Coverage of core population and individual NCD interventions and services in Mauritius
Table 6 summarizes the assessment team’s evaluation (on a three-point scale, extensive, moderate or limited as per criteria given in the WHO assessment guide) of 24 core population-based interventions geared towards tackling the four main risk factors for NCDs, that is tobacco smoking, harmful alcohol use, unhealthy diet and physical inactivity.
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The coverage of 4 (16.7%) of the interventions was rated extensive, 9 (37.5%) moderate and 11 (45.8%) limited. Out of the six antismoking interventions, two were rated extensive and four moderate. Out of the six interventions to prevent harmful alcohol use, one was rated extensive, one moderate and four limited. Of the six interventions to improve diet, one was rated extensive, two moderate and three limited. Of the six interventions to promote physical activity, none was rated extensive, two were rated moderate and four were rated limited. According to the assessment team’s rating, Mauritius still needs to invest more in scaling up the coverage of population NCD control interventions to the extensive level.
Table 7 encapsulates the assessment team’s evaluation (on a three-point scale, as extensive, moderate or limited based on criteria given in the WHO Assessment guide) of the 15 core individual services for controlling cardiovascular diseases (CVD), diabetes and cancer.
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Three (20%), eight (53%) and four (27%) of the 15 individual NCD services were rated extensive, moderate and limited respectively. With regard to CVD, effective primary prevention in high-risk groups and secondary prevention after AMI were rated extensive; effective detection and management of hypertension, and rapid response and secondary care after AMI and stroke were rated moderate; and risk stratification in primary health care was rated limited. All the individual services for diabetes (detection and general follow-up, patient education, hypertension management and prevention of complications) were rated moderate. In the case of cancer first line services, prevention of liver cancer through hepatitis B immunization was rated extensive, and screening for cervical cancer and treatment of precancerous lesions were rated moderate. About the four cancer second line services, only vaccination against human papilloma virus was rated extensive; with the early case-finding for breast cancer and timely treatment of all stages, population-based colorectal cancer screening, and oral cancer screening coverage rated limited.
Health system challenges hindering scale up of core NCD interventions and services
In relation to each intervention/service, the evaluation team assessed each challenge as either 1 = minor, 2 = moderate, 3 = major, or 4 = major persistent challenge. Table 8 summarizes the average scores and ranking of the top five health system challenges (interagency cooperation, explicit priority setting approaches, managing change, distribution and mix human resources, population empowerment, and political commitment) hampering scale-up of coverage of population-based NCD interventions in Mauritius.
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The top five challenges had average scores of between 3.1 (interagency cooperation) and 2.4 (distribution and mix of human resources). Additional Files 4 details the scores pertaining to degree of challenge for NCD population-based interventions.
Table 9 presents the average scores and raking of the top five health system challenges (integration of evidence into practice, explicit priority-setting approaches, adequate information solutions, population empowerment and distribution and mix of human resources) hindering optimal expansion in coverage of individual NCD services.
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The top five challenges for individual interventions had mean scores varying between 2.6 (integration of evidence into practice) and 1.7 (distribution and mix of human resources). Additional Files 5 portrays the scores pertaining to degree of challenge for individual NCD services.
The remaining part of this subsection present an analysis and scores of the 15 health system features contained in Table 5.
Political commitment to NCDs: The Mauritius Government’s political commitment to continually improve the level and distribution of health is expressed in Mauritius Vision 2030 , Government Programme 2015–2019 , MOHQL vision and mission statement  and health sector strategy 2017–2021 . The MOHQL mission is to create a modern high-performing quality health system that is patient centred, accessible, equitable, efficient (uses available human, financial and physical resources without waste) and innovative (using the full potential of information and communications technology) . In relation to NCDs and health promotion, Mauritius strategic objective is to reduce the burden of premature morbidity, mortality and disability associated with NCDs and their risk factors . At the time the assessment was conducted, efforts were underway to update the expired action plans on tobacco control [55, nutrition , physical activity  and cancer control .
The Government has enacted various public health legislations targeting various NCD risk factors. For instance, the 2008 public health regulations which prohibit advertisement, sponsorship and sale and consumption of alcoholic drinks in public places . Another set of public health regulations that came into force in March 2009 imposed restrictions on tobacco products; and was reinforced by the June 2018 Mauritius accession to the WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products . The Minister of Health and Quality of Life published the Government Gazette of Mauritius No. 74 of 15 August 2009 entitled “Food (Sale of Food on Premises of Educational Institutions) Regulations 2009”, which specifies the types of food which may be sold on the premises of educational institutions (pre-school, primary school, secondary school or pre-vocational school) .
Political commitment to NCDs was rated either major or major persistent challenge for 12 population interventions and for 2 individual services. The average score for population interventions was 2.5 and 1.6 for individual services. Sustaining high-level political commitment through effective budgetary and legislative support and improved coordination of NCD activities across government agencies remains an ongoing challenge.
Explicit priority-setting approaches: The strategic long term direction for development plans priorities has been spelt out in the Mauritius Vision 2030. The Ministry of Finance and Economic Development (MOFED) strategic plan provides a medium term strategic direction and targets. MOFED three-year strategic budget plan establishes indicative expenditure ceilings for the ministries. The MOHQL proposed annual budget estimates, which are established on historical basis, alongside those of other ministries, are reviewed by the Budget Estimates Committee meeting chaired by the MOFED.
The current budget allocation to the MOHQL is divided into five major subheads: general, curative services, primary health care and public health, treatment and prevention of HIV and AIDS, and prevention of noncommunicable diseases and promotion of quality of life (see Table 10).
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Between 2016/17 and 2019/20 total government expenditure increased from Rupees (Rs) 10.9 to 12.3 billion, representing a 13% increase. During the same period expenditure on prevention of NCDs and promotion of quality of life grew from Rs 106.8 million to Rs 137.3 million, accounting for a 29% increase [15,51].
Application of explicit priority-setting approaches was rated either major or major persistent challenge for 17 population interventions and for 3 individual services. The average score for population interventions was 2.8 and 2.1 for individual services.
The use of national health accounts (NHA) to link the process of national health policy development to allocation and reallocation of resources is still in the nascent stage. Moreover, the use of cost effectiveness evidence in allocation of resources has not been institutionalized. Therefore, there is no explicit mechanism for prioritizing health services and public health spending. In addition, there is absence of prioritization of the health budget with regard to burden of disease, cost-effectiveness and equity considerations.
Interagency cooperation: The MOHQL recognizes that multi-sectoral action and partnerships are crucial for core interventions and services to have the greatest impact on NCD outcomes; the MOHQL is forming close partnerships with other sectoral ministries and national institutions; and with UN agencies, diplomatic missions, and civil society organizations including NGOs, the media and other relevant stakeholders . For example, the Ministry of Education and Human Resources, Tertiary Education and Scientific Research has been an important partner in the prevention strategies which include health education, screenings and referrals, sale of healthy food items in school canteens, human papilloma virus (HPV) vaccination, etc.; the Ministry of Social Security, National Solidarity and Environment and Sustainable Development has been a partner particularly in providing preventive, promotive, curative and rehabilitative services to older people and people with disabilities; the Ministry of Agro Industry and Food Security is also collaborating with the MOHQL to ensure food security and safety and to encourage consumers to change their eating habits; the Ministry of Youth and Sports is promoting physical activities by providing incentives for purchase of sports equipment, increasing accessibility of sports infrastructure to the general public and allocation of grants to sports clubs; the Ministry of Gender Equality, Child Development and Family Welfare is organizing regular talks and sensitization campaigns on healthy eating habits, physical activities and cancer through the network of women centres in the island. The NGOs active in the health sector expressed to the assessment team strong desire to have closer cooperation, better communication and more exchange with the MOHQL.
Interagency cooperation was rated either major or major persistent challenge for 20 population interventions. The average score for population interventions was 3.1. The assessment team deemed interagency cooperation not application for individual services in Mauritius.
The main challenges include lack of functional interagency cooperation mechanism; and dearth of synergy through joint government/NGO efforts for combatting NCDs.
Population empowerment: The MOHQL has developed infrastructure for planning and implementation of policies, programmes, services and activities aimed at raising health literacy among the population. Some of that infrastructure includes the Health Information Education Counselling Unit; the NCD and Health Promotion Unit; and the Primary Health Care Programme. A Health Literacy Framework was developed by MOHQL in 2013; it incorporated the strengthening of the health literacy components of the different national action plans being implemented to reduce risk factors and premature mortality as well as a strategy to guide actions to improve health literacy across the life course .
In addition, health promotion efforts care buttressed by pertinent health awareness raising activities of the Ministry of Social Security, National Solidarity and Environment and Sustainable Development; Ministry of Gender Equality, Child Development and Family Welfare; Ministry of Education and Human Resources, Tertiary Education and Scientific Research; Ministry of Youth and Sports; and Ministry of Agro Industry and Food Security. Four NGOs also contribute to population empowerment and protection of patient rights, including the Link to Life (focusing on breast cancer), TiDiam (focussing on diabetes), APSA (focusing on diabetic foot care) and VISA (targets tobacco use).
Population empowerment was rated either major or major persistent challenge for 12 population interventions and for one individual service. The average score for population interventions was 2.5 and 1.8 for individual services.
Despite the various strategies implemented for population empowerment, there is high prevalence of NCD risk behaviours and poor adherence to treatment plans, attributed to inadequate empowerment of population to change behaviour towards taking responsibility for their own health; lack of active engagement in decision-making processes around policy issues as well as individual treatment options/plans; lack of structured peer to peer patient support groups; high-risk population groups not adequately targeted for more tailored health promotion; and lack of explicit health literacy approach for the elderly.
Effective models of services delivery: Mauritius has a strong primary health care system that provides health promotion (health education, empowerment and health talks), disease prevention (health check-ups and opportunistic screening), curative services (NCD clinics and diabetologist clinics) and rehabilitation . The primary health care centres are manned by community physicians, nutritionists, nurses and health care assistants, among others. In principle, patients visit a primary health care provider at a community health centre/area health centre for non-emergency needs, and if necessary, the service provider issues a referral memorandum to an hospital for specialist care.
Even though the assessment team did not rate impact of effective model of services delivery on population interventions and individual services, the assessment identified factors that undermine referral system, including patients bypassing the PHC providers and going directly to secondary or tertiary hospitals for non-complicated NCD care; lack of patient identifier leading to duplication of care and dysfunctional transition of care; many PHC centres do not have optimum physician consultation time; and dearth of diagnostic and preventive services for a significant segment of the population in prediabetes stage.
Coordination across providers: The coordination across providers at the different levels of care in Mauritius such as home care, PHC, and emergency care, regional and specialized hospitals is patient-focused with a referral system addressing the needs of NCD patients . Multidisciplinary cooperation is effective at facility level, and patients attending PHC centres are seen by a multidisciplinary team of health professionals.
Even though the assessment team did not rate impact of coordination across providers on population interventions and individual services, the working groups identified key challenges for coordination across providers to be lack of effective interoperable patient clinical data transfer system; and inefficient functioning of PHC as a hub for general coordination of care and referral to specialists.
Regionalization: The overall public health-care system is well structured with three distinct levels of care, namely primary, secondary and tertiary. Effective regionalization of care has been achieved with a regional hospital and an extensive PHC network in each of the five health regions with a defined catchment population . All five regional hospitals have a fully equipped cardiac unit for treatment of AMI. There are no wide variations in availability and quality of services within regions. Tertiary care hospitals are accessible within reasonable driving distance. There is also a 24-hour free public emergency ambulance service manned by doctors and nurses with specialized training in emergency medicine .
Regionalization was rated as a major challenge for scale-up of coverage of one individual NCD service, i.e. the early case-finding for breast cancer and timely treatment of all stages one individual service. The average score for individual services was 1.4. The key issues surrounding regionalization challenge included lack of clarity in the definition of roles and responsibilities for management of NCD conditions at the different health service delivery levels; and implementation of stroke unit care.
Incentive systems: The public health professionals receive their salaries and allowances based on recommendations of the Pay Research Bureau (institution responsible for reviewing the pay and grading structures and conditions of service in the public sector) and these are linked to position levels, years of service and responsibilities assigned . Continuing professional development (CPD) is mandatory for doctors  and dentists . Creation of the Mauritius Institute of Health (MIH) has availed opportunities for continuing education for other health workforce cadres to develop new competencies and skills, which makes them eligible for internal promotions and career advancement .
Inspite of the fact that the impact of incentive systems on population interventions and individual services was not rated, the working groups assessment revealed that absence of monetary incentives linked to outstanding provision of quality NCD care at individual and institutional levels. Also, since the public health service delivery system provides free access to all core NCD population-based interventions and individual services, there are no incentives for healthy behavior change in population, better self-management for patients with chronic conditions, and adherence with the referral system.
Access to quality medicines: Concerning access to quality of medicines, based on the WHO concept of Essential Drugs , the MOHQL has developed its own medicine list covering all pharmacological classes including specialized items . The list is reviewed every two to three years by the Drug Formulary Committee to assess its adequacy and the list approved serves as a guide for medical officers at public health facilities for prescription of medicines using their generic names and for drugs that are not on the essential list on a case-by-case basis. The Hospital Drugs Committee set up at regional level evaluates such requests and advises on the purchase of drugs needed for specific cases. In addition, monitoring of prices of pharmaceutical products is carried out by relevant authorities. So far, no cases of malpractices have been found in this respect and a National Pharmacovigilance Committee (NPC) has been set up under the aegis of MOHQL to collect and analyze data on any adverse drug reactions in relation to the prescription and use of drugs in the treatment and control of disease and reporting of suspected quality issues . Public procurement of medicines is highly efficient in terms of procuring medicine at competitive prices through pooled Small Developing Island Project for procurement of priority medicines.
Access to quality medicines was rated either major or major persistent challenge for none of the population interventions and for one individual service, i.e. effective detection and general follow-up of diabetes cases. The average score for population interventions was one; and 1.1 for individual services.
The WGs identified factors accounting for sub-optimal access to quality medicines to include cumbersome administrative formalities in procurement of drugs sometimes cause delays in supply; lack of dedicated quality control laboratory to monitor the quality of drugs in the local market; NPC is not very effective; and existing inventory management sometimes is the cause of stock outs at central warehouses and health facilities.
Integration of evidence into practice and adequate information solutions:Research , surveys [49,50] and other databases on NCDs have been useful in providing local evidence for identifying more effective actions for combating NCDs. For example, the vaccination strategy against cervical cancer for young girls which started in 2016 was finalized after studies on HPV subtype prevalence done by the Central Health Laboratory and the Mauritius National Cancer Registry (MNCR) [69,70]. The Virtual Health Library (VHL) in Mauritius which was set up in 2015 by the MIH provides all public health professionals electronic access to scientific knowledge on health .
Research is complemented by other information systems solutions, for instance, the civil registration systems. Morbidity conditions and mortality causes are coded according to the 10th Revision of the WHO International Classification of Diseases . The Health Statistics Report published annually also contains information on population and vital statistics, infrastructure and personnel, morbidity, mortality and the activities of almost all health services pertaining to the Republic of Mauritius. Most importantly, NCD Surveys that have been regularly carried out during the last 30 years provide trends in the prevalence of NCDs and their risk factors and measure impact of actions taken previously [29–31]. Other surveys conducted periodically or on an ad hoc basis such as surveys on nutrition , salt intake , tobacco control [74,75], household out-of-pocket expenditure [48,52], risky behaviours in children  and adolescents [77,78,79] also provide key information that cannot be obtained from routine sources. Annual and four-year reports are published regularly from the National Cancer Registry . Since 2015, Mauritius has been conducting NHA and it has since been institutionalized [15,51].
Integration of evidence into practice was not rated as a challenge for NCD population interventions in Mauritius. However, it was rated either as a major or major persistent challenge for nine individual NCD services. The average score for individual services was 2.6.
Adequate information solutions were rated either major or major persistent challenge for seven population interventions and for none of individual services. The average score for population interventions was 2.1 and 2 for individual services. The assessment revealed that optimal integration of evidence into practice was constrained by a number of factors, including lack of a structured process for coordinated development, reviewing (for quality assurance), updating and monitoring of the NCD disease management guidelines and protocols; absence of an action research framework for prevention and control of NCDs; and structures and mechanisms for national NCD registries have not yet been institutionalized.
Distribution and mix of human resources: Out of the total number of human resources for health (HRH) in Mauritius, 23.9% are physicians, 40% nursing and midwifery personnel, 4.7% pharmaceutical personnel, 3.6% dentistry personnel, 3% laboratory health workers, 2.2% environment and public health workers, 2.2% community and traditional health workers, 1.4% other health workers, and 19% management and support workers . In terms of health workforce distribution by services, 2.9% are in general services, 82.3% hospital and specialized services, 13.7% primary health care and public health, 0.3% treatment and prevention of HIV and AIDS, and 0.8% prevention of NCDs and promotion of quality of health. Approximately 73% of the MOHQL budget goes into remuneration of human resources for health . All medical specialists are allowed private practice two years after their registration with the Medical Council of Mauritius.
Distribution and mix of human resources was rated either major or major persistent challenge for 13 NCD population interventions and for one individual service. The average score for population interventions was 2.4 and 1.7 for individual services. The main HRH weaknesses relate to absence of written HRH policy and needs assessment which can provide evidence to optimize health workforce performance; and limited up-to-date in-service training for service providers with regard to CVD, diabetes prevention and NCD surveillance capacity.
Effective health system management: Figure 2 shows organograms pertaining to top management positions at primary, secondary and tertiary levels of the public health system.
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