality committees’ on boards. HCA
NIHSS
Re-engineer health processes so that quality becomes a Quality governance and management system set up. PHA
disciplined and integrated management system. HCA
1.9 Mobilise Mobilise buy-in for HiAP by sensitising Cabinet and NA, and HiAP meetings held with Cabinet and NA. MoH
commitment and obtain pledges PHA
action for HiAP Advocate for extended health impact assessment before the Health impact assessment conducted. MoH PHA
development of key projects
Conduct annual review of HiAP commitments Annual HiAP Report
MoH

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SD2 Protect and Improve Universal Health Coverage
Health services are free, easy to access geographically and have high utilisation rates. However, quality,
equity, outcomes and user experience and satisfaction are not adequately measured. This may imply
certain population groups may be ‘left behind’, but not picked up by current routine monitoring –
making a case for stronger measurement of these aspects of care. While public health sector services
remain free of user charges, a series of NHA reports show increasing out-of-pocket spending on health,
chiefly driven by increasing utilisation of private health services.

The two seminal global conferences on primary care (Alma-Ata, 1978, and Astana, 2018) have
emphasised the importance of primary care as the key vessel to deliver quality health services to all, to
improve everyone’s health and wellbeing. In recent years, UHC (defined in Box 1) has been the flagship
approach of the WHO (and the wider United Nations) for improving health and wellbeing within the
Sustainable Development Agenda 2030 framework48. The principle aims to expand the range of health
services provided, at high quality, to the whole population, with maximum financial protection. The
ideals of achieving and improving UHC through strengthening primary care, are well aligned with both
the global health goals (SDG 3) and the National Vision for Health.

Box 1 Definition of Universal Health Coverage (UHC)

“Universal health coverage means that all people have access to the health services they need,
when and where they need them, without financial hardship on them. It includes the full range
of essential health services, from health promotion to prevention, treatment, rehabilitation,
and palliative care… high quality health services… through people-centred primary care.”

– Definition of Universal Health Coverage, World Health Organisation

Primary care and the achievement of UHC are intricately linked to public health (aimed at prevention),
health promotion (aimed at prevention and promotion), and health systems strengthening (provides the
supports to improve the platform through which UHC services are delivered).

Seychelles has a relatively high UHC index of 7149. WHO criteria and targets are, however, generally not
tailored for high-income contexts, and do not accurately reflect changes to UHC in the Seychelles
context. As such, particularly in the context of an economic crisis, there is risk for erosion of past gains in
UHC, which may go undetected in the annual standard UHC index measurements, hinting at a need for

48
https://www.who.int/health-topics/universal-health-coverage#tab=tab_1 (accessed 24 Nov 2021).
49
World Health Statistics Report, WHO, 2021, p67.

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more tailored criteria and thresholds. There are also a need to measure equity and quality of health
services.

SD2 Outstanding Issues

 Urgent need to address priority diseases: NCDs (cancer, diabetes and cardiovascular disease
outcomes) and communicable diseases (COVID-19, HIV, Viral Hepatitis).
 Measurements and reporting are mortality-centric; non-fatal outcomes are not well measured.
 Weak clinical governance mechanisms:
 Lack of standardisation of care – great variation across health system.
 Gaps in clinical care: inadequate guidelines, unclear care pathways, no clinical audit cycles,
weak referral systems, no standards for care, inadequate measurement of quality and safety
in services, lack of a quality policy, and no formal clinical audit.
 Traditionally tertiary-care-centric role of clinical specialities – need for oversight and
responsibility for improving care and services under the relevant speciality for the whole
country, and not just the specific hospital unit.
 Lack of a clear policy on process for overseas treatment, a major cost-driver.
 Only a few innovations in care delivery; inadequate modernisation of services; outdated service
delivery models.
 Majority of health funding focused on curative care, much less on primary care, promotive
and/or preventive health services.
 Effectiveness, efficiency and cost-benefits of services are not measured.
 Equity is not measured – possibly leaving behind certain groups.
 Communication barriers – with public, and within health system.
 Fragmentation of operations within health system; weak coordination mechanisms.

SD2 Priority Areas

1. Use a combination of life-course (RMNCAH, men’s health, healthy ageing, etc.) and disease-
specific (cancer, CVDs, COVID-19, HIV, etc.) approaches to address health needs.
2. Innovate and modernise care delivery – new service delivery models aimed at improving
outcomes of prevention and care.
3. Make quality a top priority in service delivery.
4. Increase spending on preventive and primary healthcare services.
5. Strengthen and promote a preventive care agenda.
6. Ensure no one is left behind: Measure and improve equity in access to health services, and
health outcomes.
7. Improve health system resilience.

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SD2 General Objective
To protect and improve Universal Health Coverage (UHC), through continued provision of quality
preventive, promotive, curative and palliative health services to everyone in-need, without undue
financial risks, and establish a system of continuous quality improvement. The key strategic domains to
guide the direction are:

 Improve health services across the life-course and address priority health conditions.
 New direction for primary health care.
 Improve secondary and tertiary care.
 Innovate and modernise health programmes.
 Champion quality improvement across the health system.
 Implement a quality framework.
 Develop and implement a clinical governance model.
 Improve efficiency and effectiveness of services.
 Improve collaboration with private health sector and health-related NGOs.
 Partnership to provide services.
 Mitigate risks and mainstream resilience across the health system.
 Improve health and safety and staff wellbeing supports.
 Climate change mitigation and adaptation in health sector.
 Institutionalise COVID-19 response functions and build resilience.

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SD2 Specific Objectives
Table 12 SD2 Protect and Improve UHC: Specific Objectives
SD 2: Protect and Improve UHC
Specific Lead Contributing
Key Interventions Milestones
Objectives Entity Entity
2.1 Improve 2.1.1 A new direction for primary health care
health services  Operationalise package of services to be offered in  PHC package operationalised HCA PHA
across the life- primary care.
course and  Reorganise community health services into a fit-for-  Criteria for PHC defined. HCA MOH
address priority purpose system, with clear organisational structure  Organisational structure defined of PHC facilities and PHA
health conditions. based on agreed criteria, to deliver effectively and services.
efficiently on the PHC package.  New Master Facility List available
 Repurpose/close health centres not meeting set  A population register for each clinic catchment area
criteria for delivery package. Redeploy any free developed.
resources.
 Establish mechanisms for strong oversight and  Create a PHC council with mandate on quality and HCA MOH
continuous service improvement. efficiency. PHA
 PHC indicators and targets defined.
 Implement chronic disease care models to support self-  Service delivery model for chronic diseases developed HCA MoH
management, treatment adherence and improve and implemented. PHA
health literacy.
2.1.2 Address challenges in operations of PHC services to maximise access and effectiveness of services.
 Fully implement appointment systems.  PHC appointment system functional. HCA
 Develop tools and processes for a seamless, active and  Active seamless referral system in place.
timely referral system.  Coordination meetings between PHC and hospital
 Establish minimum language proficiencies for health services conducted at least twice a year.
service providers.
 Review operating hours of PHC facilities
 Improved coordination and support across services and
centres, including with Praslin and La Digue.

 Address discrimination and protect rights of vulnerable  Access for vulnerable populations to health and social MoH
population groups (substance abuse, mental health, services improved in existing facilities and planned for HCA
social ills). future facilities. PHA

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  Targeted interventions to reach vulnerable populations
developed.
2.1.3 Improve secondary and tertiary care
 Define needs, roles and package of services for  Inpatient and Specialised Care package of services HCA
inpatient and specialised care services. define and used to inform clinical guidelines and access
to diagnostics and therapeutics.
 Establish adequate management capacity for  Competent staff to fill all management HCA
Seychelles Hospital and annexes. positions/functions appointed
 Strengthen governance and coordination of specialist  Governance structure for specialised services defined. HCA
outpatient, oncology and accident and emergency
(A&E) services.
 Review scope-of-work for specialist services, to ensure  Scope of work for clinical leads (PMOs, PNOs, NMs, CICs, HCA
relevant broader health system and societal needs are Regional lead Dr) are redefined, with reporting/M&E
incorporated. and service improvement roles.
 Review after-hours service provision based on needs,  After-hours services package and requirements and HCA
access and utilisation. location defined
 Improve standards of inpatient care.  Define standards of operations and minimum HCA MoH
requirements for all wards and units/services. PHA
 Rationalise use of diagnostics and therapeutics.  Guidelines developed for access to diagnostics and HCA
therapeutics
 Improve long-term care (LoTC) services.  Package of services provided in LoTC facilities defined. HCA
 Closer coordination with social workers in care  Dedicated Social workers for different health services
planning for vulnerable groups. appointed.
 Transfer ‘Regional Homes’ management to Ministry  Regional homes transferred to relevant ministry.
responsible for social affairs.
 Establish clear governance and accountability structure  Governance structure for overseas treatment HCA MoH
for overseas treatment. established.
 Establish overseas treatment policy to complement the  Overseas treatment policy developed.
Act.  Review and annual report on overseas treatment
 Conduct a review of overseas treatment (needs, costs, developed.
outcomes).
 Annual reports on overseas treatment services, with
outcomes.
2.1.4 Innovate and modernise health programmes
 Improve leadership, organization and management of  Organizational structure and coordination of HCA MoH
health programmes programmes reviewed. PHA
 Build capacity in programme leaders for M&E and  Capacity building of programme leaders for M&E and
quality improvement. quality improvement conducted.

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 Strengthen programmes to address health needs across  Programmatic services on offer are better aligned with HCA MoH
the life-course and across disease conditions. target population needs. PHA
 Support the conduct of the next round of the Seychelles
Heart Study series.
 Review implementation of new initiatives.
 Implement PHC package of services  Implement programmes according to PHC Package HCA
 Monitor outcomes of programmes  Key indicators and targets for each programme PHA
developed.
 Annual report of programmes developed and shared.
 Build synergies across programmes through  Communities of practice for related groups of HCA PHA
communities of practice. programmes set up and running. MoH
 Develop and pilot an integrated preventive health  Health Prevention Hub developed.
services hub.
 Address policy support gaps for key programmatic  National Cancer Control Strategy developed. HCA MoH
services.  School Health Policy developed. PHA
 Expand utility of vaccination in disease prevention  Revised EPI schedule for children. HCA MoH
 Expand capacity of the Expanded Programme on  Capacity of EPI Unit strengthened.
Immunisation (EPI).  Review current vaccination schedule to include
additional evidence-based vaccination in: (1) routine
childhood vaccination, (2) routine adult vaccination, and
(3) travel vaccination.
 Strengthen collaboration between programmes and  Coordination mechanisms for programmes and health MoH HCA
health promotion. promotion developed. PHA
 Develop a health promotion policy and strategy.  Health promotion policy and strategy developed.
Improve community engagement for addressing priority  Focal persons in the community for key programme MoH HCA
health conditions. areas identified and sensitized. PHA
2.1.5 Address priority health conditions
Substance abuse and Harmful use of Alcohol  Quality indicators for harm reduction services MoH PHA
 Ensure continued, quality, service provision for mental developed and monitored. HCA
health and substance abuse disorders.  Programme to address harmful use of alcohol revived.
 Institutionalise and consolidate essential services for  Aspects of harm reduction services mainstreamed into
substance abuse (prevention, treatment and after- PHC services.
care, as per the NDCMP).
 Expand services to address harmful use of alcohol.
 Integrate provision of substance abuse and mental
health services into the PHC.

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 Key Non-Communicable Diseases  Regular Monitoring and reporting on key priority PHA MoH
 Revitalise implementation of the NCD Strategy. diseases (HIV/AIDS, COVID-19, Cancer, Cardiovascular
 Support conduct of the next iteration of the Seychelles diseases, Viral Hepatitis, etc.).
Heart Study series, and use information to inform  Annual report on implementation of NCD Strategy.
review and update of the NCD Strategy 2016-2026.  End-term review of NCD Strategy conducted; new NCD
 Review implementation of new disease-specific Strategy developed.
initiatives (such as SEYPEN).  New Cancer Control Strategy developed.
 Report of the next Seychelles Heart Study survey results.
Key Communicable Diseases  End-term review of HIV/AIDS and Viral Hepatitis NAC
 Review the National Strategy for HIV/AIDS and Viral Strategy conducted. PHA
Hepatitis Strategy.  Updated policy and strategy on HIV/AIDS, Viral Hepatitis
 Update and implement the COVID-19 response plan. and STIs developed.
 Also refer to SD3 for COVID-19 response and priority  Integrated COVID-19 response plan developed. Annual
vector-borne and zoonotic diseases. reports produced.
2.2 Champion 2.2.1 Improve quality of health services
Quality Develop and implement a quality framework.  Quality Framework developed and operationalized. HCA MoH
Improvement (QI)  Regular clinical audits in all units and service areas
across the health conducted.
system  HCWs and public sensitized on QI initiatives.
Establish standards of care and quality indicators by  Standards of Care and Quality indicators defined and HCA MoH
service area. implemented. PHA
 Formal unit/service-area specific monthly CPD/CME
system in place.
Promote rational prescribing and antibiotic stewardship.  AWaRe classification of antibiotics, with monitoring HCA
through the implementation of GLASS framework used.
 Adherence to treatment protocol monitored regularly.
Define Care Pathways for key conditions/services.  Care pathways defined, disseminated and implemented. HCA
2.2.2 Improve efficiency and effectiveness of services at all levels (Subject to joint discussion with Department of Finance).

 Build capacity for monitoring efficiency in the health  Health economist recruited. MoH
system.  Cost-benefit assessments for key services and health HCA
 Improve technical and allocative efficiency in services. condition s conducted.
 Guidance for efficiency developed and used.
 Line managers and administrative staff aware of costs
and benefits of common health services.
 A formal system for monitoring cost-efficiency, as part
of wider M&E framework developed.
2.3.1 Explore social franchising with private health sector and health-related NGOs.

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 2.3 Improve  Utilise private health sector and/or health-related  Annual meetings with private sector conducted. HCA MoH
collaboration with NGOs to help deliver key preventive, promotive and  Social franchise developed. PHA
private health primary care services.
sector and health-  Build social franchise where appropriate.
related NGOs
2.4 Mitigate risks 2.4.1 Climate change mitigation and adaptation in health.
and mainstream  Improve awareness of climate impacts on health.  Vulnerability and adaptation assessment for the health MoH HCA
resilience across sector; Establish relevant CPD and training conducted PHA
the health system  Considerations of climate change mainstreamed in
plans for health facilities
 Mainstream climate mitigation and adaptation through  Develop a Health National Adaptation Plan aligned with MoH HCA
climate-informed health system strengthening. National Climate Change Policy. PHA

 Access global climate finance for supporting wider  Improved networking with Department of Climate MoH HCA
health system strengthening. Change to access climate funds for mitigation and PHA
adaptation projects.
2.4.2 Institutionalise COVID-19 services and build resilience
 Institutionalise COVID-19 care and other related  Finalise and implement the Continuity of Essential HCA
considerations throughout the health system. Health Services (CEHS) plan. PHA
 Define essential health services; ensure their  Emergency Operations Plan and SOPs.
continuity.  Define key Indicators for prevention, preparedness, etc.
for health emergencies.
 Continue relevant up/cross-skilling of staff in basic
COVID-19 response related functions across health
system.
 Clear guidelines for care of long-COVID/post-COVID
syndrome.
 Ensure continued, dedicated isolation and treatment  Rational utilization of tier 2 and tier 3 COVID-19 care HCA
capacity. capacities.
 Full implementation of COVID-19 care pathway and
clinical management guidelines.

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SD3 Address Health Security
Global health security is defined as the proactive and reactive activities required to minimise the danger
and impact of acute public health events that endanger people’s health across geographical regions and
international boundaries.

Population growth, rapid urbanization, environmental degradation, and the misuse of antimicrobials are
disrupting the equilibrium of the microbial world. New diseases, like COVID-19, are emerging at
unprecedented rates, disrupting people’s health and causing negative social and economic impacts.
Billions of passengers travel on airplanes each year, increasing the opportunities for the rapid
international spread of infectious agents and their vectors.

The use of chemicals in agriculture and industry has increased, as has an awareness of the potential
hazards for health and the environment. Air quality may decline with increasing urbanisation and the
increasing use of fossil fuels. As the globalisation of food production increases, so does the risk of
tainted ingredients and foodborne diseases. With the world’s population becoming more mobile and
increasing economic interdependence, these global health threats increase. Traditional defences at
national borders cannot protect against the invasion of a disease or vector. Pandemics, health
emergencies, and weak health systems.

Climate change effects, including sea-level rise, coastal erosion, extreme weather events and flooding,
hold immediate and long-term threats to health. Effects on the marine eco-systems will adversely
impact food availability and quality and elevate the risk of toxicity.

SD3 Outstanding Issues

One-Health Approach

The One Health approach50, which promotes multi-stakeholder collaboration to achieve better public
health outcomes, is yet to be well understood and appreciated by the different sectors. One key aspect
of One Health is the collaborative, multi-sectoral, and transdisciplinary approach working at the local,
regional, national, and global levels, to achieve optimal health outcomes recognizing the
interconnection between people, animals, plants, and their shared environment. It aims at designing
and implementing programmes, policies, legislation and research in which multiple sectors
communicate and work towards the prevention of illnesses and disease outbreaks in people. There is an
urgent need to build strong partnerships with non-health sectors to prevent effectively detect, prevent
and respond to zoonosis and food safety problems.

50
WHO. https://www.who.int/news-room/questions-and-answers/item/one-health

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A Joint External Evaluation conducted in 2018 systematically evaluated the strengths and weaknesses of
the different sectors and derived a plan of action for implementation by all the relevant sectors. The
National Action Plan for Health Security will guide the process to strengthen this multi-sectoral
collaboration.

Integrated Disease Surveillance and Response (IDSR) and IHR capacity

Seychelles has validated the adapted 3rd Edition IDSR Technical Guidelines since August 2019. Rollout of
the guidelines, including training, was planned for 2020, but has been delayed because of the COVID
pandemic. These revised guidelines is will support the implementation of a robust disease surveillance
system for early detection of outbreaks and swift response.

Non-Communicable Diseases

NCDs cause considerable morbidity and are the leading causes of death. The country is implementing
the National Strategy 2020- 2025 that was developed in line with global recommendations. While there
has been a decrease in the prevalence of smoking over recent years, there are increases in obesity, and
diabetes; in particular, rising obesity among children is alarming.

A more coordinated and integrated national approach and actions is vital for efficient and effective A
more coordinated and integrated national approach is vital for efficient and effective intervention
surveillance, prevention, detection, screening, treatment and control of NCDs and palliative care. These
are key components of the response to NCDs to meet national and global targets to reduce the burden
of NCDs.

Communicable Diseases

Seychelles detected its first case of COVID-19 in March 2020 and moved quickly to implement required
public health measures and health system response. The country experienced a surge in cases in April-
June 2021, with COVID-19, directly and indirectly, leading to excess mortality in 2021. COVID-19 has also
negatively affected all the building blocks of the health system and the national economy.

Other communicable diseases of importance for Seychelles are HIV/AIDS, Viral Hepatitis C, Dengue and
Leptospirosis. Like the rest of the world, the country conducts surveillance for newly emerging or re-
emerging diseases that threaten health security.

The country is committed to achieving the global goal to end HIV/AIDS as a public health threat by 2030.
In the two years before the COVID-19 pandemic, HIV testing increased; however, more efforts are
needed to implement effective biomedical prevention interventions at scale and for better HIV
treatment and care outcomes.

Several factors contribute to the increase in dengue infections the country has recorded over the last
five years; they include high mosquito density, susceptibility to circulating serotypes, favourable air

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temperatures, precipitation, and humidity. Although no studies were done recently, these can be linked
to change in weather patterns due to climate change.

Vaccine-preventable, foodborne, zoonotic, healthcare-related and communicable diseases pose

significant threats to human health and may sometimes threaten international health security.
Socioeconomic, environmental and behavioural factors, as well as international travel and migration,
foster and increase the spread of communicable diseases.

Health Regulatory Structure

The private health sector is expanding rapidly, and the number of private healthcare facilities has
increased over the years, including pharmacies, health clinics, and diagnostic laboratories. There is a
need for strong regulatory instruments and monitoring to ensure that all private health facilities adhere
to norms, regulations and good practices. Currently, required legal instruments are either lacking or
outdated and cannot respond to the continued development and expansion of the private health sector.
Presently the Seychelles Licensing Authority licenses these activities and the concern is that once a
license is issued, there is no follow up and ensure compliance. The PHA has been given the task of
developing the necessary legislation, tools and processes for regulating the private health sector.

SD3 Priority Areas

1. Strengthen the One Health approach.

2. Implement the IHR to prevent and swiftly detect outbreaks.
3. Implement IDSR.
4. Develop and strengthen regulatory function of the PHA.
5. Improve public health standards and legislative documents.
6. Strengthen public health law enforcement.
7. Strengthen public health programmes.

SD3 General Objective

To promote and protect health security, through the:

 Strengthening and implementation, in collaboration with national and international partners,

the One Health Approach, in line with the IHR and IDSR.
 Development and implementation of legal instruments and national standards in accordance
with the provisions of the Public Health Authority Act 2013.
 Strengthening of public health programmes.

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SD3 Specific Objectives
Table 13 SD3 Address Health Security: Specific Objectives
SD 3: Address Health Security
Lead Contributing
Specific objectives Key Interventions Milestones
Entity Entity
3.1 Strengthen the Establish coordination mechanism for  National One Health Coordination Committee established. PHA
One Health One Health approach.  Clear TOR developed.
approach  Formalized processes in place to guide communication between animal
health and human health sectors.
Implement and monitor National Action  A final and workable National Action Plan for Health Security NAPHS PHA
Plan for Public Security (NAPHS). validated and operationalized.
 Performance indicators and targets defined
 Annual Progress reports from PHA and other sectors involved.
3.2 Implement the Establish a functional team for the  A functional team established. PHA
IHR to prevent, and coordination and integration of relevant  TOR developed.
swiftly detect and sectors in the implementation of IHR.
manage disease Build, strengthen and maintain the IHR  Staff including sectoral focal persons adequately trained. PHA
outbreaks workforce capacity.  Public health workforce strategy developed.
 Local training capacity on field epidemiology developed.
Establish mechanisms for detecting and Mechanisms established and implemented. PHA
responding to public health threats and
events or emergencies.
Map priority public health risks and Mapping completed and disseminated. PHA MoH
resources.
Monitor implementation of IHR.  Indicator and targets defined. PHA
 State Party Annual Report (SPAR) submitted.
3.3 Implement IDSR Strengthen disease surveillance and  Revised IDSR guidelines widely disseminated PHA
response.  SOPs for implementing surveillance developed.
 IDSR training rolled out to human and animal health staff.
Develop regulations to strengthen  Regulations developed and implemented PHA
reporting from private facilities.  Real-time reporting from all reporting sites.
Improve analytical capacity to maximize  Analysis modules in web-based surveillance system. PHA
the use of surveillance data.  Selected staff trained in biostatistics.
 Ongoing operational research.

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 3.4 Strengthen Strengthen human resource capacity for All units adequately staffed. PHA
regulatory regulatory functions.
functions of the Finalize regulations for registration of  Regulations approved and implemented. PHA
PHA health and health-related facilities.  New facilities registered under new regulations.
 Deadlines and guidelines for existing facilities to comply with new
regulations.
Define roles, responsibilities, M&E Roles, responsibility and M&E defined. PHA
requirements for regulatory services.
3.5 Improve Public Revise and update existing and required  Directory of outdated or substandard legal instruments developed. PHA MoH
health standards public health laws/regulations.  Legislative review calendar developed.
and legislative  New and revised legislative documents as per calendar.
documents Develop SOPs guidance documents. SOPs and guidance documents developed, disseminated and implemented. PHA
Develop national standards to ground National standards developed and endorsed. PHA
preventive public health.
Monitor adherence to standards and take  Standard monitoring tools developed. PHA
corrective action where needed.  Ongoing monitoring.
 Annual compliance report published.
3.6 Develop and Strengthen programme management  Strong programme managers appointed PHA
Strengthen public capacity.  Clear job description and TOR developed
health programmes  Formal coordination and communication mechanism in place to facilitate
and encourage collaboration between programmes
Develop and revise relevant disease  National Cancer Strategic Plan endorsed. PHA MoH
specific strategic plans and policies.  Mental Health Policy finalised.
 Conduct mid-term review of NCD Strategy.

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SD4 Promote Healthy Populations
The WHO defines health as “the state of complete physical, mental and social wellbeing, and not merely
the absence of disease and infirmity”. The right to health is fundamental for every human being and
enshrined in Article 29 in the constitution of Seychelles51.

The conditions in which people are born, grow, live, work and age are known as the social determinants
of health (SDHs) and include factors like socioeconomic stability, education, neighbourhood and physical
environment, employment, and social support networks, as well as access to health care (Figure 18).

Figure 18 Social (Environmental and Economic) Determinants of Health (SDH).

Source: Social Determinants of Health, based on Dahlgren and Whitehead (1991).

These SDHs, in-turn, influence various risk factors and behaviours, which subsequently lead to ill health
and disease Figure 19.

51
Constitution of the Republic of Seychelles, 1994.

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Figure 19 Causal pathways linking poor SDHs with risk factors and later disease.

Social Risk Factors & Disease

Determinants of Behaviours
• Cancer
Health • Alchohol • Diabetes
• Poverty • Smoking • Heart Disease
• Unemployment • Poor diet • Infections

Addressing social determinants of health is not only important for improving overall health, but also for
reducing health disparities that are driven by social and economic disadvantages. Higher income and
social status are usually linked to better health. The greater the gap between the rich and the poor in
society, the greater the differences between their health52. In regards to education, low education levels
are linked with poor health, more stress and lower self-confidence.

Additionally, the MPI report of 2019, published by the NBS, showed that factors such as large
household/ overcrowding, substance abuse, unemployment, and low education level, strongly
contributed to multidimensional poverty, thereby also impacting the health status of individuals.

A healthy, productive population forms the pillar of the country’s sustained growth and prosperity. The
health and wellbeing of the people of Seychelles continuously faces major threats. The double, and
increasing, burden of infections (like HIV, Viral Hepatitis, and pneumonia), as well as chronic non-
communicable diseases (like diabetes, hypertension, cancer, and cardiovascular disease), combined with
social and mental health problems (like injection drug use, psychological disorders), are creating an
unprecedented challenge to maintain and improve health, as well as to maintain sustainability of
livelihoods and economic growth.

52
Marmot, Michael, and Ruth Bell. "Fair society, healthy lives." Public health 126 (2012): S4-S10.

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Harmful use of alcohol is one of the four modifiable and preventable risk factors for NCDs. Excessive
alcohol consumption has been associated with negative social impacts such as interpersonal violence,
unemployment, poor academic performance, and in addition, child and elderly neglect. These collective
factors have devastating impact on individuals and their families further affecting overall health.

Strong political leadership is essential to address social determinants of health. Promoting healthier
population requires improving the physical and mental health and wellbeing of the population. This can
be extremely challenging as it requires intensive, coordinated long term efforts, across many
government departments and sectors.

The HiAP is an approach that promotes collaboration between government sectors and non-government
stakeholders to maximize the health benefits of government policies and reduce health inequalities,
such as differences in life expectancy between different population groups. The approach also aims at
minimizing any harmful consequences of public policies on determinants of health and health system.
The Government of Seychelles has pledged to the HiAP approach in 2017 and committed to engage all
sectors of the government and non-governmental organizations through leadership, partnership, and
advocacy to achieve improved health outcomes.

Climate change is an insidious but very real threat to health and the wider society. Its impacts on health
can be direct (through extreme weather events and related injuries and deaths), indirect (through
changes to quality of air, water and nutrition) or through disruption of social and economic activity
(which lead to adverse health outcomes). Figure 20 describes the mechanisms that drive climate change,
and lead on to population exposures that result in ill health.

Evidence for the extreme health consequences of climate change are already evident – increased rates
of cardiovascular disease, kidney disease, diabetes, malnutrition, etc. The poorest countries, countries in
hotter climates, and coastal and small-island states will be impacted the hardest from these changes.

Even though Seychelles is only a minor contributor to climate change, we will bear the brunt of the
consequences of climate change, emphasising the importance of elaborate and timely evidence-based
mitigation and adaptation strategies, including in the health sector.

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Figure 20 Framework describing how climate change impacts global public health.

Source: Framework for climate change and global public health, Source: Tord Kjellstrom and Anthony J.McMicheal
(2013).

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SD4 Outstanding Issues

Health in All Policies Approach (HiAP)

Although the HiAP approach was endorsed by the Cabinet of ministers (from previous administration) in
2017, not a lot has been done since. There is a strong need for the endorsement of the current
administration and re-integration of the HiAP in all government sectors, private entities, and civil
societies. MoH needs to build linkages with other government entities and ensure that there are health
considerations in their policies and projects.

Communication strategy (for addressing risks to health)

A coordinated advocacy and communication plan to guide the ongoing efforts at reaching out to
communities and households is not yet in place. Communication strategies are needed to address
behavioural, environmental, and metabolic risk factors.

Health Promotion

Some of the NHSP 2016-2020 objectives and expected outcomes were not achieved, like behaviour
change communication advocacy. There is also weak national coordination system for health promotion
activities. Inadequate access to finance makes it difficult to plan impactful interventions.

Cancer and mental health

Outstanding needs include the development and implementation of a National Cancer Control Plan, and
finalisation and implementation of the National Mental Health Policy, with participation of other
sectors, as well as the community.

Nutrition

 Create a supportive environment for breastfeeding in workplaces, and fully implement code of
marketing of breast-milk substitutes, to protect and promote breastfeeding.
 Develop and implement policies that protect children from the harmful effects of marketing of
unhealthy products on media.
 Integrate regulatory reforms to improve food environments.
 Develop appropriate policies to facilitate introducing nutrition and environmental standards for
public institutions.
 Build capacity of health and community workers as food system agents of change everywhere
when developing and implementing solutions.
 Conduct operational research to assess barriers to behaviour change.
 Fully implement strategies outlined in the National NCD Strategy (2016-25).
 Enforce policies and regulations for quality of foods and drinks that are sold in commercial
outlets.

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  Finalize and implement school nutrition policy, policy for nitrites and trans-fatty acid.

Health in Educational settings

 Build capacity of those working in School Health Programme.

 Child and Adolescent Health areas deficient in life-course approach to health promotion.
 Ensure health policies cover educational institutions at all levels (pre-primary, primary,
secondary and post-secondary).
 Need for strict bans on fast-food outlets in proximity of schools, need to finalize and implement
school health policy.

SD4 Priority Areas

1. Promote healthy living for different age groups.

2. Address key risk factors for health.
3. Revitalize the health in all policies approach.
4. Promote prevention and management of substance abuse and mental health.
5. Transform Health Promotion.
6. Promote/ advocate for Effective Public Health.

SD4 General Objective

Support the creation of a conducive environment to:

 Support healthy living.

 Reduce and control risk factors for health.
 Promote safe and healthy neighbourhoods.
 Engage MDAs and other stakeholders to promote and improve health and wellbeing of people.

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SD4 Specific Objectives
Table 14 SD4 Promote Healthy Populations: Specific Objectives
SD 4: Promote Healthy Populations
Specific Lead Contributing
Key Interventions Milestones
Objectives Entity Entity
4.1 Promote Develop and implement new evidence-based approaches for promoting healthy living.
healthy living for
Introduce monthly healthy living/ well-being clinic. Healthy living/ well-being clinic introduced. HCA MoH
all age groups
PHA
Adopt a gradient approach across the life course to cater for the Gradient approach adopted. HCA MoH
needs of different age groups and socioeconomic groups in the PHA
population.
Integrate healthy living approach in all health programmes Healthy living approach developed. HCA
Develop healthy living approach for specific health program. PHA
4.2 Address risk Address risk factors for NCDs and communicable diseases.
factors for health Integrate WHO best- buys for NCDs into relevant health WHO best buys for NCDs integrated PHA MoH
programmes.
Strengthen implementation of NCD strategy to address key risk Existing NCD strategy implemented PHA
factors. HCA
 Develop and implement NCD campaign: ‘Know your numbers’. NCD Campaign developed and implemented. MoH
 Launch a ‘know your status’ campaign for addressing HCA
communicable diseases in the community. PHA

 Declare obesity as a public health emergency and introduce  Childhood obesity is declared as a public health PHA
population-based and multi-level approaches to gain emergency. MoH
participation from multiple actors.  Combating obesity mainstreamed across life HCA
 Develop national framework to prevent and manage obesity course and disease-specific programmes.
jointly with other MDAs.  Multi-sector framework developed.
Develop and implement nutrition sensitive programmes and Nutrition sensitive programmes and approaches and PHA
approaches and nutrition specific programmes to address the nutrition specific interventions developed and
burdens of malnutrition. implemented
Promote physical activity in the population (clubs at school, Physical activity clubs set up. PHA MoH
workplaces, districts, etc.). HCA
Review and modernise sexual health education for youth, including New toolkit for sexual health education. PHA
education on avenues for accessing supports. HCA

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 Ensure strategic information is available for action.
Set up the Nutrition Information System (NIS) to improve nutrition NIS set up and functional. HCA MoH
data system and monitoring. PHA
Conduct population survey to understand NCD risk factors.  Population survey on NCDs conducted PHA MoH
(Seychelles Heart Study V, UPCCD).
 NCD survey findings used to revise/ strengthen
programmes and interventions.
Develop, support, and monitor the Global Nutrition Framework Seychelles’ GNF developed and implemented. MoH
(GNF) for Seychelles.
Empower people to develop life skills to better manage their health.
Teach practical life skills to enable people to better manage and Key life skills training conducted MoH
take control of their health PHA
Develop self-management tools for key chronic health conditions Self-management tools developed and in-use. MoH
PHA
Promote use of new technologies and devices to support healthy New devices to support healthy living promoted. HCA
living, e.g. Fitbit, physical activity trackers; and empower them to MoH
use new devices to self-monitor existing chronic medical conditions
and/or risk factors.
4.3 Revitalize the Revive, implement, and monitor the HiAP.
HiAP Introduce the HiAP to, and gain the endorsement of, new Cabinet Endorsement of the HiAP by Cabinet and the MoH
of ministers and members of the NA National Assembly
Expand role of Health Impact Assessments Expanded HIA tools and training developed and put PHA MoH
in use.
Monitor and report on HiAP HiAP annual report developed and disseminated. MoH

Institutionalize the Health of Our Nation campaign (HOON)

Revive and institutionalize HOON. HOON institutionalized. MoH HCA; PHA
Other Sectors
4.4 Promote Prevention of tobacco use, illicit drugs, and harmful use of alcohol.
good mental
Promote supportive environment in the communities to prevent Availability of family-based prevention programmes MoH PHA
health and
or reduce the use of illegal substances to address substance abuse.
prevent and
Promote use of harm reduction services Utilization of harm reduction services increased MoH PHA
manage
substance abuse  Develop and implement new campaign to address alcohol Campaign developed and implemented. MoH PHA
disorders abuse in the country.
 Develop campaigns to reduce tobacco use in the population.
Develop policies and regulations to control the use of alcohol  Policies and regulations developed and PHA
implemented. MoH
 Fully implement alcohol-control policy.

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 Improve access to, and awareness of, smoking cessation support More individuals accessing the smoking-cessation PHA
services. programme.
Address mental health issues in the community.
Promote good mental health (e.g. Practical interventions on coping Activities to promote good mental health PHA
with stress, bereavement, etc.) for different age groups. implemented. HCA
Introduce social prescribing. HCWs and clients sensitized on social prescribing; HCA
Social prescribing implemented.
Facilitate the development of support groups. Support groups set up. HCA
4.5 Transform Bring health closer to people.
Health Develop, disseminate, and implement new health promotion Health promotion policy developed and MoH PHA
Promotion policy. implemented. HCA
Equip people to better take care of their health
Develop and implement health literacy project  Increased health literacy in the population MoH PHA
 Health literacy project developed and HCA
implemented.
 Support community ‘champions’ to advocate for programmes Community ‘champions’ identified and supported MoH HCA
promoting health. PHA
 Provide capacity building for youths and adults to champion Other Sectors
and promote health programmes.
Strengthen Health Promotion frameworks, resources and supports
 Develop a sector Health Promotion Committee Health promotion committee set up and operational. MoH PHA
 Set up a health promotion committee to provide oversight and HCA
guidance on methods of dissemination of health promotion
messages.
 Strengthen capacity to leverage on legal, fiscal and other policy Relevant fiscal, legal and partner-supports available MoH
interventions to transform health promotion. and used. PHA
 Implement relevant international treaties to support health
promotive environment at domestic level.
4.6 Promote/ Advocate for safe and peaceful neighbourhoods
Advocate for
Promote safe food and water supply in the community Safe food and water supply achieved and monitored. PHA MoH
Effective Public
Health Promote safety at home, school, on the road, at work, leisure Safe community concept promoted
events etc.
Establish collaboration with civil societies on health related Quarterly meetings with civil societies involved in MoH
matters. health
Advocate for safe recreational areas in the community Safe recreational areas available in the
neighbourhoods MoH

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SD5 Invest for Results
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”53.

Figure 21 shows the intricate relationships between these critical inputs for the production of health
interventions. It is clear that it is extremely important to balance the mix of resources for maximum
health benefits54.

Figure 21 Health Finance inputs and pathways to production of Health interventions

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.

53
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
54
The World Health Report 2000: health systems: improving performance.

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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
health55. 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 abroad56. 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.

55
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
56
Health Workforce Situation in Seychelles: Insights from baseline National Health Workforce Accounts, MOH, 2021

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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 quality57. 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

1. Develop a national Human Resources Strategic Plan.

2. Empower professional councils to become more effective regulators.

57
Understanding National Health Workforce Accounts, WHO 2017

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 3. Make careers in health more attractive.
4. Enable HR to deliver on all core HR Functions.
5. Provide support and guidance for career planning.
6. Care for the carers.
7. 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 20183. 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
201758.

58
National Health Accounts (NHA), 2016-202017 Report

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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’59. 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 cost-
efficiency 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

1. Make PPBB work for the sector.

2. Address inefficiencies in health care management and delivery.
3. Improve revenue collection.
4. Ensure sustainability of health care financing.
5. Increase spending on preventive and promotive care.

59
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

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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

1. Make PPBB work for the sector.

2. Address inefficiencies in health care management and delivery.
3. Improve revenue collection.
4. Ensure sustainability of health care financing.
5. Increase spending on preventive and promotive care.

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.

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Priority Areas in Health Technologies

1. Strengthen procurement and stock management capacity

2. Digitalise Stock management
3. Engage Service providers in procurement processes
4. Improve service maintenance contracts
5. 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 201960) 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

1. Support for new health care delivery models – appointment systems, reminders, treatment
adherence support, health education, health promotion, self-management supports.
2. Provide health professionals with point of care access to information – guidelines, standards,
decision-making tools.
3. Facilitate data collection – routine reporting, surveys, monitoring.
4. Institutionalise eLearning and CPD.
5. Utilise Telemedicine to improve access to services, including in crises.

60
Seychelles in Figures, 2020 Edition, NBS, Seychelles

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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 cost-
benefit analyses of key services (including outsourced services), and redirecting funding to more cost-
effective 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.

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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.

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SD5 Specific Objectives
Table 15 SD5 Invest for Results: Specific Objectives
SD 5: Invest for Results
Specific Lead Contributing
Key Interventions Milestones
Objectives Entity Entity
5.1 Human 5.1.1 Make professional councils more relevant
Resources for Revise regulatory frameworks to give Professional Professional councils’ legislation revised and harmonised. Councils MoH
Health Councils the power and authority to deliver on all
functions of a professional regulatory body.

Develop partnerships with other Councils and Public MOUs signed and implemented. Councils MoH
Health Authority to allow sharing of resources and PHA
competencies.

Make CPD mandatory for relicensing. Clear CPD requirements in place and monitoring of CPD for Councils MoH
different cadres. HCA
5.1.2 Plan for the future HR needs
Develop National Human Resources for Health National Human Resources for Health Strategic Plan developed MoH HCA
Strategic Plan. and implemented.
5.1.3 Make HR planning, administration and management fit-for-purpose
Create an HR Structure that meets the needs of the Structure established, roles and responsibilities clearly defined HCA
sector.
Increase HR expertise.  Trained and competent HR managers recruited for all HR HCA
functions
 In-service training plan for HR personnel developed and
implemented
Develop policies and Standard operating procedures  Policies and SOPS developed and implemented HCA
for key HR administration functions.
Implement PMS Pillar of RBM.  Performance management system institutionalised MoH
HCA
PHA
5.1.4 Make Health careers attractive
Develop a career promotion plan.  Promotion plan developed and implemented. MoH HCA
 Promotional material developed. NIHSS PHA
 Planned promotional activities carried out.

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 Re-invent health clubs in schools.  Health clubs up and running in all secondary schools MoH HCA
 Health ambassadors identified in all secondary schools MoEdu PHA

5.1.5 Support and guide staff throughout their careers

Make recruitment clear, transparent, expeditious and  Recruitment policy developed and implemented MoH
ethical  Clear and transparent job descriptions available for all cadres HCA
and positions PHA

Comprehensive Induction Package for all new recruits  Entity and unit specific induction programme developed and MoH
implemented HCA
 All new recruits undergoing induction PHA

Provide mentorship and supportive supervision.  Cadre specific mentorship programmes developed and HCA MoH
implemented. PHA
 Framework for supportive supervision of all cadres developed
and implemented.
Make career progression fair and transparent.  In-service training policy developed and implemented. MoH
 Revised appraisal forms developed and implemented. HCA
 Salary enhancement and promotion guidelines widely PHA
disseminated.
 All health professionals have a clear five-year professional
progression plan.
Identify and develop future leaders Succession plans for leadership positions developed and MoH
implemented. HCA
PHA
Improve work ethics.  Employee handbook revised and widely disseminated. MoH
 MoH Vision and Mission Statement visible displayed in all HCA
facilities. PHA
 National ethics and professional standards developed.
5.1.6 Care for the Carers
Make health and safety a priority for HCWs  Role and responsibility of health and safety officer defined. HCA
 Health and safety focal persons identified in all units. PHA
 Tailored cadre and age-specific HCW screening programmes
developed.
Address mental wellbeing  Support groups and programmes for at-risk HCWs established MoH
and running HCA
 Structures for debriefing and counselling in place PHA
 Introduce social prescribing for HCW (yoga, meditation,
exercise, etc.)

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  Mechanism for identification and reporting of HCWs with
alcohol and drug problems in place
Equip HCW to provide peer support Peer counsellors identified and trained HCA
PHA
Explore non-monetary options for recognition of good Awards and other non-monetary recognition programme in MoH
work. place. HCA
PHA
5.1.7 Use data to inform HR decision making
Introduce Human Resources Information System. Functional Human resource information system in place. MoH HCA
PHA
Councils
Use evidence-based tools to guide data collection,  National Health Workforce Accounts (NHWA) MoH HCA
management and analysis. institutionalised. PHA
 Workload Indicators of Staffing Needs assessment conducted Councils
in health facilities.
Make HR data available (develop information  Annual HRH performance report produced and disseminated. MoH
products).  Cadre specific annual reports produced and disseminated.
 Annual NHWA reports produced and disseminated.
5.1.8 All HCWS are proficient in at least one of the three national languages
Establish a language proficiency framework for all Language proficiency standards for recruitment and existing staff MoH HCA
HCWs defined and implemented PHA
Councils
5.2 Health 5.2.1 Ensure sustainable financing for health
Financing
 Advocate for increased investment in health  Aim to have 15% of total government expenditure allocated MoH
to health. HCA
 6% of GDP allocated to health. PHA

5.2.2. Make health care spending more efficient

Spend more on prevention and primary care  Expenditure for primary care and preventive services MoH MFTIEP
increased. HCA
 Additional earmarked funding for improvement of PHC (1%
GDP re-directed).

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 5.2.3 Make PPBB work for the health sector
 Align PPBB programmes with service delivery  Revised/tailored PPBB programmes. MoH
system.  KPIs aligned to entity mandate and NHSP targets. HCA
 Review entity KPIs and align to core mandate and  Internal cost centres introduced and implemented. PHA
NHSP targets.
 (Re-)Introduce cost centres so managers are aware
of their unit budgets (pending discussion with
MFTIEP).

Improve capacity for budgeting and priority setting  Managers actively engaged in the budgeting process. MoH
(discuss with MFTIEP).  All managers have received basic training in PPBB.
5.2.4 Ensure efficient use of resources.
Institutionalise costing of health services  Institutionalisation of costing of health services. HCA
 Training of staff conducted. PHA
 Baseline costing completed.
Raise cost-benefit awareness amongst stakeholders  Costing information available for all services. HCA
 Managers/Unit heads are aware of their unit budget. MoH
 Mechanisms to prevent and monitor pilfering and diversion
of resources in place.

Ensure efficiency of outsourced services.  Guidelines for outsourcing services developed and HCA
implemented.
 Review and renegotiate outsourcing contracts.
 Monitoring mechanisms in place for all outsourced services.

Review and report on key expenditures (cost drivers  Key expenditures for review identified. PHA
e.g. spending on COVID-19 response, Overseas Rx,  Review and reporting cycle determined. HCA
Haemodialysis, Cancer care …).  Reports produced and disseminated.

Cost-benefit analysis done before the introduction of Cost-benefit analysis conducted. MoH
key new services. HCA
Implement interventions to reduce wastage. Interventions to reduce wastage in health implemented. HCA
Conduct a review of services to identify low-value Review conducted and appropriate measures taken. HCA PHA
care. MoH

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 5.2.5 Improve revenue collection
Determine who pays for what services.  Beneficiary Criteria for free services clearly defined HCA
 Fees for services or service packages established and
disseminated.
 Fees policy for specialised services for private patients
reviewed.
Make revenue collection easier  Cashless payment systems widely used in all facilities.
 Functioning revenue collection system, active 24x7, in place.

5.2.6 Consider alternative financing mechanisms

Explore the potential for the introduction of social Analysis of potential and scope of social insurance schemes MoH
insurance schemes. conducted Benefits pitfalls etc.
Develop Public-Private Partnerships for investment in Policy on public-private partnerships developed and MoH
health (discuss with MFTIEP). implemented.
Explore revenue generation through collaboration  Framework for the provision of ambulatory care services to MoH
with the private sector. tourism establishments as a mechanism for revenue
generation.
 Framework for the private health sector to access key MoH
infrastructure and services at cost.
5.3 Health 5.3.1 Create a legislative framework for the regulation of health technologies
Technologies
Finalise Medical Products and Pharmacy Operations Medical Products and Pharmacy Operations Bill enacted and HCA
Bill. implemented. PHA
5.3.2 Revise and strengthen procurement and supply chain management
Strengthen management capacity of central stores.  All core management positions filled with trained staff. HCA
Move to complete digitalisation of store functions.  Electronic store management system in place and fully- HCA
functional.
 Store personnel trained and competent to operate within the
digital environment.
Promote rational use of health products  Guidelines for rationale use of health products HCA
 Review use of disposable products (e.g. protective gowns,
drapes, OT towels).
 Shelf life and expiry dates of products closely monitored.

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 Implement structural and governance processes to  Effective measures in place to address diversion and wastage. HCA
stop diversion and wastage
Develop and monitor key performance indicators for  Key performance indicators developed. HCA
Central Store  Regular performance reports produced as per agreed
reporting cycle.
5.3.3 Ensure uninterrupted supply of essential health products at point-of-use
Develop an essential list of health technologies  Essential list of health products developed and implemented. HCA
commensurate with the health service package.  Facility specific health technology inventories developed.

Revise essential medicines list taking into account new  Essential Medicine List revised HCA
evidence-based treatment guidelines for priority  New Drugs for priority NCDs are readily available.
NCDs.
Introduce new health products. New health products introduced in line with the approved care HCA
package and clinical guidelines/protocols.
5.4 Health 5.4.1 Build for purpose
Infrastructure
Develop infrastructure Masterplan based on actual Infrastructure Masterplan developed. HCA Infrastructure
and anticipated needs (to be discussed). Agency
Develop and implement local accreditation standards  Accreditation standards developed and implemented. PHA
for health infrastructure.  Accreditation cycle anchored in legislation.

5.4.2 Make infrastructure resilient, safe and accessible for all

Conduct inventory of infrastructure and create a Real-time inventory of infrastructure available. HCA
facilities master-list.
Draw up an infrastructure and equipment  Maintenance plan developed and implemented HCA
maintenance plan.  Preventive maintenance conducted in line with maintenance
plan.

Assess infrastructure for fire, flooding, chemical,  Fire risk assessment of all health facilities conducted. HCA
radiological and biological risks.  All facilities have a fire evacuation plan in place.
 Regular fire drills conducted.
 Facility specific risk assessment conducted.

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 Ensure facilities are disabled friendly.  Establish minimum standards for disability access in health HCA
facilities.
 Wheelchair access available to all health facilities
 Facilitate access for visually impaired.

Address increased infrastructure needs for high-care  ICU bed capacities expanded to meet demand. HCA
and infectious-disease isolation.  Dedicated purpose-built Isolation Unit ready.
Mainstream climate resilience in all infrastructure Potential effects of climate change considered in all new service HCA
planning. and infrastructure planning.
5.5 Information 5.5.1 Create supportive IT environment
Technology
Ensure internet access.  All facilities have reliable around-the-clock internet access. HCA
 Review content restrictions. DICT

Invest in required hardware  Teleconferencing solutions available in health facilities. HCA

 All facilities have access to tablets, laptops and desktop DICT
computers.

Create the appropriate regulatory framework Appropriate legal and regulatory instruments developed and MoH
implemented
5.5.2 Use IT to improve health care

Support for new service delivery models  Systematic Appointment reminders generated. HCA
 IT solutions to support treatment adherence in use.
 Service users receive targeted health education and health
promotion.

Provide information and decision support to health  SOPs, guidelines, algorithms and other decision-making tools
professionals at the point of care readily available. HCA
Institutionalise telemedicine widely available  Telemedicine services defined.
 Teleconsultations offered per regular schedule. HCA

Facilitate learning and continuous professional  Regular virtual CPD sessions organised. HCA MoH
development  Online CPD Platform introduced. PHA

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SD6 Improve Data for Impact
Reliable and timely health information is an essential foundation of public health action and health
systems strengthening, both nationally and internationally61. The health sector needs real-time, reliable
and actionable data. According to WHO, one of the key lessons from the COVID-19 pandemic is that
countries need to invest in data and health information systems, as part of overall public health
capacity62. An integrated and collaborative approach to information governance enables health
organisations to effectively manage, maintain, and use data to improve health care quality and
performance within and across organisational boundaries.

SD6 Outstanding Issues

Health Data Governance

Data governance is a set of principles and practices that ensures high quality throughout the complete
lifecycle of data. In MoH, there are no formal standards and SOPs to guide data management along the
life cycle to safeguard the quality and privacy of health data. The roles and responsibilities of the
different data processing units are poorly defined, and there are no coordination mechanisms in place.
Measuring health is complex, and health care data is complex. There is a need to have governance
principles to maximise the value of health data and to improve outcomes.

Healthcare data governance is the discipline of managing data as a strategic asset. It paves the way for
data to support organisational priorities through the orchestration of people, processes, and technology.
Data governance helps organisational leaders improve clinical, operational, and financial outcomes by
focusing on enhanced decision-making. Importantly, data governance is an ongoing, enterprise-wide,
cross-functional effort to optimise data for the benefit of patients, staff, and the community.

Electronic Health Information System (eHIS)

Data capture is primarily paper-based, using a variety of often duplicating reporting tools. Transitioning
to an electronic health information system (eHIS) has been on MoH's agenda for over a decade. In 2020,
work started to implement an eHIS system; however, this has stalled. There is an urgent need to
complete the implementation and move from a paper-based system to an electronic one.

61
World Health Organization. Framework and standards for country health information systems / Health Metrics
Network, World Health Organization. – 2nd Ed.
62
World Health Statistics 2020: monitoring health for the SDGs, sustainable development goals. Geneva: World
Health Organization.

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Research

The NHSP 2016-2020 objectives and expected outcomes were not achieved. The research unit in MoH
remains very small; there is no policy to guide research and no specific budget allocated to research.

Data Use

Despite the availably of data, data are not always used at the point of collection, and it is often difficult
to understand how metrics are used to make decisions.

SD6 Priority Areas

1. Build one integrated Health Information System (HIS) for MOH.

2. Implement eHIS.
3. Improve data governance.
4. Invest in health data.
5. Strengthen research capacity and use research to improve practice.
6. Enable data use.

SD6 General Objectives

To build an integrated HIS, and strengthen efforts to collect, process, report and use health data.
Increase the availability, quality, value and use of timely and accurate strategic health information for
the following:

 Estimating disease burden

 Understanding health needs
 Allocating resources
 Developing and delivering services
 Improving patient care
 Identifying inequities
 Tracking progress towards national, regional and global commitments.

The health sector will also generate appropriate knowledge from research needed for evidence-based
decision-making and improving practice.

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SD6 Specific Objectives
Table 16 SD6 Improve Data for Impact: Specific Objectives
SD 6: Improve Data for Impact
Lead Contributing
Specific Objectives Key Interventions Required Milestones
Entity Entity
6.1 Set-up one integrated Develop a shared vision and agenda for health data in One integrated HIS set up for MoH and functioning. MoH HCA
HIS line with organizational priorities and set up PHA
governance structure for an integrated HIS
(Stop fragmentation of
data collection, processing Develop an integrated HIS strategic framework HIS strategic framework developed. MoH HCA
and use, and reduce (Resources, indicators, data sources, data PHA
reporting burden) management, information products, and use)63.

Implement one integrated HIS for MoH. MoH HCA

PHA
6.2 Improve Data Develop a data governance framework (Define roles Data governance framework developed. MoH HCA
Governance and responsibilities for data management throughout PHA
data life cycle).
(Principles, processes and
practices to ensure quality Develop standards and SOPs for managing data Standards and SOPs for data management developed, MoH HCA
management of data throughout its life cycle. disseminated and training conducted. PHA
across the data journey) Set up a data governance committee to lead Data governance committee set up and functioning. MoH HCA
development of policy, standards and SOPs and PHA
oversee implementation.
Develop and implement a data sharing policy. Data sharing policy developed and disseminated. MoH HCA
PHA
6.3 Invest in health data Ensure data processing units have the human Statisticians recruited including a bio-statistician. MoH
resources necessary. PHA
(Ensure adequate HR, hard HCA
and soft ware) Build capacity of Statistics Unit and programme Staff trained in data analysis. MoH
managers in data processing and analysis. PHA
HCA
Ensure data collection and processing units have All units fully equipped. MoH
adequate hardware. PHA; HCA

63
WHO. Framework and standards for country health information systems/Health Metrics Network, World Health Organization. – 2nd Ed.

87 | P a g e
 6.4 Improve health Develop and disseminate regular information Regular information bulletins developed and MoH
information products bulletins with data on vital statistics, disease disseminated (Statistics, Disease surveillance. PHA
surveillance, service utilization, programmes etc. HCA
(Transforming data into Develop and disseminate annual high-quality Annual Reports: MoH
information and evidence) statistical report with priority analyses.  Statistics report. PHA
 Disease surveillance report. HCA
 Cancer registry report.
 Programme report.
Develop dashboards and summary charts to convey Dashboards developed and maintained. MoH
health data and information. PHA
HCA
6.5 Improve quality of vital Develop briefs for new Civil Status Bill. Briefs developed. MoH PHA; HCA
statistics
Conduct sensitization meetings with maternity staff. Sensitization training conducted (Mahé, Praslin and La MoH PHA; HCA
Digue).
(Improve CRVS, ensure
everyone is counted) Conduct training to improve quality of cause of death Complete training for planned cohort of doctors. MoH PHA; HCA
reporting.
Conduct training to improve analysis of cause of Staff trained. MoH PHA; HCA
death data.
Monitor quality of cause of death reporting. Monthly review of quality of cause of death conducted HCA MoH
for Hospital and community.
6.6 Strengthen research Establish one research unit for the MoH to oversee MoH Research Unit set up with clear mandate, HR and MoH HCA
capacity and follow up on all research activities. processes. PHA
Develop a policy to guide research in MoH Policy developed MoH HCA
PHA
Identify priority areas for research Research agenda set MoH
PHA
HCA
Develop research culture in MoH by engaging young Young professions engaged in research. PHA MoH
professionals HCA
Strengthen Ethics Committee Ethics committee strengthened. PHA

Develop mechanisms to translate research findings Mechanisms developed. MoH HCA

into practice improvement PHA
Assign budget line to research activities. Research budget set annually. MoH
Set up a research advisory committee. Research advisory committee set up. MoH HCA; PHA;
Dissemination of report on activities and findings of Annual report on research. PHA
research.

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 6.7 Enable data use in Seek global TA to develop an integrated data Integrated data repository set-up. MoH HCA
decision making repository or portal with easy access PHA
Use data to produce high-quality policy briefs and Policy briefs and summaries developed and MoH
(Use data to create summaries with findings identifying key action disseminated PHA
solutions) needed to improve health sector performance

Develop mechanisms to connect data production with Information products shared with data contributors. MoH
its use. PHA
HCA
Develop culture of evidence-based decision -making Track use of data in key decisions in MoH. MoH
(policy, planning, budget, etc.). PHA
HCA
Disseminate health data to community and non-  Annual meeting with the community on key health MoH PHA
health stakeholders. data. HCA
 Meeting with NGOs working in health to present
relevant data.
6.8 Implement eHIS Conduct User Acceptance Testing (UAT). UAT conducted. HCA MoH
PHA
Conduct HMIS end-user sensitisation and training. Training conducted. Training report. HCA
eHIS fully implemented and functional.  Go LIVE - Phase I - roll out of the Client HCA MoH
Registration / Appointment module across all PHA
relevant units
 Go LIVE - Phase II - rolling out of the In-Patient
Department, Laboratory , Radiology , Billing,
Doctors Desk modules
 Go LIVE - Phase III - rolling out of the rest of the
modules including Procurement/Store module,
Biomedical module etc.

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 Chapter 5

Implementation Arrangements

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5 Implementation Arrangements
The NHSP 2022-2026 is a comprehensive document outlining the health sector’s overall direction for the
next five years. It renews the long-term vision of the health sector development and re-affirms the
Ministry’s commitment to meeting its vision. The plan outlines the strategic framework for further
strengthening operations in the entire health sector to address priorities and ensure consistent
strategies across programmes.

The NHSP 2022-2026 has six interlinked strategic directions derived from a thorough assessment of the
documented progress on the last strategic plan, of the country’s current health status and broad
technical input from various stakeholders. SD2 Protecting and improving UHC, SD3 Addressing Health
Security, and SD4 Promoting Healthy Populations encompass all the sector plans to achieve in the next
five years, while SD5 Invest for Results and SD6 Data for Impact, reflect the health system support to
strengthen to help achieve these objectives. Successful implementation of this strategic plan will require
strong leadership (SD1 Good Governance and Leadership), unity of purpose, ownership and
accountability of sector and entity-specific goals and targets.

5.1 Roles and Responsibilities

Full implementation of all four pillars of the Results-Based Management Framework will positively
impact the implementation, monitoring and evaluation of the NHSP 2022-2026, with a shift from
traditional public-sector management to results-oriented management.

The Seychelles National Strategic Planning Policy64 clearly defines the roles and responsibilities for the
decision-making and different actors in implementing national strategic plans, summarised in Table 17.

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Table 17 NHSP Roles and Responsibilities at senior levels of Government.
Position/Institution Roles and Responsibilities

The President Accountable for the establishment of national priorities and the overall
performance of the government in achieving the national vision and the
results set out in the National Development Strategy (NDS).

The Vice-President Responsible for delivering the President’s national strategic plan-related
roles and responsibilities, including presiding over the cabinet of Ministers
on national strategic plan (NSP) matters, during the absence of the
President. Also accountable for achieving the results set out in the NSP
instruments for the departments and agencies under his authority.

The Cabinet of Accountable collectively for reviewing, approving and ensuring the
Ministers alignment and synergy of national priorities and key NSP instruments,
monitoring their implementation and determining when corrective actions
are required.

The Ministers Accountable individually for achieving the results set out in the NSP
instruments for the MDAs under their respective authority.

Minister for Finance Responsible for effective coordination of the NSP system across government
and its integration with the other RBM pillars.

Principal Secretaries, Accountable for ensuring that policies are implemented effectively,
Heads of efficiently and transparently in their respective MDAs, working
Departments and collaboratively with all institutions across their portfolio and ensuring that
Agencies all staff under their authority contribute to the achievement of results set
out in relevant NSP instruments.

Source: Seychelles National Strategic Planning Policy

MoH recognises that while it has the responsibility of health care, the achievement of the broad health
objectives of the NHSP 2022-2026 will only be possible in partnership with non-health governmental and
non-governmental stakeholders. All sectors should recognise the vital role they play in achieving
national health goals.

A clear outline of the roles and responsibilities of non-health actors in the implementation of the health
sector agenda are given in Table 18.

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Table 18 Roles and Responsibilities of Non-Health Stakeholders.
Position/Institution Roles and Responsibilities

The National  Hold the health sector to account for use of public funds.
Assembly  Scrutinize the assurances, promises and undertakings given by the
Minister for Health on the floor of the Assembly.
 Support and promote the HiAP approach within the legislative branch of
government.

The Cabinet of  Responsible for monitoring the contributions of the health sector to the
Ministers attainment of national strategic goals.
 Advocate for the implementation of the HiAP approach towards public
policies across sectors taking into account the health implications of
decisions, seeking synergies, and avoiding harmful health impacts in
order to improve population’s health and health equity.

The Office of the  Develop laws and regulations that supports the implementation of the
Attorney General NHP and the NHSP.
 Integrate and articulate health considerations into the law-making
process to improve health outcomes.

Ministry of Finance, Apart from their mandates stipulated under Acts and their respective
Economic Planning portfolios, the MDAs should support the implementation of the HiAP to
and Trade positively influence the social determinants of health and support the health
sector to achieve its goals and objectives in line with national development
strategy.

Other MDAs Apart from their mandates stipulated under Acts and their respective
portfolios, the MDAs should support the implementation of the HiAP to
positively influence the social determinants of health and support the health
sector to achieve its goals and objectives in line with national development
strategy.

Parastatal  Provision of clean water and sanitation.

Organizations  Advocate and educate the public about adopting clean energy to
enhance health outcomes.

Business Sector Support through funding and participation in public-private partnerships

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 District Development  Responsible for supporting the national health agenda and ensuring that
Partners whenever appropriate, it is aligned with the global health agenda.
 Support community-based strategies to improve health outcomes in line
with the NHP and NHSP.

Households Seek adequate information and education, adopt health seeking behaviours
and the appropriate and timely use of health services in order to maintain
and improve health.

Individuals Personal accountability means taking ownership over your actions and the
outcomes of your actions. Individuals should take responsibility for their
health to improve their personal health and wellbeing.

The RBM framework prescribes the establishment of a portfolio RBM Committee to oversee
coordination and harmonization across all portfolio MDAs. At the agency or department level, the
internal RBM Committee, RBM Coordinator and focal point responsible for NSP will ensure that NSP
coordination and alignment with other RBM pillars occur65. An NHSP Oversight Committee with a clear
mandate and terms of reference will oversee the implementation of the health strategic plan.

MoH with its specific entities, and the private health sector, have the responsibility of implementing the
key interventions of NHSP 2022-2026, achieving results, and for monitoring and reporting on
performance (Table 19).

Table 19 MoH and Entities' Roles and Responsibilities in implementation of NHSP 2022-2026.
MoH and its Roles and Responsibilities
Entities

The Minister and  Support a results-driven work culture where accountability for results is
the MoH continually strengthened and monitored.
Secretariat  Lead and support change management processes to promote growth and
minimize resistance for the successful implementation of the NHSP.
 Accountable for achieving the results set out in the NHSP.
 Accountable to Cabinet and the National Assembly for the happenings in
the health sector.
 Set up a NHSP Oversight Committee to ensure successful implementation
and attainment of strategic goals and objectives of the NHSP (Mandate and
ToR).

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  Establish a sector RBM Committee to be chaired by Principal Secretary to
coordinate the NSP process within and across portfolio and ensure
coherence with other RBM pillars.
 Appoint an RBM Coordinator who will also act as Secretary to the Sector
RBM committee.
 Play its stewardship role towards the development of policies, laws and
regulations to guide the health sector.
 Provide and conduct sector monitoring and reporting where necessary in
line with the intended outcomes of the NHSP.
 Mobilise funds to ensure adequate financing of interventions in the NHSP.
 Institute and maintain linkages with all stakeholders involved in the health
sector.
 Ensure and monitor equity in access to health care services
 Drive dialogues to keep health on the national agenda
 Support effective implementation of the HiAP through collaborative policy
platforms with other MDAs
 Ensure entities develop 2-year costed operational plans to implement
interventions set out in the NHSP
 Guide the non-state health actors so that they contribute and work
positively towards the vision and goals of the NHSP.
 Collaborate with institutions that deliver institutional learning and training
programmes, such as the Guy Morel Institute, to address capacity deficiency
 Implement special programmes.

Public Health  Pursuant to the Public Health Authority Act, PHA will regulate, monitor and
Authority evaluate all health-related services and ensure that they adhere to good
practices in the interest of the public.
 Implement SD3 interventions and all other interventions under the
responsibility of PHA; and support the implementation of other relevant
SDs.
 Develop and implement 2-year costed Operational Plan in line with
interventions/objectives of strategic direction set out in the NHSP.
 Conduct sector monitoring in line with mandate of PHA.
 Promote and implement the HiAP; expanded HIAs.
 Report on entity performance on an annual basis.

Health Care  Pursuant to the Health Care Agency Act, HCA will promote, protect and
Agency restore the health of the public by acting appropriately to prevent, treat and
control illness and prevent disability and death resulting from illness or
other causes.

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  Implement interventions under SD2 and all other relevant interventions
under the HCA mandate.
 Develop and implement 2-year costed Operational Plan in line with
interventions/objectives of strategic direction set out in the NHSP.
 Ensure that the prescribed requirements and standards for the provision
and delivery of health care services are met.
 Ensure continuous development of staff to deliver on strategic directions
set out in the NHSP and maintain high professional standards.
 Report on entity performance on an annual basis.

National Institute  Develop and implement NIHSS Strategy.

for Health and  Contribute to health and social workforce production (in and pre- service) as
Social Studies per NHSP objectives and targets.
 Support development of NHWA.
 Develop annual performance report.

Boards (NIHSS,  The Board members should be well versed with, and guided by, the NHP
PHA and HCA) (2015) and the NHSP (2022-2026).
 Ensure that entities have appropriate structures in place to support
implementation of the NHSP.
 Manage entities to achieve goals and objectives set out in the NHSP.
 Monitor performance of entity.

Division for the  Develop and implement 2-year costed Operational Plan in line with
Prevention of Drug interventions/objectives of strategic direction set out in the Drug Master
Abuse and Plan and NHSP.
Rehabilitation  Report on performance on an annual basis.

Professional  Mobilise and engage health professionals.

Councils (SMDC,  Set and monitor mandatory requirements for the continuing professional
SNMC, HPC) development of all registered practitioners.
 Set and maintain standards of training and practice for healthcare
professionals, and discipline those who fall short of those standards.
 Should be well versed with the content of the NHP and NHSP.
 Set professional and ethical standards in line with principles and values of
the NHP and NHSP.

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 Non-State Health NGOs (e.g. ASFF, Soroptimist, Round Table, Lion’s Club, Rotary Club)
Service Delivery
Actors (Private  Support and advocate for the implementation of health programmes,
sector, PNFPs, through adequate funding and awareness, in line with the NHSP.
NGOs, TCMP)  Understand the strategic directions of MoH and advocate towards that
vision.

Private Health Sector

 Provide health services to compliment services provided by government

institutions and increase consumer options for health services.
 Contribute towards the achievement of health goals and objectives of NHSP.
 Should be guided by the NHP other health policies.
 Report notifiable diseases and other health statistics as required.
 Maintain high professional standards.

Patient Support Associations (e.g. Seychelles Patient Association, Cancer

Concern, HASO, Pearl Autism, Diabetic Society)

 Advocate for the rights of patients and support implementation of health

programmes in specific areas of concerns.
 Promote and advocate for the implementation of the HiAP approach.
 Understand and contribute positively towards the successful outcome of
the NHSP.

The NHSP assigns each broad strategic direction to a lead entity, primarily responsible for the targets
under that pillar (Table 20). This, however, does not absolve the other entities of their collective
responsibility for the objectives listed under each pillar. For ownership of specific objectives, kindly refer
to section 4 Strategic Agenda for 2022-2026.

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Table 20 Lead Responsibility for Implementation of Strategic Directions of NHSP 2022-2026.
Strategic Direction Lead Entity(-ies)

SD1 Strengthen leadership, governance and administration MoH

SD2 Protect and improve UHC HCA

SD3 Address health security PHA

SD4 Promote healthy populations MoH

SD5 Invest for results MoH/HCA

SD6 Improve data for impact All Entities

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5.2 Implementation Risks and Assumptions
Successful implementation of the NHSP is anchored on the assumption that the necessary inputs and
conditions will be available, however, several risks can have a negative impact on the achievement of
defined goals.

Assumptions
 Strong leadership and governance.
 Accountability at all levels.
 Ownership of the goals and targets by all entities and health workers.
 Strong coordination mechanisms within and across entities.
 Oversight and steward role of MoH strengthened.
 Concrete actions to work more upstream (increased resources for prevention and
innovation).
 Leaders monitor performance and take remedial actions when and where needed.
 RBM functions fully implemented at sector and entity level.
 Institutional capacity available.
 Health in all policy becomes a reality with sectors mainstreaming health in their policies and
strategic plans.
 Strong community engagement with population invested in being an active partner protecting
health.

Risk and Mitigation strategies

The current NHSP has been developed during a pandemic; the direct health impact of the COVID-19
pandemic and the economic difficulties resulting from the pandemic pose several known and some
unforeseen risks for successful implementation of the NHSP 2022-2026. Identifying factors that may
negatively impact the achievement of health sector goals is a crucial element of the NHSP. Understand
these risks will permit steps to be taken to reduce their impact. Close monitoring will enable initiation of
timely corrective measures.

MoH has identified the following risks to the successful implementation of the NHSP:

COVID 19 Pandemic

The development of COVID-19 vaccines and roll-out of vaccination on a global scale was expected to
bring the COVID-19 situation under control. However, waning immunity from COVID-19 vaccines,
vaccine inequalities, vaccine scepticism and the emergence of new variants have raised concerns about
the future trajectory of the pandemic. A protracted health emergency will put pressure on the health
system and divert resources from other priority areas outlined in this strategic plan. Maintaining the

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current parallel governance structure for COVID-19 is not sustainable as it diverts the focus of senior
management from other core health system functions.

Leadership and Governance

The current organisational structure with fragmentation, unclear lines of accountability and lack of
formal coordination will negatively affect outcomes.

Human Resources for Health

HCWs have been under considerable pressure due to staff redeployment, absenteeism due to isolation
or quarantine and leave restrictions since the beginning of the pandemic. This is likely to continue during
a protracted epidemic resulting in burnout and other mental and physical health consequences,
impacting the COVID-19 response and other priority areas.

Health financing

The health budget is unlikely to increase substantially in the next few years. Shifting the focus from
curative-centric to prevention will necessarily take funds away from curative care. Additionally, the
unpredictable nature of the COVID pandemic may divert additional funds away from interventions
proposed in this strategic plan.

Health technologies

Despite promising signs of recovery, the Seychelles economy remains fragile and vulnerable to external
shocks, including the effects of a protracted COVID-19 epidemic. This will have repercussions on the
procurement of medicines and other health technologies.

Continuity of Essential Care

Cessation or downscaling low value interventions and services and catering for identified unmet needs
may threaten continuity of care. Diversion of resources and focus towards the COVID-19 will
compromise other areas of care and potentially erode health gains, e.g. decrease in life expectancy,
worsening of health status. Furthermore, the impact of COVID-19 on society, including social
determinants of health, cannot be ignored.

MoH organisational architecture

The situational analysis has clearly outlined certain deficiencies of the current health organisational
structure - fragmentation, inadequate coordination and effective communication, within and across
entities. Therefore, it is imperative that MoH revisits the organisational structure and implement
measures, including changing mind-sets to address the identified deficiencies.

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Budget allocation for health not commensurate with health needs

While there are signs of economic recovery, the economy remains fragile and vulnerable, especially in
the uncertain COVID situation. With funding diverted to the pandemic response, adequate funding for
continuity of care may be at risk.

Prioritising curative over preventive care

Health expenditure is heavily skewed towards curative care. Demands for new technologies and very
costly specialised care services continue to increase, often fuelled by media hype and to garner political
support. Investment in preventive care has sustained returns and delivers substantial health benefits.

Full implementation of the eHIS

The eHIS is a long-awaited investment in the health system. Partial implementation with a persisting
parallel paper-based information system will increase workload on staff, hamper efforts to streamline
data management processes, and significantly reduce the expected benefits of the eHIS (collaborative
care, cost savings, availability of real-time data).

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Some of the anticipated risks and mitigation strategies are outlined in Table 21.

Table 21 Anticipated Risks and proposed Mitigation Strategies

Risk Overview Mitigation Strategies

 Decrease transmission of
COVID-19 becomes a  MoH leadership continues with
COVID-19.
protracted public emergency governance structure.
 Increase vaccination
health emergency  MoH leadership shifts focus away from
coverage.
NCDs and old challenges/gaps to
 Improve COVID-19 case
COVID-19 response.
management.
 All building blocks of HS negatively
 Define package of essential
affected.
services and metrics.
 Redeployment of human resources
 Develop plan for
with continuity of essential services
continuation of services in
compromised.
case of emergencies.
 YLL due to COVID-19 lead to decrease
 Designate a lead person to
in life expectancy.
implement, monitor and
 Poor health outcomes for non –COVID-
report on continuation of
19 conditions (Increased morbidity and
essential services in
mortality).
emergencies.

 Revise organizational
MoH organizational  Current MoH architecture is
structure to ensure fitness
architecture remains maintained with continued
for purpose.
unchanged fragmentation and lack of coordination
 Define, implement and
leading to poor results.
monitor coordination within
and between entities.

Poor buy-in Leaders and Health workers to do work Engage and involve health care
together to enact change. workers in problem solving and
decision-making.

 Advocate for increased

Budget allocation for  Significant fraction of budget already
spending on health, as it is
health not spent on COVID-19 services can lead to
an asset and foundation of
commensurate with a decrease in health funding for core
development.
health needs health system operations and new
 Ensure efficient use of
initiatives.
resources in health.
 Rapid forecast of 5 yr. prevalence of
 Mobilize funds for health
key risk factors indicate increased
from partners.
health needs.

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 Spending on Majority of spending on curative, and Advocate for discrete budget
prevention not specialist treatment. lines for prevention
increased interventions.

eHIS not fully  Reliable, real-time data not available HCA to develop work plan and
implemented for decisions-making. monitor implementation and
 Continued difficulty to provide full use of eHIS.
seamless care.

 Implement and monitor

Lack of Commitment  Increase in risks factors for health
HiAP across all sectors.
for HiAP (harmful use of alcohol, drug abuse,
 Monitor equity in all
tobacco use, lack of exercise, poor diet,
programmes.
increasing unemployment and poverty,
 Ensure that metrics capture
reduced social supports, etc.).
those ‘left behind’ and
 Poor treatment outcomes.
develop targeted strategies.

 Create posts for necessary

Lack of capacity  Lack of capacity in specialised clinical
specialised fields.
and non-clinical posts required to
 Recruit key expertise needed
implement objectives of the NHSP.
for successful
implementation of NHSP
(e.g. epidemiologist, human
resource expert, supply
chain expert, etc.)

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 Chapter 6

Monitoring and Evaluation

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6 Monitoring and Evaluation
6.1 Monitoring Achievement of Goals and Targets
The government is pursuing the 2013 Results-Based Management (RBM) strategy as the organizing
principle behind public sector reform. RBM comprises four pillars: Strategic Planning (SP); Program
Performance Based Budgeting (PPBB); Performance Management System (PMS); and Performance
Monitoring and Evaluation (PM&E).

PM&E has the following benefits:

 It increases public sector efficiency, thus creating greater fiscal savings through greater value for
money, such as reduced human and financial resources and quicker delivery of programs and
projects; including faster project completion;
 It enhances public sector effectiveness, including the use of innovative ways and alternative
ways of service-delivery, structures, tools and processes, thus enhancing both access to and the
quality of service-delivery contributing to greater equity;
 It strengthens transparency, thus making information more accessible and making government
more open; and
 It strengthens accountability, thus ensuring that government delivers on its mandate to
implement service-delivery as planned, by the responsible staff, within the existing budget and
timeframes.

The MoH and its entities have the task of monitoring the implementation of sector strategic plans,
policies, programmes. There are no formal PM&E Units within the health sector, however, MoH reports
on progress towards achievement of core health indicators annually through the annual sector
performance report. In the next five years, it is hoped that MoH will develop and implement an M&E
framework, and that formal PM&E units will be set up, with support of other relevant ministries, with
the responsibility of advancing RBM.

Among very important milestones for this NHSP is the establishment of strong sector health information
system, data governance and the full implementation and use of eHIS. The implementation of eHIS,
combined with the support of the Department of Economic Planning, will enable the health sector to
successfully fulfil its PM&E obligations.

A conceptual framework for monitoring and evaluation is depicted in Figure 22. A set of core indicators
to monitor progress along the results chain has been developed for this NHSP and in summarised in
section 6.5 Indicators.

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Figure 22 Monitoring and Evaluation Conceptual Framework

Source: World Health Organization. Monitoring the building blocks of health systems: a handbook of indicators and
their measurement strategies. Geneva; WHO, 2010.

6.2 Data Needs

The sector requires the joint action of public and private facilities to produce quality, timely data for
evidenced –based decision-making. For M&E, core data is needed for the following:

 To understand the social determinants of health.

 To monitor health status:
 Vital statistics.
 Disease surveillance and response.
 Disease and mortality trends.
 To monitor the six building blocks of the health system
 PM&E - to monitor progress towards implementation of national commitments:
 NDS.

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  PPBB key performance indicators.
 NHSP goals and targets.
 Disease –specific goals and targets.
 To report on global commitments (e.g. SDGs).
 For accountability and transparency.

6.3 Data Sources

The MoH uses a number of data sources to inform decision-making and report on local and global
commitments (Table 22).

Table 22 Data Sources

Data Source Data type

National Bureau of Statistics  Population census

 Population bulletins
 Household Budget Surveys

Civil Status Office Vital Statistics

Health Facilities/services  Service availability

(Public/Private)  Service utilization
 Disease notification

Programmes Service coverage

Individual user records Data on diseases and risk factors

Population surveys; User Prevalence of disease, risk factors, service

experience/satisfaction etc. utilization/equity gaps

NHA, NHFWA Data on resources (health financing and human

(resources).

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6.4 Data Architecture
All health facilities and services collect data, which is shared with a select number people. Data capture
is still largely paper-based, but this will change after the implementation of eHIS. Three data processing
units exist, housed in different entities, and have the responsibility of processing the data and
developing information products (Figure 23 Data Architecture).

Figure 23 Data Architecture

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6.5 Indicators
A series of indicators and targets have been developed to monitor performance of the health sector in
implementing the NHSP 2022-2026 over the next five years. These are outlined in following tables.

 Table 23 Indicator Matrix: Inputs.

 Table 24 Indicator Matrix: Outputs.
 Table 25 Indicator Matrix: Service Coverage.
 Table 26 Indicator Matrix: Health Risk Factors
 Table 27 Indicator Matrix: Health Status
 Table 28 Indicator Matrix: Health Security

The majority of indicators are standard, global health indicators, which are comparable over years and
across countries. Quality of care indicators will be developed within the quality-of-care framework. The
NHSP indicators have been matched to relevant Strategic directive(s) and SDGs.

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Table 23 Indicator Matrix: Inputs
Health System Inputs
Baseline value End term Reporting Responsible
SDG SD NHSP Indicator Data Source
(2020) (2026) Frequency Entity
Health Financing
SD1/5 Total Health Expenditure (estimated by NHA) (SCR/USD) 1,225,843 (2018) NHA Biennial MoH
SD1/5 Total Government Health expenditure as % of nominal GDP 4.0% (2018) >6% HCA
PHA
SD1/5 Total Govt Allocation to Health as % of Total Govt Budget 11.75% (2022) >15%
Allocation
SD1/5 Total health spending per capita (SCR/USD) 911 USD (2018) >1,000 USD
SD1/5 Externally sourced funding (% of current health expenditure) 2% >3%
SD1/5 OOP payment for health (% of current health expenditure) 23.1% (2018) <20%
Health Workforce
3.c.1 SD5 Health worker density NHWA Biennial MoH
SD5 Practising doctors per 10,000 pop. 26 HCA
SD5 Practising nurses per 10,000 pop. 66 PHA
SD5 Practising dentists per 10,000 pop. 4.27
SD5 Practising physiotherapists per 10,000 pop. 1.74
SD5 Practising surgeons per 10,000 pop. 3.1
SD5 Training Output (NIHSS, other, by cadre) 71 (2017-19 NIHSS Annual Annual NIHSS
Average) Reports
SD5 Measuring CPD/CME by cadre N/A CME Criteria Councils Annual MoH
Health Information Governance
SD6 Number of facilities using eHIS 0 All DICT Annual HCA
SD5 Registration in PHC facilities by district 0 >60% DICT Annual HCA
Health Infrastructure
SD5 Updated master facility list – private and public. Partial All Facilities HCA Annual HCA
66
SD5 Hospital bed density (acute beds ). 352 Maintain; HCA Annual HCA
 Increase ICU beds; establish Isolation Unit. Incl. 12 ICU
Commodities
SD5 Number of medicine stock outs (central store) Frequent None Pharmacy Annual HCA

66
Acute beds for public health sector only.

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Table 24 Indicator Matrix: Outputs
Health System Outputs
End-Term Reporting Responsible
SDG SD NHSP Indicator Baseline Value (2020) Data Source
Value (2026) Frequency Entity
Doctor Consultation
SD2 PHC 262,430 Statistics Unit, MoH Annual HCA
SD2 Emergency 41,456 Statistics Unit, MoH Annual HCA
SD2 SOPD 35,601 Statistics Unit, MoH Annual HCA
Prescription Filled
SD2 PHC (including inner islands) 331,854 Statistics Unit, MoH Annual HCA
SD2 Seychelles Hospital (wards) 57,249 Statistics Unit, MoH Annual HCA
SD2 SOPD 36,105 Statistics Unit, MoH Annual HCA
Specialised Services
SD2 Oncology Unit 5545 (consultations); Statistics Unit, MoH Annual HCA
158 (new patients started chemotherapy)
SD2 Haemodialysis 193 (patients); 25,332 (sessions) Statistics Unit, MoH Annual HCA
67
SD2 Overseas Treatment 160 (patients); 162 (cases) Statistics Unit, MoH Annual HCA
Inpatients Services
SD2 Hospital Admissions (government- 10,613 (Note: 9749 acute care wards on Statistics Unit, MoH Annual HCA
owned hospitals) Mahé & 864 admissions to other wards)
SD2 Bed Occupancy (by ward) Male medical (90%) ICU (85%) Statistics Unit, MoH Annual HCA
Female medical (54%) Paediatric (47%)
Male surgical (57%) NICU (35%)
Female surgical (53%) Maternity (69%)
Logan La Digue (11%) Psychiatric (89%)
Hospice (94%) BSA Praslin (25%)
North East Point (84%)
SD2 Operating Theatre (surgeries) 4484 Statistics Unit, MoH Annual HCA
Diagnostic Unit
SD2 X-Ray 27,434 Statistics Unit, MoH Annual HCA
SD2 CT Scan 8066 Statistics Unit, MoH Annual HCA
SD2 MRI 1354 Statistics Unit, MoH Annual HCA
SD2 Ultrasound exams 10,574 Statistics Unit, MoH Annual HCA

67
Note that two patients went twice

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 SD2 Mammography 773 Statistics Unit, MoH Annual HCA
Clinical Lab
SD2 Tests done by unit 677,873 Statistics Unit, MoH Annual HCA
Allied Health Services
SD2 Physiotherapy (attendance) 49,388 Statistics Unit, MoH Annual HCA
SD2 Occupational therapy (attendance) 7437 Statistics Unit, MoH Annual HCA
SD2 Audiology (attendance) 1112 Statistics Unit, MoH Annual HCA
SD2 Speech therapy (attendance) 951 Statistics Unit, MoH Annual HCA
Oral Health Services
SD2 Consultations dental therapists Statistics Unit, MoH Annual HCA
SD2 Consultations dentists Statistics Unit, MoH Annual HCA

Table 25 Indicator Matrix: Service Coverage

Health Services Coverage
Baseline value End term Reporting Responsible
SDG SD NHSP Indicator Data Source
(2020) (2026) Frequency Entity
RMNCH
3.7.1 SD2 Demand for family planning satisfied with modern methods 47%* >60% World Health Annual HCA
Statistics Report
SD2 Antenatal care coverage 99% >99% Programme Annual HCA
3.1.2 SD2 Births attended by skilled health personnel 99% >99% Programme Annual HCA
SD2 Postpartum care coverage – home >99% Programme Annual HCA
SD2 Postnatal care coverage – clinic <70% >99% Programme Annual HCA
Immunization
3.b.1 SD2 Immunization coverage Programme Annual HCA
 DPT Dose 3 97% >95%
 Penta-/Hexa-valent Vaccine Dose 3 96.9% >95%
 HPV girls (and boys, if schedule revised) 99% (2019) >95%
 COVID-19 % fully vaccinated (2 doses) Adults >80%; Adults >80%; PHEOC Annual HCA
Adolescents Adolescents
60% (2021) >80%
HIV, Viral hepatitis , Tuberculosis
SD4 People living with HIV who know their status No baseline 90% NAC Annual PHA
SD2/4 Prevention of mother-to-child transmission 11% <2% MTCT CDCU Annual PHA

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 SD2 % Mother-baby pairs who receive full PMTCT interventions 89% 100% CDCU Annual PHA
SD2 Antiretroviral therapy (ART) coverage 82% >90% CDCU Annual PHA
SD2 HIV viral load suppression No data >90% CDCU Annual PHA
2019/2020
SD2 % Of treatment eligible HCV patients who received DAAs No Data >75% CDCU Annual PHA
SD2 % Of patients on DAAs with SVR 12 No Data >90% CDCU Annual PHA
SD2 % Of TB patients tested for HIV 100% 100% CDCU Annual PHA
SD2 TB treatment coverage 100% 100% CDCU Annual PHA
SD2 TB Treatment success coverage 100% >90% CDCU Annual PHA
Screening and preventive care for cancer68
SD2 Cervical Cancer screening (Pap smear) 6096 >20,143 Programme Annual HCA
SD2 Mammography screening for Breast Cancer 773 >2,500 Programme Annual HCA
SD2 Colonoscopy screening for bowel cancer 511 >1,000 Programme Annual HCA
Mental health
3.8 SD2 Coverage of services for severe mental health disorders (bipolar No baseline >90% Psychiatric Unit Annual HCA
affective disorder, moderate-to-severe depression & psychosis).
Substance abuse69
3.5.1 SD2 Number of people accessing services for alcohol dependence 124 500 DSAPTR Annual MOH
SD2 Treatment coverage for drug dependence 424 1080 DSAPTR Annual MOH
SD4 Number of syringes distributed 37,516 DSAPTR/CDCU Annual PHA/MOH/NAC
SD2 Total number of active clients on Methadone 1884 2100 DSAPTR Annual MOH
SD2 Number on Low threshold Programme 3005 DSAPTR Annual MOH
SD2 Number on High Threshold Programme 134 300 DSAPTR Annual MOH
SD2 Aftercare and Psycho-social supports 937 100% DSAPTR Annual MOH
SD2 No. of communities covered by Community-based programme No baseline All districts DSAPTR Annual MOH
SD2 Prevention and Education for substance use (interventions) 79 100 DSAPTR Annual MOH
SD2 Number of People engaged in outreach services 5400 DSAPTR Annual MOH
UHC Index
3.8.1 SD2 UHC index 71 >80 Statistics Unit Annual MoH

68
Indicators may be revised based on final version of Cancer Strategy.
69
Choice of indicators may be subject to revision based on updated DSAPTR operational plans.

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Table 26 Indicator Matrix: Health Risk Factors
Health Risk Factors
SDG SD NHSP Indicator Baselin End term Data Source Frequency of Responsible
e value value Reporting Entity
(2020) (2026)
Nutrition
SD4 Exclusive breastfeeding rate 0-6 months 20.90% ≥50% Nutrition Unit Annual HCA
SD3/4 Prevalence of obesity among school children (9-17 ≥50% 28.60% UPCCD Annual PHA
years)
2.2.1 SD3/4 Children under 5 years who are stunted 7.60% 3.04% Nutrition Unit Annual PHA
2.2.2 SD3/4 Children under 5 years who are wasted 4.30% 4.30% Nutrition Unit Annual PHA
2.2.2 SD3/4 Children aged under 5 years who are overweight 8.80% 8.80% Nutrition Unit Annual PHA
SD3/4 Anaemia prevalence in women of reproductive age no data Reproductive/ Maternal PHA
Health Program
SD3/4 Anaemia Prevalence in children no data Nutrition Unit PHA
Infections
SD3/4 Prevention of HIV in key populations AIDS program PHA
SD3/4 MSM reporting condom use 14.9% DSAPTR Survey PHA
SD3/4 PWIDs reporting using clean needles 58.20% DSAPTR Survey PHA
SD3/4 FSW reporting condom use 24.10% DSAPTR PHA
Environmental risk factors
6.1.1 SD3 Population using safely managed drinking-water 96% PHA Annual PHA
services (2019)
6.2.1 SD3 Population using safely managed sanitation services 99.38% PHA Annual PHA
(2019)
7.1.2 SD3 Population with primary reliance on clean fuels and PHA
technologies
11.6.2 SD3 Air pollution level PHA
Public Health risks
SD3 Fraction of food-related services monitored (farms, No data PHA PHA
abattoirs, kitchens, etc.)
SD3 Sales of tobacco 6032 Seychelles in Figures 2020 PHA

SD3 Sales of alcohol 52 Seychelles in Figures 2020 PHA

million

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 NCDs
SD3/4 Proportion of overweight and obesity in school-age 28.6% Zero UPCCD Annual PHA
children and adolescents 9–18 years (9-17 years) increase
3.5.2 SD3/4 Total alcohol per capita (age 15+ years) 48% 10% UPCCD Survey 5 years PHA
consumption (11-17 Years) relative
reduction
3.a.1 SD3/4 Age-standardized prevalence of current tobacco use 15% 30% UPCCD Survey 5 years PHA
among persons aged 15+ years (11-17 years) relative
reduction
SD3/4 Age-standardized prevalence of raised blood 29.5% 5.90% UPCCD Survey 10 PHA
pressure among persons aged 18+ years (25-64 years
years)
SD3/4 Age-standardized prevalence of overweight and 64.5% Zero UPCCD Survey 10 PHA
obesity in persons aged 18+ years (25-64 years) increase years
Injuries
5.2.1 SD4 Intimate partner violence prevalence 113 Social Affairs Annual Social Affairs

16.2.3 SD4 Sexual violence against children 168 Social Affairs Annual Social Affairs

8.8.1 SD3 Frequency rates of occupational injuries Employment & Annual PHA
Occupational Health

Table 27 Indicator Matrix: Health Status

Health Status

SDG SD NHSP Indicator 2019 Baseline End term Data Source Reporting Responsible Entity
value value frequency
(2020) (2026)
Mortality by age and sex

SD4 Life expectancy at birth (yrs) HCA

SD4 - Men 69.7 72.7 74 Statistics Unit Annual
SD4 - Women 78.4 82 83 Statistics Unit Annual
SD4 - Both sexes 73.9 77.3 79 Statistics Unit Annual

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 SD2/4 HALE (yrs) M: 62.2 M: 62.2 F: M: ? F: ? World Health Annual HCA
F: 69.5 69.5 Statistics Report
SD2/4 Adolescent mortality rate (per 1000 0.98 0.96 <0.5 Statistics Unit Annual HCA
adolescent population)
SD2/4 Mortality rate in males aged 15 - 60 5.5 5.2 <4.0 Statistics Unit Annual HCA
(per 100 men in age group)
SD2/4 Infant Mortality rate (per 1,000 live 16.8 11.6 10 or less Statistics Unit Annual HCA
births )
3.2.1 SD2/4 Under-five mortality rate (per 1,000 live 17.4 14.2 12 or less Statistics Unit Annual HCA
births)
3.2.2 SD2/4 Neonatal Mortality Rate (per 1,000) 8.7 9 <5 Statistics Unit Annual HCA
SD2/4 Stillbirth rate ( per 1000 total births) 5.0 5.1 <5 Statistics Unit Annual HCA
Mortality by cause

3.1.1 SD2 Maternal mortality ratio ( per 100, 000 62.3 64.4 <50 Statistics Unit Annual HCA
live births)
SD2 AIDS-related mortality rate (per 100,000 16.4 10 <5 CDCU Annual HCA
population)
3.4.1 SD3/4 Premature NCD Mortality 21.2 21.2 Reduce World Health Annual HCA
(Probability off dying from any of by 25% of Statistics Report
cardiovascular diseases, cancer, diabetes baseline
or chronic respiratory diseases between
age 30 and exact age 70 [%])
SD2 Pulmonary embolism related mortality 139 145 Statistics Unit Annual HCA
rate ( per 100, 000 population)
3.6.1 SD3 Mortality rate due to road traffic 11.3 11.2 <10 Statistics Unit Annual HCA
accident (per 100,000 population)
3.4.2 SD4 Suicide rate (per 100,000 population) 6.1 6.1 <5 Statistics Unit Annual HCA
16.1.1 SD4 Mortality due to homicide (per 100,000 2 1 No Target Statistics Unit Annual HCA
population)
SD3 Mortality from unintentional poisoning 0 0 0 Statistics Unit Annual HCA

SD2/3 Pneumonia related Mortality ( per 100, 158 132 <130 Statistics Unit Annual HCA
000 population)
SD2/3 Covid-19 related deaths (per 100 000 0 0 < Statistics Unit/PHEOC Annual HCA
population )
SD2/3 Covid-19 case fatality rate (%) 0 0 <1% PHEOC Annual HCA

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 Fertility
SD4 Total Fertility Rate 2.3 2.3 Below 3 NBS Annual HCA

3.7.2 SD4 Adolescent birth rate ( per 1000 females 69 60 <30 Statistics Unit Annual HCA
aged 15-19)
SD4 Number of live births in girls aged <15 9 4 Zero Statistics Unit Annual HCA
Morbidity
SD2 New cases of vaccine preventable Zero DSRU/Programme Annual HCA
diseases cases
SD2/4 ASR of cancers in males (all sites) (per 274 255 Cancer registry; end- Annual HCA
100,000 persons at risk) term targets to be
based on Cancer
Control Plan
SD2/4 ASR of cancers in females (all sites) (per 302 207 Cancer registry Annual HCA
100, 000 persons at risk)

Table 28 Indicator Matrix: Health Security

Health Security
IHR/ Baseline value End term Data Frequency of Responsible
SD NHSP Indicator
SDG (2020) value (2026) Source Reporting Entity
SD3 Emergency Prepare (IHR Capacities)
C1 SD3 Legislation and financing PHA
C2 SD3 IHR coordination and national IHR focal-point functions PHA
C3 SD3 Zoonotic events and the human–animal interface PHA
C4 SD3 Food safety PHA
C5 SD3 Public Health Laboratory PHA
C6 SD3 Surveillance and Response PHA
C7 SD3 Human resources for Emergency Preparedness PHA
C8 SD3 National health emergency framework PHA
C9 SD3 Health service provision PHA/HCA
C10 SD3 Risk communication PHA/MOH
C11 SD3 Points of entry PHA
C12 SD3 Chemical events PHA
C13 SD3 Radiation emergencies PHA
SD3 Emergency Prevent (Routine and Emergency Vaccination Coverage)

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 SD3 Routine & campaign vaccination for epidemic- and pandemic-prone HCA/PHA
diseases (Yellow Fever, Meningitis, Measles, Polio, etc.)
SD3 COVID-19 Vaccination 0% >80% per EPI Annual HCA
protocol Programme
SD3 Detect and Respond
SD3 Timeliness of detection and response PHA
T0 – Time to Detect PHA
T1 – Time to Notify PHA
T3 – Time to Respond PHA
SD3 New cases of IHR Notifiable diseases and other Notifiable Diseases
SD3 Leptospirosis N/A DSRU Annual PHA
SD3 Dengue N/A DSRU Annual PHA
SD3 COVID-19 Cases 0.8 cases/day < 20 / day PHA/DSRU Month PHA
3.3.1 SD3/4 HIV incidence (newly detected cases) 84 < 50 NAC Annual PHA
SD3/4 HCV incidence (newly detected cases) 91 < 1/2 CDCU Annual PHA
3.3.4 SD3/4 HBV incidence (per 100,000 population ) 34 CDCU Annual PHA
SD3/4 STI incidence 425 CDCU Annual PHA
3.3.2 SD3 TB incidence rate (per 100,000 population) 9 5 or < CDCU Annual PHA

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List of Annexes

Annex 1: List of National Health Commitments

Annex 2: Seychelles Progress on SDGs

Annex 3: List of in-person Consultations

Annex 4: Tasks and Objectives of the TWGs

Annex 5: Strategic Investment Priorities

Annex 6: Results Chain 2022-2026 NHSP

Embedded PDF of annexes:

NHSP 2022-2026
Annexes.pdf

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 The National Health Strategic Plan 2022-2026

January 2022

For queries, please contact the Policy Unit of the Ministry of Health

Sanjeev Pugazhendhi
Sanjeev.Pugazhendhi@health.gov.sc

Doreen Zelia
doreen.zelia@health.gov.sc

Juddy Jean-Baptiste
juddy.jean-baptiste@health.gov.sc

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