REPUBLIC OF VANUATU

OFFICE OF THE OMBUDSMAN

PUBLIC REPORT

ON THE

DELAYED APPOINTMENT OF A
GYNAECOLOGIST/OBSTETRICIAN
AT
VILA CENTRAL HOSPITAL

09.12.99

6202/9/20

---------------------------

PUBLIC REPORT
ON THE DELAYED APPOINTMENT
OF A
GYNAECOLOGIST/OBSTETRICIAN
FOR
VILA CENTRAL HOSPITAL

SUMMARY

This report concerns mal-administration in the Health Department from 1994 to 1997. It raises four main issues in the health administration. These issues are:

1.	delay in recruiting a qualified gynaecologist & obstetrician for the Vila Central Hospital

2.	loss of financial assistance from the British Government for some technical positions in the Hospitals including the position of G&O.

3.	recruitment of a general health practitioner to practise as a gynaecologist & obstetrician in the major Hospitals in Vanuatu without the practitioner’s having obtained proper training and qualification

4.	degrading, tarnishing and undermining the trust and cordial bilateral relations between two sovereign states

The former Director of Health at that time, Mr Yves Niowenmal and his team of high officers in the Health Department had priorities other than recruiting a qualified specialist in G&O for the health of mothers and babies in Vanuatu. Proposals were made to them to recruit recommended candidates for the position. They however, delayed the recruitment because they had other priorities.

The British Government had signed an agreement with the Vanuatu Government for the Medical Staffing Project. In this agreement, the British Government had offered to fund the position of a qualified G&O practitioner for Vila central Hospital. The Aid Management Office and the National Planning Office provided all the assistance to speed up the recruitment, but the Health Department made no effort to recruit the G&O practitioner under this assistance. The British Government finally withdrew the funding assistance after the Health Department failed to recruit a G&O practitioner under the fund.

The Health Department recruited an expatriate general medical practitioner and employed her as a gynaecologist/obstetrician at the two major Hospitals in Vanuatu. On enquiry, the Ombudsman revealed that Dr Anita Harish had no proper training and qualification in gynaecology and obstetrics. However, she was given the responsibility to perform the duties of a G&O practitioner in the major Hospitals in Vanuatu.

The Ombudsman found that Mr Yves Niowenmal was incompetent to have held the position of Director of Health at that time. He was careless and inefficient in the performance of his official duties. He had other priorities, which resulted in the withdrawal of the British Government Assistance.

It was also found that Mr Gedion Mael and Ms Kathleen Rarua should also be held responsible for the withdrawal of the assistance. As planners of the Health Department at that time, they were both careless and negligent in the performance of their official duties.

The Ombudsman also made findings against former Acting Director of Health, Mr Daniel Kalorib; Senior Personal Officer, Mrs Judith Melsul; and Mrs Myriam Abel, a senior officer in the Health Department. Their decisions assisted Dr Anita Harish, a general medical practitioner, who had no proper training and qualification in gynaecology and obstetrics to practise as a G&O practitioner in Vanuatu. Their decisions contravened s. 5(1)(a) and s. 18(2) of the Health Practitioners Act.

The Ombudsman recommended that Mr Niowenmal and Mr Kalorib should not be appointed again to any positions of responsibility in the Public Service. The Ombudsman also asked the Public Service Commission to take disciplinary actions against Mr Mael, Ms Rarua, Mrs Abel and Mrs Melsul.

TABLE OF CONTENTS

SUMMARY
1.	JURISDICTION
2.	PURPOSE, SCOPE OF INVESTIGATION AND METHODS USED
3.	RELEVANT LAWS, REGULATIONS AND RULES
4.	OUTLINE OF EVENTS
5.	FINDINGS
6.	RESPONSES TO THE PRELIMINARY REPORT
7.	RECOMMENDATIONS
7.	INDEX OF APPENDICES

-----------------------------

1.	JURISDICTION

1.1	The Constitution and the Ombudsman Act allow us to look into the conduct of government-related bodies, and Leaders. This includes the conduct of Mr Yves Niowenmal, former Director of Health; Mr Daniel Kalorib, former Acting Director of Health; Mr Gedion Mael, former Principal Planner of the Health Department; Mrs Kathleen Rarua, former Senior Health Planner; Mrs Myriam Abel, former Acting Director of Health; and Mrs Judith Melsul, Senior Personal Officer. The Ombudsman can also look into defects in laws or administrative practices, including the long delay in recruiting a consultant in gynaecology and obstetrics for Vila Central Hospital between 1994 – 98, when aid money was made available to the Vanuatu Government for that purpose.

1.2	In this case, we enquired into the administration of the Department of Health for the reasons that aid money was made available to the Vanuatu Government from 1994 – 95 by the British Government to fund a position of a consultant gynaecologist/obstetrician at Vila Central Hospital. The money was withdrawn in 1995.

1.3	We also enquired why the Health Department and the Vanuatu Government took five (5) years to finally get a consultant gynaecologist/obstetrician specialist to Vanuatu.

1.4	We enquired into this alleged maladministration because we received numerous complaints from the adult female population about allegedly poor health care in the prenatal and maternity clinics in the Hospital.

2.	PURPOSE, SCOPE OF INVESTIGATION AND METHODS USED

2.1	The scope of this investigation is to establish the facts about the reasons why the Health Department did not employ a practitioner in gynaecology and obstetrics for the Vila Central Hospital before aid money offered to fund the position was withdrawn. This investigation is also to determine whether the administrative practices of Mr Niowenmal, Mr Kalorib, Mr Mael, Mrs Abel, Mrs Melsul and Mrs Rarua were defective.

2.2	This Office collected information and documents by informal request, summonses, letters, interviews and research.

3.	RELEVANT LAWS, REGULATIONS AND RULES 

3.1	THE CONSTITUTION

	FUNDAMENTAL RIGHTS AND FREEDOMS OF THE INDIVIDUAL

5(1)	The Republic of Vanuatu recognises, that, subject to any restrictions imposed by law on non-citizens, all persons are entitled to the following fundamental rights and freedoms of the individual without discrimination on the grounds of … sex but subject to respect for the rights and freedoms of others and to the legitimate public interest in … health—

(k)	equal treatment under the law or administrative action… 

3.2	Public Service Act (CAP 129) and is repeated in 10.1 (c), (d), (h) and (I) of the Public Service Staff Manual:

11	Every officer commits a disciplinary offence for the purposes of disciplinary proceedings who:

(c)	is negligent, careless, indolent, inefficient, or incompetent in the discharge of his duties;

(i)	is guilty of any improper conduct in his official capacity, or of any other improper conduct which is likely to affect adversely the performance of his duties or is likely to bring the Public Service into disrepute;

(emphasis added)

3.3	Health Practitioners Act (CAP 164):

5(1)	A person shall be entitled to be registered under this Act if he proves to the satisfaction of the [Health Practitioners] Board:

(a)	in the case of an applicant for registration to practise medicine and surgery or dentistry, that he is a holder of a degree or diploma granted by a recognised university, medical school or similar institution and that he is entitled so to practise in the country in which the degree or diploma was granted.

18(2)	Any person who being registered for and in respect of any health profession, practises, or holds himself out as registered to practise a health profession other than that in respect of which he is registered shall be guilty of an offence.

(emphasis added)

4.	OUTLINE OF EVENTS

4.1	In September 1993, the former Director of Health, Dr George Bule made a request to Dr Maoris Panos, a consultant in gynaecology & obstetrics at the Vila Central Hospital (VCH), to make a reference for Dr Kaiva Tulimanu, a private medical practitioner working in Vila. Dr Panos' contract was due to expire at the end of December 1993. Dr Bule’s request was made in the hope that the Health Department would submit Dr Tulimanu's application for the Public Service Commission (PSC) to consider appointing Dr Tulimanu temporarily to the position of gynaecologist/obstetrician at the VCH when Dr Panos left the country. 

4.2	On 11 September 1993, Dr Panos issued references for Dr Tulimanu and recommended him for the position. 

4.3	On 13 October 1993, Dr Bule wrote to the Senior Personal Officer in the Public Service Department, Mr Job Boe to inform him of the end of Dr Panos’ contract and to propose that the PSC consider appointing Dr Tulimanu to take over the position in G&O at VCH temporarily, during the absence of a G&O specialist. Nothing came out from that proposal

4.4	In November 1993, Dr Bule was terminated by the Vanuatu Government as Director of Health. 

4.5	In January 1994, Dr Panos left the country after completing his contract with the Government.

4.6	On 21 March 1994, the British High Commission (BHC) forwarded a proposed British funded project called 'Medical Work Force Support Project' to the former Prime Minister, Mr Maxime Carlot Korman for approval. This offer was made to the Vanuatu Government for the British Government to support and assist with the recruitment of doctors. Copies of this document were also sent to the National Planning Office (NPO) and the Ministry of Health.

4.7	On 25 May 1994, Mr Niowenmal was appointed as the new Director of Health.

4.8	On 7 July 1994, the former Director of NPO, Mr George Maniuri wrote to the Aid Management Officer (AMO) in the British High Commission, Ms Kate English, to request the recruitment of doctors under the British Technical Assistance Program.

4.9	On 8 July 1994, Mr Maniuri sent a memo to Mr Boe in the Public Service Department (PSD) with the completed form for the technical assistance in the Health Department. The post of G&O for the Vila Central Hospital was included (Refer to Annex A).

4.10	On 13 July 1994, Ms English responded to Mr Maniuri’s letter and stated that, although the project documents had been sent to the Prime Minister in March 1994 for formal Government acceptance, the British High Commissioner had received no reply from the Prime Minister. Ms English stated that they could not take any action until they received formal acceptance from the Government (Refer to Annexure B).

4.11	On 9 August 1994, a meeting was convened between the AMO and NPO. One of the agenda items of that meeting was the medical staffing support project. It was revealed in the meeting that the Prime Minister, Mr Maxime Korman had approved the above project. Ms English offered to provide advice to the Health Department and NPO on the next steps to be taken.

4.12	On 8 September 1994, Mr Boe sent a memo to the Director of NPO to confirm that approval has been given for the three positions of specialist doctors in the Health Department. The position for G&O for VCH was also included (See Annexure C).

4.13	On 16 September 1994, the Child Health Adviser at the VCH, Dr Chris Williams informed Ms English that the Director of Health has asked him to activate the recruitment of the three doctors under the British Technical Assistance. He proposed that they place an advertisement in the British Medical Journal and Bureau of Overseas Medical Service.

4.14	On 28 September 1994, a meeting was convened between the AMO and NPO. The meeting heard that during another meeting held few weeks earlier between the AMO and Health Department, it was stressed to the Director of Health that it was the Government’s responsibility to recruit the doctors as they would be funded from the low cost financing scheme. The AMO would be there only to advise. It was not their responsibility to do the recruitment.

4.15	On 18 October 1994, Dr Williams wrote to Mr Niowenmal and put forward some proposals for the former Director of Health to consider and take up with the AMO. He stated that one of the main stumbling blocks with the scheme was the need to find a contract with Vanuatu Government that would slowly allow the payment of a salary that was over and above the current doctors’ salary. This would cause considerable jealousy amongst the doctors who were already in the post and would therefore be difficult to put in place (See Annex D).

4.16	On 26 October 1994, the Senior Health Planner in the Health Department, Mrs Kathleen Rarua, wrote to the Under-Secretary of the Ministry of Health and Medical Services in the Solomon Islands, Dr Jimmie Rodgers to get information on how the Solomon Islands medical services had successfully run its Medical Staffing Support Project under a similar British Government scheme.

4.17	On 3 November 1994, another monthly meeting was convened between the AMO and NPO. That meeting revealed that sometime between 24 and 28 October 1994, a meeting was held between AMO and Health Department. It appeared that the primary reasons for the delay in the recruitment exercise were that the Health Department had not yet established the offer package, additional Health Department budget allocation or logistics of how and where to advertise for the recruitment. AMO offered again to advise on the recruitment process.

4.18	On 6 December 1994, AMO and NPO held another monthly meeting. The meeting heard that the Senior Health Planner of the Health Department had contacted the Medical Services in the Solomon Islands but no definite information had been received.

4.19	On 13 January 1995, Ms English wrote to Mrs Rarua with the information obtained from the AMO Office in Solomon Islands about the details of the package offered to the doctors under the Medical Staffing Support Project under British funds in the Solomon Islands (Refer to Annex E).

4.20	On 25 January 1995, Mrs Rarua sent a memo to the former Medical Superintendent of VCH, Dr O A Ajayi, about the technical assistance positions at the VCH. She wanted Dr Ajayi’s comments on the posts that would be left vacant at the Hospital.

4.21	On 25 January 1995, Dr Ajayi, responded to Mrs Rarua’s memo and stated that one of the positions to be filled urgently, as a matter of VCH’s greatest priority, was the post of G&O practitioner, which had been left vacant since Dr Panos had left at the end of 1993.

4.22	On 26 January 1995, another monthly meeting between AMO and NPO convened. AMO reported that there still had been no response from the Health Department on whether the Department wished to proceed with the recruitment for the three vacant positions (G&O included) under this project. AMO explained that the offer had been on the table for some 12 months and that the Health Department had been advised that if they did not respond by 31 March 1995, the offer of support by the British Government would be withdrawn.

4.23	On 23 February 1995, AMO and NPO held their monthly meeting again. AMO reported no progress for the recruitment of a G&O practitioner under the British fund. It was still maintained that if nothing happened by the above deadline, the aid money would be lost.

4.24	On 20 March 1995, the Principal Health Planner, Mr Gedion Mael met Ms English to discuss the then current situation of medical staffing in Vanuatu. One of the issues discussed was the British Government financial support for the four medical doctors’ positions in the Health Department. The position of a G&O practitioner for VCH was included.

4.25	On 21 March 1995, Mr Mael wrote to Ms English and asked for the AMO to secure the funds for the assistance in medical staffing. He stated that the Department would proceed immediately with the recruitment of doctors before the deadline, but they failed to do so.

4.26	0n 30 March 1995, another meeting was convened between the officials of the Ministry and Department of Health, British High Commission, Australian High Commission, New Zealand High Commission, NPO, VCH, French Embassy and Peace Corps. The main area discussed was to establish exactly what each donor was prepared to offer for the medical staffing project.

4.27	On 1 April 1995, a registrar in G&O at Waikato Women’s Hospital in Hamilton, New Zealand, Dr George Bugg applied for the vacant G&O post. He sent his curriculum vitae with his application to Dr Ajayi.

4.28	On 3 April 1995, the acting Director of Health Mr Daniel Kalorib forwarded to Ms English the names of the interested applicants for the three positions that were to be funded under the promised British funds. The post of G&O was also included.

4.29	On 13 April 1995, Dr Ajayi wrote to Dr Bugg and informed him that his application had been forwarded to the Department of Health to be processed. However Dr Bugg appears not to have received any follow up from the Health Department.

4.30	On 28 April 1995, another meeting between the NPO and AMO was convened. It was reported that a specialist physician, Dr Dennis Galvon had been recruited under the medical staffing support project with the British funds.

4.31	On 9 May 1995, NPO sent a memo to Mr Boe about the medical staffing project. The memo indicated that the British Government would fund the vacant G&O post for VCH under its technical assistance program.

4.32	On 16 May 1995, Mr Niowenmal sent another memo to Mr Boe about the British Government Technical Assistance Program for doctors. He also indicated that the British Government has agreed to fund the position of a G&O practitioner for VCH.

4.33	On 12 June 1995, Mr Niowenmal sent a letter to the Project Officer in the British High Commission and requested that due to the delay in the recruitment of doctors under British aid package, the terms of agreement in the project memorandum for technical assistance should be changed.

4.34	On 19 June 1995, Ms English responded to Mr Niowenmal’s request and indicated that the project detailing the terms of Medical Staffing Support Project was formally submitted by British High Commissioner to the Vanuatu Government in March 1994. The project was formally accepted by the Prime Minister on 14/07/94. After that date several meetings and discussions had been held between officials of AMO and the Department of Health to recruit doctors under the project. Unfortunately, all attempts had failed. The ‘cut off date’ for agreeing on the project support was 31 March 1995. However, ODA had agreed to extend the ‘cut off date’, provided doctors are recruited quickly. Ms English warned that the situation could not go on indefinitely and that it was crucial that Health Department take urgent action to appoint suitably qualified specialists as soon as was possible.

4.35	On 20 June 1995, in the meeting between NPO and AMO it was revealed that the Health Department had instructed the PSD not to recruit Dr Galvon. AMO stressed that it was very crucial that PSD and Health Department sit down together and prepare a contract for Dr Galvon. It was also stressed that the Vanuatu Government and Department of Health needed to do something or the Vanuatu Government would lose the aid funds. Funding for this project had been reduced from three years to two years as from this date.

4.36	On 19 July 1995, AMO reported in a monthly meeting with NPO that the Health Department and PSD have finally prepared a contract offer for Dr Galvon for the post of Specialist Physician at VCH. Regarding the vacant post of G&O for VCH, AMO stated that the Health Department had confirmed in a meeting held on 05/07/95 that they were still keen to fill the vacant position. AMO had suggested to the Health Department to advertise this vacant post of G&O widely throughout the South Pacific countries.

4.37	On 23 August 1995, in another monthly meeting between AMO and NPO, the meeting was informed of Dr Galvon's arrival in Vanuatu on 13/08/95. However, the former Prime Minister, Mr Korman had not yet approved his contract for employment. AMO was liaising with PSD for the contract to be made and signed. NPO raised its concern regarding the slow approval of all technical assistance requests. It was suggested that proposals be made to the Prime Minister to delegate responsibility to endorse technical assistance applications to another official. NPO suggested that the British High Commissioner meet with the Prime Minister to discuss the above concerns.

4.38	In August 1995, because there was no qualified G&O practitioner at VCH, a newly graduated doctor, who had only an interest in gynaecology and obstetrics, Dr Thomas Sala Vurobaravu was appointed to be in charge of the Prenatal Clinic and Maternity Ward at VCH.

4.39	On 11 September 1995, Mr Niowenmal sent a letter to the Director General of Finance, Mr Jeffrey Wilfred to request the use of Leprosy Project Funds to pay the salary of a G&O practitioner under a local contract.

4.40	On 30 November 1995, in another monthly meeting between NPO and AMO, AMO advised that since the recruitment of Dr Galvon as specialist physician for VCH, AMO had not received any further requests for support for the other two positions offered under the project. One of these posts was the G&O position for VCH. The deadline for the British Government’s offer has been extended 3 times so far to allow the Department of Health to submit the requests. The final deadline was now set for 30/10/95. There would be absolutely no possibility for further British support under this project after this date.

4.41	On 30 November 1995, Ms English confirmed in a letter to Mr Niowenmal that the deadline for requesting funds under the Medical Staffing Support Project would not be extended any further. (Refer to Annexure F). The British Aid funding was withdrawn.

4.42	On 7 February 1996, the Ombudsman received a first complaint about the poor health care services in the Maternity Ward at VCH. The complaint was about twin infants who had died just after they were born prematurely.

4.43	On 29 March 1996, Dr Galvon resigned as specialist physician at VCH. He gave his reasons as lack of support and cooperation from the Health Department.

4.44	On 2 July 1996, the VCH Management re-submitted Dr Tulimanu’s application for the position of G&O practitioner, as a matter of urgency.

4.45	On 2 August 1996, following the Ombudsman's enquiry into the death of the twins, it was revealed that VCH, the main referral hospital in the country, had been operating without a G&O specialist for more than 2 years.

4.46	On 8 August 1996, the former Minister of Health, Mr Metmetsan informed the Ombudsman that the Health Department had made provision in its budget for the post of G&O. However, he blamed the Finance Department for cutting the Health Department's budget and making it impossible for the Health Department to recruit a G&O specialist.

4.47	On 12 August 1996, the Hospital Management informed the Ombudsman that the issue of the G&O position at VCH being vacant for too long had been repeatedly discussed with Director of Health, Ministry of Health, Senior Personal Officer, Health Planner and PSD during the last 3 years. Since no positive response had been received from the Health Department and PSD for the recruitment of a G&O specialist, the VCH Management had re-submitted Dr Tulimanu’s application for temporary employment as a matter of urgency.

4.48	On 11 October 1996, Mr Kalorib informed the Ombudsman that due to the fact that the aid donors’ assistance had failed and had been exhausted, the Department of Health had requested that additional funds be budgeted for the posts of G&O specialist, physician and paediatrician in its 1997 annual budget. However, the budget for the position of G&O was omitted in the Health Department’s 1997 budget. This showed the low priority in the Health Department for the care of women. (Refer to Annexure G)

4.49	On 15 October 1996, Mr Kalorib sent application documents to the PSD for recruiting a qualified G&O specialist for VCH on a local government contract.

4.50	On 15 October 1996, Mr Maniuri informed the Ombudsman that NPO had forwarded to the Aid Management Office of the British High Commission a formal application for the funding of the position of a G&O specialist.

4.51	On 28 October 1996, the Ombudsman received another complaint of alleged poor health care services in the maternity ward. The allegation was about an infant who had died just after birth.

4.52	On 28 November 1996, the Principal Administrative Officer in the Health Department, Mr Morrison Bule sent copies of documents to indicate that the Health Department had done its very best to recruit a G&O specialist. He also stated that the Ministry of Health, Finance Department, Prime Minister’s Office, PSD, NPO and Donor Agencies had also played their parts in an effort to recruit a G&O specialist. (Refer to Annexure H)

4.53	On 1 November 1996, the Health Secretariat sent information to the Ombudsman about local doctors leaving Vanuatu to find jobs in other countries. We also received Dr Galvon’s opinion and comments on the state of health services at the Vila Central Hospital.

4.54	On 5 November 1996, Mr Kalorib made another effort to recruit a G&O specialist under the local contract. The list of doctors’ positions requested to be advertised were sent to the PSD. The post of G&O specialist for VCH was also included.

4.55	On 18 November 1996, the Administration Assistant in the British High Commission, Mr Nick Duggin informed the Ombudsman that under the Medical Staffing Support Project for 1994 - 95, the British Government had proposed to provide up to 150,000 British pounds to assist with the recruitment of three positions at VCH including a position of G&O. The Health Department had failed to meet the necessary administrative requirements to recruit the doctors for these positions. During 1995, the AMO had set a number of deadlines to speed up the recruitment process, but once the final deadline had expired on 30/10/95, the Health Department was informed that no further doctors would be supported within the time scale of the project.

APPOINTMENT OF DR ANITA HARISH AS GYNAECOLOGIST/OBSTETRICIAN TO NORTHERN DISTRICT HOSPITAL AND VILA CENTRAL HOSPITAL 

4.56	On 12 January 1995, Dr Anita Harish signed a two-year contract under the local agreement of service with the Vanuatu Government to work as G&O practitioner at the Northern District Hospital ('NDH') in Santo.

4.57	On 19 January 1995, the Personnel Officer in the Health Department, Mrs Judith Melsul sent an application to the Ministry of Health for the registration of Dr Harish to practise as a medical Officer in G&O in Vanuatu. This is a requirement under the Health Practitioners Act. However, Dr Harish was registered as a 'General Practitioner', not as a G&O practitioner, because she was not a qualified specialist.

4.58	In September 1996, Mrs Myriam Abel stated in a meeting held between the Ombudsman, Mr Alfred Maho, Mrs Blondine Boulekone, Mr Daniel Kalorib and Dr Lesley that a qualified G/O practitioner then based in the NDH would be transferred to VCH. . She was then referring to Dr Anita Harish. Dr Harish would also take on the responsibility of performing pap smears on women to detect cervical cancer. Following expressions of concerns, Mrs Abel reassured everyone by saying that Dr Harish has proper qualifications as a G/O practitioner.

4.59	On 5 November 1996, Dr Harish's contract was renewed for a further two years to work as a G&O practitioner in Vanuatu (See Annexure I).

4.60	On 31 December 1996, Dr Harish was transferred from NDH to VCH.

4.61	On 5 May 1997, Mr Kalorib informed the Ombudsman that the post of G/O practitioner had never been advertised. Dr Harish’s transfer to VCH was an internal appointment and transfer within the Health Department.

4.62	On 9 May 1997, Dr Harish’s Curriculum Vitae ('CV') was sent to the Ombudsman (See Annexure J for Dr Harish’s CV).

4.63	In May 1997, we sent Dr Harish’s CV to Dr Sue Belgrave, a consultant Gynaecologist & Obstetrician at the National Women’s Hospital in Auckland for her to review.

4.64	On 19 May 1997, after assessing Dr Harish CV, Dr Belgrave responded by saying that, 'it appears that Dr Harish had no formal training and no specialist qualification in gynaecology and obstetrics.' The training of a specialist G&O usually involves several years of supervised training in obstetrics and gynaecology followed by a formal examination. Dr Harish had no such training and examination. Vila Central Hospital, being the main referral centre in Vanuatu, needs a qualified G&O specialist. This view that Dr Harish was not a qualified G&O was consistent with Dr Harish’s registration as a 'General Practitioner', and was confirmed by Dr Harish herself.

4.65	Although Dr Harish was not a qualified G&O specialist, she was responsible for all maternity services at VCH. She regularly did obstetrical surgery (Caesarean sections), which she would not have been allowed to do as a 'General Practitioner' in her home country or in many other countries. (Neither the Health Practitioners Board nor the Health Department or VCH has clearly defined the scope of practice of a 'General Practitioner' in Vanuatu.) The nursing staff working with Dr Harish were not aware that she was not a fully qualified G&O specialist. The VCH’s surgeons, who are specialists in surgery and are qualified to conduct surgery including obstetrical surgery, were not required to do the c-sections in place of Dr Harish, despite their higher qualifications.

4.66	The Office of the Ombudsman continued to receive complaints about maternity care at VCH while Dr Harish was in charge. One case involved the death of a woman, Elsie Lovo, after a c-section delivery by Dr Harish. Dr Harish and her husband (a surgeon at VCH) both stated to this Office their belief that the death was caused by anaphylactic shock, a reaction to medication. However, all other medical and nursing personnel at VCH believed that the death was due to haemorrhagic shock (internal bleeding) from the c-section. It is impossible at this point to reach a definite conclusion as to the cause of death, since there was no autopsy, no medical review of the case, incomplete or no reports by the medical personnel, and a number of people involved left Vanuatu shortly after the death. Nevertheless, it is a serious concern that the VCH staff believe that Ms Lovo’s death was preventable, and that the care of a fully qualified G&O specialist may have avoided this death.

4.67	Dr Harish’s employment contract ended on 1 June 1998. She left Vanuatu in late April 1998 to take outstanding leave.

Further enquiry into the Health Department's effort for the recruitment of a G&O specialist

4.68	On 28 May 1997, the Ombudsman released a Public Report on the premature birth and death of the twins at VCH. One of the recommendations made to the Government in that report was to recruit a qualified gynaecologist/obstetrician specialist for VCH urgently.

4.69	In June 1997, Mr Kalorib wrote a letter of apology to the Trading Post about the incorrect and misleading statement he had made to the newspaper that Vila Central Hospital had already recruited a G&O specialist for the vacant post at VCH. He had been referring to Dr Anita Harish. Mr Kalorib had made this comment after the Ombudsman released the Public Report on the death of the twins and recommended the urgent recruitment of a qualified G&O specialist for the main health referral centre in the country.

4.70	On 22 July 1997, Mrs Melsul informed the Ombudsman that Ausaid was not interested in funding the position of a gynaecologist/obstetrician. The British Government had initially offered to fund the position but since it had cut its aid, specialist gynaecologist/obstetricians were no longer attracted to working in Vanuatu. The Health Department lodged applications to the Public Service Department to recruit a gynaecologist/obstetrician under a local employment contract, but the PSD did nothing to follow this request.

4.71	On 26 July 1997, the Director of Health, Mr Johnson Wabaiat informed the Ombudsman that the Health Department had approached the French Embassy and the New Zealand High Commission to help out with the recruitment of gynaecologist/obstetrician for VCH.

4.72	On 29 July 1997, Mr Maniuri informed the Ombudsman that NPO had received no documents from the Health Department to advertise the position of gynaecologist/obstetrician outside of Vanuatu.

4.73	On 2 September 1997, Mr Wabaiat informed the Ombudsman that the former Prime Minister, Mr Serge Vohor had signed an agreement with the French Government in New Caledonia for a gynaecologist/obstetrician specialist from Noumea to visit Vanuatu on a monthly or quarterly basis for consultancy on gynaecology and obstetrics. We were also informed that Dr Thomas Sala Vurobaravu would undertake post-graduate studies in gynaecology and obstetrics at the School of Medicine in Fiji in 1998.

4.74	On 6 April 1998, Mrs Judith Melsul confirmed that the above agreement made by the former Prime Minister, Mr Vohor and the French Government was never implemented.

4.75	In April 1998, the Ombudsman's Office was advised that the Chinese Embassy had expressed its interest in bringing in a G & O practitioner with its team of doctors, but had not received a favourable response from the Vanuatu government.

4.76	On 15 April 1998, Mr Ross Naylor, the Interim Health Advisor and Mr Wabaiat made a joint request for technical assistance to Ausaid to fund a gynaecologist/obstetrician position for Vila Central Hospital. This request to Ausaid was made to be in line with the Australian Government’s five (5) year program to assist Vanuatu in a Health Sector Planning and Management Development Project.

4.77	On 16 April 1998, Mr Wabaiat sent an official application to the National Planning Office indicating that AusAid had confirmed an interest for supporting the position of a gynaecologist/obstetrician practitioner at Vila Central Hospital.

4.78	On 16 April 1998, Mr Edgell Tari from the National Planning Office informed the Ombudsman that health officials could not contact the donor agents directly for technical assistance. Such requests would appear unofficial to donor agencies. The official procedure for a request of such nature is for the Health Department to apply to the Public Service for approval, which is later forwarded to the National Planning Office for it to negotiate with donor agencies for funding. There were times after the Government lost the funds from the British High Commission that the Department of Health approached aid agencies directly. This resulted in no positive answers to the requests made to donor agencies to fund the gynaecologist/obstetrician position. The Health Department had to submit another application through the official process for the recruitment of a gynaecologist/obstetrician specialist.

4.79	On 21 April 1998, the acting Director of NPO, Mr Jimmy Adeng forwarded an application to the Secretary of the Public Service Commission to request formal approval and endorsement of technical assistance for the position of a gynaecologist/obstetrician for the Vila Central Hospital. This followed a request made to the Ausaid Office prepared by Mr Naylor, the advisor, to review the Health Ministry and Department’s application. The request was signed by Mr Naylor and Mr Wabaiat. Mr Naylor stated to the Ombudsman during his stay in Vanuatu that he had been shocked by the lack of a G/O practitioner in the VCH. He had considered it a top priority and had initiated all steps possible to get one recruited from Australia. Apparently no one in the health sector had such priority.

4.80	On 28 April 1998, Mr Adeng made a formal Government request to the Australian Government to fund a position for a gynaecologist/obstetrician under the Australian Staffing Assistance Scheme.

4.81	On 12 May 1998, the AusAid Office in Vila confirmed in a fax to Mr Ray Marsden of CPM Vanuatu that, after the position was advertised in Australia, Mr Ross Naylor received seven (7) applications. Dr Alan Grice was selected for the position of consultant gynaecologist/obstetrician for Vila Central Hospital. He commenced a 2-year contract in October 1998.

4.82	Later, in November 1998, the new team of doctors funded by the Chinese Government also included a G & O specialist.

4.83	The statistics for stillbirths, premature births, neonatal deaths and maternal deaths at Vila Central Hospital from 1995 – 98 were as follows:

1995	1996	1997	1998

Stillbirths	17	24	26	24
Premature births	56	67	73	99
Neonatal deaths	14	12	22	18
Maternal deaths	  0	  0	  4	  2

5.	FINDINGS

Finding 1:	MR NIOWENMAL WAS INCOMPETENT IN PERFORMING HIS OFFICIAL DUTIES

5.1	I found that Mr Niowenmal was incompetent to have held the position of the Director of Health. His carelessness and inefficiency in performing his official duties in 1994 - 95 resulted in the British funds allocated for the position of the G & O specialist being withdrawn. He offered no justifiable reason for his delay in acting to take advantage of the British aid funds.

Finding 2:	MR MAEL & MS RARUA WERE NEGLIGENT AND CARELESS IN THE PERFORMANCE OF THEIR OFFICIAL DUTIES

5.2	I also found that Mr Mael and Ms Rarua were negligent and careless in the performance of their official duties. As Planners of the Health Department, they would be also held responsible for the withdrawal of the British funds allocated to fund the position of a G & O specialist for VCH in 1994 -95. They offered no justifiable explanation for their delay in acting.

Finding 3:	DR CHRIS WILLIAMS' ADVICE WAS BASED ON IMPROPER AND IRRELEVANT MOTIVES

5.3	Dr Chris Williams’ advice to the Director of Health that the payment of salary for the doctors under the British aid over and above the current doctors’ salary would create jealousy amongst the doctors was found to be based on improper and irrelevant motives. Dr Williams himself was an expatriate doctor who was also working on a contract. His advice also demonstrates that he was in a conflict of interest.

Finding 4:	MR NIOWENMAL, MR KALORIB, MR MAEL AND MRS MELSUL WERE NEGLIGENT, CARELESS AND INCOMPETENT IN THE DISCHARGE OF THEIR DUTIES 

5.4	I found also that Mr Niowenmal, Mr Kalorib, Mr Mael and Mrs Melsul were negligent, careless and inefficient in performing their official duties. Their failure to process VCH Management's request for Dr Tulimanu to be appointed temporarily as a G & O practitioner by the PSD as a matter of urgency in 1996, was delayed for no justifiable reason.

Finding 5:	MRS MELSUL'S CONDUCT WAS BASED ON AN ERROR OF FACT

5.5	I found that Mrs Melsul acted on an error of fact when she requested that the Health Practitioners Board to register Dr Harish to practise gynaecology and obstetrics in Vanuatu. Dr Harish has no formal training or qualifications in gynaecology and obstetrics.

Finding 6:	MR KALORIB'S DECISION TO TRANSFER DR HARISH WAS BASED ON AN ERROR OF FACT

5.6	I found that Mr Kalorib's decision to transfer Dr Harish from NDH to VCH to practise gynaecology and obstetrics because of the delayed recruitment of a G & O specialist was based on an error of fact. Dr Harish was not a G & O specialist.

Finding 7:	DR HARISH'S CONDUCT TO PRACTISE AS A G&O SPECIALIST WAS CONTRARY TO LAW

5.7	Dr Harish was registered as a general health practitioner under s 5(1)(a) of the Health Practitioners Act. I found that in practising in NDH and VCH as a G & O, she appears to have breached s 18(2) of the Act.

Finding 8:	BREACH OF ARTICLE 5(1)(K) OF THE CONSTITUTION – FUNDAMENTAL RIGHTS 

5.8	I found that the actions and omissions of all health officials who were directly or indirectly involved and failed in the administrative process of recruiting a consultant G/O under the British funding, appointing a newly graduated doctor, Dr Vurobaravu to be in charge of prenatal and maternity wards and transfer of Dr Harish to VCH to perform the responsibilities of a G/O, amount to a breach of the fundamental rights under the Constitution against discrimination on the basis of gender. Throughout our enquiry, we encountered total indifference and inaction on the part of the appropriate authorities on medical issues relating to the care of women in Vanuatu. The difference in the reaction of the Australian advisor, Mr Naylor, who initiated as a matter of priority an assistance project to hire a G/O, was stark. The local health administrative team was indolent, careless and negligent in assessing this priority, resulting in poor medical treatment for women and the alleged deaths of mothers and children.

It appears that such negligence was not demonstrated in such an obvious way for the posts of surgeons, anaesthetists and general practitioners who regularly applied and granted posts. I was led to conclude that issues concerning women were disregarded by the very people who should have been given them top priority. The hiring of G/O should have been top priority by the Health Department in the circumstances.

Finding 9:	MRS MYRIAM ABEL’S ACTIONS IN ISSUING A STATEMENT ABOUT DR HARISH’S QUALIFICATION WAS BASED ON AN ERROR OF FACT

5.9	I found that Mrs Myriam Abel was negligent, careless and inefficient in the discharge of her official duties when she stated that Dr Harish was a qualified G/O, without first verifying the information she would speak about. As we now know, her statement was in error. As a result, Mrs Abel brought the Health Department and the Public Service into disrepute. She allowed Dr Harish to practise as a G/O when she has no qualification in that specialised area of medicine. Such conduct by Mrs Abel was in breach of s 11(c)(d) and (i) of the Public Service Act of 1988 and s 10.1(c)(d) and (i) of the Public Service Staff Manual.

6.	RESPONSES TO THE PRELIMINARY REPORT

6.1	A preliminary report in this matter was issued on 18 August 1999 to give those persons or bodies complained about an opportunity to reply.

6.2	However, none of these persons responded to the preliminary report sent to them.

7.	RECOMMENDATIONS

Recommendation 1:	Mr Yves Niowenmal never to be appointed again to any responsible position in the Public Service

7.1	Without prior remedial training, Mr Niowenmal should never be appointed again to any responsible positions again in the Public Service. It was under his directorship of the Department of Health that the Vanuatu Government was not able to recruit the G&O specialist and secure the aid funding from the British Government.

Recommendation 2:	The Public Service Commission should impose disciplinary actions against Mr Mael and Ms Rarua. 

7.2	The Public Service Commission should imposed disciplinary actions against Mr Mael and Ms Rarua for failing to carry out their responsibilities efficiently at that time as planners of the Department of Health. The delay in their actions and advice led to the Health Department not recruiting any qualified G&O from 1994 – 98 and the loss of aid money from the British Government.

Recommendation 3:	Mr Kalorib never to hold any responsible position again in the Health Department

7.3	Without prior remedial training, Mr Daniel Kalorib should not be appointed again to hold any responsible position again in the Health Department. As Acting Director of Health, he allowed Dr Anita Harish, who holds no proper qualification in gynaecology & obstetrics to practise as a gynaecologist & obstetrician in the two major Hospitals in Vanuatu.

Recommendation 4:	The Public Service Commission should impose disciplinary actions against Mrs Abel and Mrs Melsul

7.4	The Public Service Commission should impose disciplinary sanctions against 
Mrs Abel and Mrs Melsul. They helped to make a decision for Dr Harish to practise as a G&O when in fact she has no proper qualification in gynaecology and obstetrics. Their actions contravened s 18(2) of the Health Practitioners Act. 

Recommendation 5:	The Health Practitioners Board should issue regulations or guidelines governing the practice of medical professionals

7.5	It is not clear what medical services are permitted and what services are prohibited to be provided under the certification of general medical practitioner in Vanuatu. The Health Practitioners Board should issue regulations or guidelines that clearly delineate, among other things which medical services a general medical practitioner is permitted to provided or prohibited to perform.

8.	CONCLUSIONS

8.1	To comply with Article 63(2) of the Constitution and Section 22 of the Ombudsman Act, the Ombudsman requests the Prime Minister and his Director General, the Public Service Commission and the Director General of Health to consider these recommendations and to put them into effect.

8.2	The Office of the Ombudsman must be notified of the decision and proposed steps to implement these recommendations within thirty (30) days of the date of this report.

Dated the 9th day of December 1999

Hannington G. ALATOA
OMBUDSMAN OF THE REPUBLIC OF VANUATU

8.	INDEX OF APPENDICES

A	Memo from Mr Maniuri, Director of NPO to PSD for approval for G&O position

B	Letter from Miss English, AMO, to Mr Maniuri informing him that the Government has not yet accept the health project documents put forward by the British Government

C	Memo from Mr Boe of PSD to NPO to confirm approval for the G&O positions at VCH

D	Dr Williams letter of advice to the Director of Health 

E	Miss English letter to Miss Rarua of Health Department on information about the same British Health Project that is in used successfully in the Solomon Islands

F	Miss English informed the Director of Health that the British Government is withdrawing its funding for the project that would have funded the position of a G&O at VCH

G	Mr Kalorib’s letter to inform the Ombudsman that the Health Department has been doing its part to recruit the G&O

H	Letter from Health Department showing details of negotiation for the post of G&O at VCH.

I	PSD renewed Dr A Harish contract for a further two years

J	Dr A Harish Curriculum Vitae (CV)

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