Personal perspective

Where on earth is Tuvalu? My year as a Health Information Manager in a developing country

Kaye Borgelt

What does an experienced Health Information Manager (HIM) do when they leave the Victorian public health sector after thirty years? I packed up my knowledge and suitcase and relocated to Tuvalu, one of the smallest and least visited countries in the world, to work for 12 months as a volunteer HIM with Australian Volunteers International, an aid program funded by the Australian Government.

Tuvalu, which comprises nine small tropical islands, has a total population of just under 11,000 and only one hospital located on the island of Funafuti. My role as HIM was designed to assist in improving medical record documentation and building capacity and knowledge for local staff. It proved to be so much more.

The Nation of Tuvalu

Tuvalu is one of the poorest and least developed of the Pacific Island countries. Diseases that are almost unheard of here in Australia – tuberculosis, leprosy, rheumatic heart disease and dengue fever – are real and ongoing health issues.

The infant and under five mortality rates are very high, and life expectancy is estimated at 67.2 years (Central Intelligence Agency [CIA] 2020), more than 15 years less than our life expectancy in Australia, although with no accurate mortality and morbidity data that is a best guess, but more of that later.

Tuvalu has the fifth highest obesity rate in the world at 51.6% (CIA 2020). Living on a coral atoll with no soil means that access to healthy food is extremely limited and the diet consumed by the population is largely processed food, very high in salt and sugar, brought to the island from Fiji every six weeks.

The Tuvalu healthcare system

There is one hospital which is located on the main island of Funafuti, with health clinics on each of the outer islands. These clinics are staffed by nurses only, which given the furthest island is a 22-hour boat ride away, makes acute health care extremely difficult. The reality is that most people on one of the outer islands with an emergency condition will die.

There is one General Surgeon, one specialist locum Anaesthetist and one specialist locum Obstetrician, who rotate from other Pacific Island countries. All other medical care is provided by General Practitioners (GPs) who are local Tuvaluans who travel to either Cuba or Taiwan for medical undergraduate training and then have one-year intern training before coming back to Tuvalu to literally run the entire health care system. In the seven years they are overseas the medical students may get to return to Tuvalu once to see family and friends.

The hospital has 50 beds and one theatre. There is no access to intensive care, with the ward designated as high dependency different from the normal wards by having an air conditioner and at least some effort made in regard to infection control. Basic radiography and pathology services are available at the hospital although there is no access to Radiologists and Pathologists, leaving all diagnosing to be done either by the technicians or GPs.

The hospital pharmacy is the only provider of drugs and medications in the country, with paracetamol only being sold in the ‘supermarkets’ from 2019 onwards. Previous to that citizens would have to come for a GP consult to even have paracetamol prescribed.

Allied health consists of two physiotherapists and one nutritionist, which given the very high obesity rate and epidemic levels of diabetes and hypertension, is substantially less than what is required to make any meaningful change.

There is an acknowledgement that public health is an incredibly important component of healthcare delivery in this developing country. A substantial public health department by Tuvaluan standards, consisting of environmental health, sanitation aides, non-communicable disease clinic, maternal and child health including antenatal clinics, tuberculosis/human immunodeficiency virus/sexually transmitted disease clinic and health promotion programs operate out of the acute hospital.

A universal healthcare system

In contrast to most of the world Tuvalu has a truly universal healthcare system, with all care provided free of charge to all citizens. Nearly 62% of the total health budget is spent on the Tuvalu Medical Transfer Scheme whereby patients requiring care and treatment that cannot be provided in Tuvalu, are transferred overseas.

Given the hospital is only the equivalent of a ‘district sized and equipped hospital’, this means a lot of people are transferred overseas. All cancer diagnoses are transferred and remain overseas for the duration of their treatment and there were about 25 patients with end stage kidney failure living permanently in Fiji with their families while they receive dialysis.

All of this comes at an enormous cost – some $7 million in 2017 against a total national health budget of only $11.3 million (Borgelt 2019). Sadly, transferring patients to Australia or New Zealand is deemed to be too expensive so patients go to either Fiji, Malaysia or India.

Healthcare challenges

Providing quality healthcare in Tuvalu is beset by a number of significant challenges. For patients living on outer islands, about 40% of the population, anyone requiring acute care must wait up to four weeks for the scheduled ferry to arrive and then travel up to 22 hours by boat back to the hospital. There is no such thing as ordering a road or air ambulance.

Accessing even basic supplies such as anaesthetic drugs and gauze dressings is difficult with all supplies coming by boat from Fiji every six weeks, with extended delays common during cyclone season. For a period of three months only emergency surgery was able to be performed, in particular emergency caesarean section deliveries, due to a critical shortage of anaesthetic drugs.

The main island of Funafuti is very densely populated with limited access to fresh water and generally poor hygiene creating a perfect environment for the spread of infectious diseases. Limited access to fresh fruit and vegetables and a heavy reliance on processed foods high in salt and sugar only adds to the generally poor health status of the population. This is one of our closest Pacific Rim neighbours and this is their everyday reality.

Kaye in the Nurses Station at Princess Margaret Hospital with Health Information Department staff Sisilia Pome’e and Tereinako Pakoa and Acting Director of Health Dr. Tuese Sinileta

Health information in Tuvalu

Like many hospitals we had a hybrid medical record system with a combination of hard copy medical records stored in very rusty filing cabinets and an electronic system provided by the Republic of China (Taiwan) which was used for emergency and general outpatients and not much else.

If you think it is hard logging issues with your in-house information technology department, try getting any changes made to a system which has been set up in Mandarin for use in a tertiary level hospital in Taiwan, translated into English for Tuvalu, and is operated from Taiwan (half a world away).

When I arrived the Admission, Transfer and Discharge system was not used at all and there was no morbidity or mortality coding done. Birth and Death Registers were maintained in spreadsheets.

The unspoilt tropical paradise of Tuvalu

Why health information is important in developing countries

Why does a country like Tuvalu, with so many challenges, need a HIM? Put simply, data and information. How can a country improve its health outcomes if it does not have access to accurate data and information to inform discussion and decisions at all levels?

The World Health Organization (WHO) regularly quotes health related information for countries throughout the world. Until now Tuvalu has not been in a position to report anything other than raw birth and death figures. Given that so much international aid is based on information relating to health outcomes, whether that is incidence and prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis rates, maternal and neonatal death rates, and sustainable development goals I suggest that for many developing countries information provided is at best a guess and worse whatever was reported last year, hence my hesitancy quoting life expectancy data previously.

Given the little that was available in Tuvalu we had to decide what information was the most important and what was actually able to be collected and reported. As a result, we concentrated on four areas; births, causes of death, reasons for admission to hospital and reasons for transfer overseas for high level care.

Mortality coding

Mortality coding was introduced for all deaths and a review of mortality over a five-year period was completed and presented to the Tuvalu Government that highlighted emerging public health issues, including the high number of deaths due to non-communicable diseases and an uncomfortable number of infants dying before their fifth birthday. The information was subsequently used to reallocate scarce public health funding and activities to these specific areas.

The Medical Cause of Death Certificate was reviewed and revised to bring it in line with the WHO recommended standard and a national guideline on how to complete the certificate was implemented.

Mortality statistics is a fundamental measure used by the WHO to calculate many key performance indicators. Without accurate and timely mortality coding such indicators become problematic and potentially worthless. In Tuvalu, and possibly many other developing countries, the absence of even this most basic information is a real problem.

Morbidity coding

Local staff were provided with basic training in morbidity coding so that admissions to hospital could be accurately counted and categorised. The online WHO International Classification of Diseases, Tenth Revision (ICD-10) system was used, which unfortunately has no capacity to code interventions, a situation that will be rectified in the Eleventh Revision (ICD-11), a great step forward for developing countries relying on this free platform. The online training module was used to train staff and provided an excellent introduction to staff with no experience.

Unlike in Australia where morbidity coding is now used predominantly for financial purposes, in a country like Tuvalu morbidity coding is important because it is the foundation for identifying public health priorities, and then monitoring whether public health programs make a difference over time.

We were able to quantify the prevalence of diabetes and hypertension and the high number of diabetesrelated complications such as diabetic foot. Even better we were able to provide data that proved that early intervention at the non-communicable disease clinic had resulted in a dramatic decrease in the number of above and below knee amputations.

Analysing admission, transfer and discharge data, including morbidity coding, we were able to identify priorities for specialist doctors – in particular the need for a Paediatrician. That position was subsequently advertised internationally.

In addition to justifying health care expenditure as part of the national budget discussions we were also able to provide policy makers with accurate information to plan for future health services. These are truly big picture outcomes.

Safety and quality

At its core health information is about improving safety and quality in healthcare.

I was able to introduce a number of basic processes to assist in making patient care at ward level safer and more effective, including using patient armbands to identify individual patients, printing patient labels to identify medical record forms and using printed progress notes rather than blank sheets.

The medical record system already had a unique patient identifier. We worked hard to reduce duplicate unit record numbers and ensure that records were merged to ensure that important health information was not lost in multiple folders. Staff were made aware of the importance of using points of identification other than given name and surname to identify patients, which in a country where literally no one has an address, meant relying on the date of birth.

Tuvalu has no private GPs which means that patients present to the hospital for all treatment and care. The introduction of an outpatient registration form to collect accurate administrative information to populate the Patient Master Index assisted in improving data quality.

In common with many other developing countries Tuvalu has a relatively high birth rate. In 2018 there were 246 births, which compared to Australia is nothing but when the entire population is only 10,645 (Government of Tuvalu 2017), is quite substantial. A birth summary form was introduced to collect important birth information to facilitate analysis of deliveries which over time should lead to improvements in outcomes for mothers and babies, including a decrease in maternal and neonatal deaths.

The introduction of booked outpatient clinics meant that medical records were able to be pulled in advance and provided to the specialist with important previous medical history, including investigations and comorbidities to assist in clinical decision making. In the health information department, we were able to introduce medical record clips so that loose pages did not fall out of the manila folders in which they were stored. Daily bed returns to count admissions and discharges commenced and handmade cardboard tracer cards using discarded manila folders reduced the number of misfiled medical records.

Not all improvements involve sophisticated technology solutions.

The volunteering experience

To be given the opportunity to live and work for 12 months in another country and culture is a tremendous privilege beyond anything I could have imagined. It is an opportunity to meet and become friends with people from many different cultures, countries and backgrounds. It is a chance to learn about who you really are and what is important, realign what truly matters, and appreciate the small things such as a beautiful sunset, receiving a bunch of bananas from your next door neighbour or finding apricot jam for sale in the supermarket.

To be a HIM in a developing country is a chance to make a real and lasting improvement to the health outcomes of an entire population and reinforced to me that HIMs have skills that are incredibly diverse and valuable – we have so much more to offer than just maximising casemix and coding outputs.

References

Borgelt KD (2019) Tuvalu Medical Transfer Scheme (TMTS) Report – 2018.

Central Intelligence Agency (2020) CIA World Factbook. Available at: https://www.cia.gov/library/publications/the-world-factbook/geos/ print_tv.html (accessed 12 August 2020). Government of Tuvalu (2017) Tuvalu Population & Housing MiniCensus 2017 – Preliminary Report. Central Statistics Division, Ministry of Finance, Economic Planning and Industries, Government of Tuvalu.

Kaye Borgelt MHSc; Grad Cert Org Chge; Ass Dip Med Rec Admin; GAICD Health Data Analyst, Gippsland Primary Health Network 325 Francis Road, Glengarry West, VIC, 3854 Tel: 0427 537 400 Email: kayeborgelt@gmail.com