Health reform or military coup - the Solomon Islands in 2000

I found myself in the middle of a military coup in Honiara, capital of the Solomon Islands back in 2000. It was the real thing, gunshots through the roof of the Honiara supermarket around 3 pm, and a lockdown at the training centre where I was trying to teach strategy development to a group of senior public servants. The chain-wire fence did not inspire confidence for its bullet stopping power as we cowered in the masonry toilet block.

One outcome of my visit was one of the most remarkable strategy documents I have ever seen. A plan to transform the provision of health services for the nation was produced by the Deputy Director of Health during the chaos of a military coup.

Two days after I escaped on one of the last planes to leave Honiara, the Malaitan Eagle Force captured the police gunboat and the Prime Minister, using the gunboat to shell bunkers occupied by the opposition Isitaba Freedom Movement guerillas near Henderson Field. Just a week earlier, I had walked into one of the bunkers left behind after WW2, as a tourist. Looking down at the airfield as the Qantas plane took off I felt a huge sense of relief. Just 6 hours earlier, sipping whisky on the deck before dinner with the Head of the Solomons Public Service and the retired Catholic Bishop of the Solomons, I had been worried about the gunfire just over the ridge.

"Don't worry" I was told "They won't shoot at us."

"How do you know?"

"Because I'm a Malaitan and my wife is a local woman." my host assured me.

I did not feel reassured, but another sip of duty free scotch helped settle my nerves.

But what has all this drama to do with a Public Health transformation strategy?

How did I come to be there in the first place?

I was working, taking time out from my consulting practice in New Zealand, to spend 2 weeks in Honiara for Massey University, teaching public sector planning to senior public servants. This was an international aid program that the Massey team had been providing in Pacific Islands for the previous 3 years. It had taken me to Samoa, Tonga and the Cook Islands already.  Now I was teaching in the Government Training Centre just above the Parliament House in Honiara. The visit was funded by the Asia Development Bank.

The teaching program required students to prepare and submit a strategic plan and implementation plan to resolve an issue of national importance as their final assignment. Over the years I have seen some outstanding work done by Pacific Island officials, as they set out to rethink government strategy to improve the welfare of their citizens.

The Public Health Strategy

A month later I received a bulky document from the student, George, and browsed the Executive Summary. I was astonished by the imagination and scope of the proposal.  It was revolutionary.

The strategy proposed nothing less than a complete reversal of funding priorities for the whole health system. Funding would be shifted from the island capital city (township) hospital, run by doctors, and put into local village health centres run by trained nurses.

George predicted a major political upheaval from the all powerful medical professionals, and set out a strategy to win the hearts and minds of the people, taking advantage of the political chaos unfolding through the nation.

His analytical support for the idea was comprehensive, demonstrating the mismatch between spending on expensive hospitals and the lack of funds for public health for small village communities dispersed on small islands. The inability of hospital-based service to reach the majority of the population was clear.  The costing of the new service was thorough and I was persuaded that the plan to achieve the change was feasible.

I marked the assignment A+ and George finished the course with distinction grades.

Did anything happen?

The Asia Development Bank asked Massey University whether there were any strategies proposed by students that should be implemented, and of course funded.  My recommendation that they should consider funding the Health Transformation Strategy was a no-brainer.

Massey was asked to submit a proposal for implementation support, which we developed and costed.  It looked as if it was going to happen.

Then ADB were forced to abandon the project by the increasing bloodshed on the island of Guadalcanal, and the political chaos. The Solomons' public service had virtually collapsed, and Honiara was marginally controlled by Australian and New Zealand peace keeping troops and police in 2001.

As I sat down to write this account, I researched more recent information from the Solomon Islands, mainly in the form of international aid agencies reports on funding of projects in the Solomons public health sector.

The 2004-5 Health Plan showed a major shift in the allocation of funds between the provinces and the hospital system when compared with the 2000 Plan

"Allocation: National Versus Provinces:

There is commitment to increase level of health activities in the provinces. Fifty-seven percent (56%) of the 2004 HBE is allocated to the provincial health services, whilst 44% is to maintain, sustain and strengthen the national health functions in support to the provincial health services. (Health Plan 2004-5, S6.3.2, Ministry of Health, Solomons Islands.)"

This seems to be lukewarm, incremental approach and not the full-blooded revolution suggested by George.  The quality of the analysis supporting the shift bears a marked resemblance to what I was reading in 2000.

I do not find it surprising that this transpired. After all Solomon islanders were grappling with a completed economic and social meltdown, and survival issues were paramount as the national tried to recover.

The final lessons

In all our work on strategy, we learn over and over again that "timing is everything."

Two weeks before the Malaitan Eagles' coup, "ethnic tension" (a polite term for a sporadic shooting war) prevailed but no-one predicted the chaos that followed.  George's health strategy was overtaken by events, but there is evidence emerging that it is gradually being put in place, and has the support of influential people.

Good ideas rarely disappear; they often reappear in a different form when the timing is right.

Reform that benefits all the people in any country can take many forms.  Armed conflict inevitably creates more damage to innocent civilian populations, and delays the slower changes to whole systems that internal government changes in policy and budgets can achieve.  The benefit of a change to the health system of the Solomons will be lasting and will improve the welfare of all the people.

The effect of the chaos precipitated by the military coup has been to delay the process, and to increase the dependence of the people on external aid donors, because of the unintended effects of destroying the economy.

The story of the hare and the tortoise comes to mind.  "Slow and steady wins the race."

I hope you enjoyed this slice of real life in far away places.