Fiji Health Sector Situational Analysis 2008 - Pacific Health Voices

Situational Analysis of the Fiji Health Sector December 2008 

A SITUATIONAL ANALYSIS OF THE 

FIJI HEALTH SECTOR 

DECEMBER 2008 

1


Table of Contents 

1. INTRODUCTION 1 

1.1. Background 1 

1.2. Objectives and Methodology used for this Situational Analysis 1 

2. THE FIJI SETTING 2 

2.1. Fiji - Demographic and Country overview. 2 

2.2. Economic and Political Situation. 3 

3. ORGANISATION, STAFFING AND FUNDING OF THE HEALTH SYSTEM. 4 

3.1. Overview of the MoH, its structure and organisation 4 

3.2. The Service Delivery Framework – a traditional model 4 

3.3. Staffing the Health System 6 

3.4. Financing the health system 10 

3.5. Planning and Managing the Health Care system, 16 

4. THE HEALTH OF THE PEOPLE OF FIJI. 17 

4.1. Key health Indicators 17 

4.2. Comparison with Pacific neighbours. 18 

4.3. Morbidity and Mortality. 18 

4.4. Key Lifestyle and other issues impacting on health of the people 20 

5. KEY ISSUES ARISING FROM THIS SITUATIONAL ANALYSIS 21 

5.1. Perception of the health services by the public. 22 

5.2. Changes in demographics and social behaviour require a rethink of the location, staffing and range of 

services provided by health facilities. 23 

5.3. Relatively Poor progress towards Achievement of Fiji’s MDGs and other designated KPIs. 25 

5.4. Old or non-functioning equipment impacts on service delivery 29 

5.5. Stock Outs of Essential drugs 30 

5.6. The importance of more focused planning and better use of management information systems. 31 

5.7. The health sector should be seen as being more than just the MoH. 32 

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5.8. The Need for an Evidence based approach to Policy and Planning. 34 

6. POSSIBLE AREAS FOR ASSISTANCE BY DEVELOPMENT PARTNERS. 34 

6.1. Overview 34 

6.2. Highest Priority Areas for AusAID Support. 35 

6.3. Other Possible Areas for support by AusAID and other donors. 37 

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LIST of TABLES 

Table 

Table 1. 2004-5 survey of population by age and ethnicity 2 

Table 2. Distribution of Health Facilities by Division 5 

Table 3. Doctor and Nurse to Population Ratio by Division 2004 6 

Table 4. MoH Medical Cadre as at 31/10/08 7 

Table 5. ‘Exit’ of staff from MoH over 5 years (2003-7) 9 

Table 6. GDP, MoH budget and MoH budget as % of GDP, 1993-2005 11 

Table 7. Govt. budget, MoH allocation and budget share, MoH revenue, MoH 

revenue as proportion of expenditure and Per-Capita Health Expenditure 1986- 

2006 

Table 8. Pharmaceutical Budget (millions FJD) 2003-2008 12 

Table 9. MOH Biomedical budget allocations 2003-2008 13 

Table 10. Examples of main areas of support provided to the health sector 

through development partners 

Table 11. Fiji’s Key Health Indicators 17 

Table 12. Selected regional comparative indicators 17 

Table 13. The Ten major causes of Morbidity and Mortality in 2007 18 

Table 14. Major causes of Mortality by diagnostic group 1998-2001 and 2005 18 

Table 15. Major causes of Morbidity by diagnostic group 1998-2001 and 2005 18 

Table 16. Fiji’s MDG Targets by 2015 25 

Table 17. Progress towards achievement of MDGs 4 and 5 26 

Table 18. Trimester of First Antenatal visits 26 

Page 

12 

14 

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ACRONOMYS 

ADB 

AIDS 

AusAID 

CCF 

CSPF 

CWM 

EPI 

EU 

FHMR 

FJD 

FSMed 

FHSIP 

FSN 

DP 

GOA 

HDI 

HIV 

HMD 

HRH 

HMIS 

HRH 

IGOF 

IT 

JICA 

KPI 

MBBS 

MDG 

MCH 

M and E 

MOF& NP 

MMR 

MoH 

MOU 

NCD 

NGO 

NZAID 

PATIS 

PC &SS 

PDD 

PEP 

PET 

PIC 

PNG 

PO 

PPH 

PSC 

SPC 

SOPAC 

Asian Development Bank 

Acquired Immune deficiency Syndrome 

Australian Agency for International Development 

Consumer Council of Fiji 

Clinical Services Planning Framework 

Colonial War memorial Hospital (Suva) 

Expanded Program on Immunisation 

European Union 

Fiji Health management Reform Project 

Fiji Dollar 

Fiji school of Medicine 

Fiji Health Services Improvement Program 

Fiji School of Nursing 

Gross Domestic Product 

Government of Australia 

Human Development Index of the UN 

Human Immunodeficiency Virus 

Hylanine Membrane Disease 

Human Resources for Health 

Health management Information system 

Human Resources for Health 

Interim Government of Fiji 

Information Technology 

Japan International Cooperation Agency 

Key Performance Indicator 

Bachelor of Medicine Bachelor of Surgery 

Millennium Development Goals 

Maternal and Child Health 

Monitoring and Evaluation 

Ministry of Finance and national Planning 

Maternal Mortality Rate 

Ministry of Health 

Memorandum of Understanding 

Non Communicable Disease 

Non Government Organisation 

New Zealand Agency for International Development 

Patient Information system 

Pacific Counselling and Social Services 

Project Design Document 

Performance Enhancing Project 

Pre eclamptic toxaemia 

Pacific Island Country 

Papua New Guinea 

Project Officer 

post partum haemorrhage 

Public Service Commission 

Secretariat for the Pacific Community 

South Pacific Applied Geosciences Commission 

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TB 

TOR 

UN 

UNAIDS 

UNDP 

UNFPA 

UNICEF 

USP 

WHO 

Tuberculosis (the disease) 

Terms of Reference 

United National 

United Nations Program on HIV&AIDS 

United Nations Development Program 

United Nation Family Planning Agency 

United Nations Children Program 

University of the South Pacific 

World Health Organisation 

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EXECUTIVE SUMMARY 

Introduction 

The health sector remains a major pillar of Australia’s bilateral assistance to Fiji. AusAID’s 

current support to Fiji is given through the Fiji Health Sector Improvement Program (FHSIP) 

and support for the Fiji School of Medicine (FSMed). In addition, AusAID currently provides 

support through a number of NGOs and a range of major regional programs in areas of 

HIV/AIDS; non-communicable diseases, support for equipment maintenance and biomedical 

engineering, visiting medical specialists and pandemic influenza preparedness. 

AusAID now wishes to build on the work of these programs and to move ahead with 

planning for a new program of support upon completion of the FHSIP. In order to make 

decisions on its future programs, AusAID now seeks to obtain good baseline data and 

analysis of the health sector situation, including progress towards achievement of the health 

related MDGs 4, 5, and 6. 

It has therefore commissioned this current situational analysis (the assessment) which will 

inform scoping and design of a future assistance program in health for Fiji sometime in mid- 

2009. The Objectives of this assessment are 

1. To provide a ‘snapshot’ of the current status of the health sector in Fiji from health 

service delivery and systems levels; 

2. To present and assess the state of health based on latest data and statistics, determine 

limitations of data and propose methodologies to enable tracking for MDGs and any 

future program support indicators; 

3. To identify opportunities and gaps for future AusAID programming, including 

strategic objectives and likely areas of impact. 

The assessment team visited Fiji from 29 th October to 18 th November. It visited health sector 

facilities and met with a wide range of government officials, international agencies, other 

development partners, training institutions and NGOs. The results of this “snapshot” mission 

and the issues that arose from it are presented in the report and summarised here. 

The Economic and Political Situation 

Fiji is an island nation in the south-west pacific, with an ethnically diverse population of 

837,271 people of whom approximately 56% are ethnic Fijians, 37% indo-Fijian and the 

remainder consisting of other ethnic groups including Caucasian and Chinese. Its main source 

of revenue is from tourism, sugar, mining and agriculture. National GDP at constant price 

was $3.505 billion in 2000 and this has grown to $5.826 billion in 2007. The country has a 

relatively good infrastructure to support its development and the populations’ standard of 

living is declining. It is rated by UNDP Human Development Index (HDI) as being one of the 

medium developed countries being ranked 92 nd among a listing of 177 nations in 2006. 

However this represents a decline from position 46 in 1995. 

Despite its middle ranking status and the important role that Fiji enjoys as a regional centre, 

its development has been curtailed over the past 2 decades by political instability. The 

country has not yet attained the levels of development that were predicted for it in the early 

1980s. There has been widespread migration to Australia, New Zealand, the USA and more 

recently selective migration to the Middle East. This is particularly apparent among the 

educated and professional groups which Fiji can ill afford to lose. Doctors and nurses have 

migrated in large numbers, as shown in this report. This outward migration is having a very 

negative effect on the staffing of the MoH. 

The Health Sector in Fiji 

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The MoH is by far the largest provider in the health sector although there is a growing private 

sector and a large number of NGOs some of whom now provide services to the public. Basic 

health care is provided to all residents through a hierarchy of village health workers, nursing 

stations, health centres, sub-divisional hospitals and divisional and specialized hospitals. This 

framework was put in place to provide ready access to all and has been functioning for many 

years. 

As stated above, this model has served the country well, but over recent years issues such as 

demographic and social change, improved transport and changing medical standards have 

meant that, while the framework is still very relevant today, the location and size of the 

building blocks requires review. Evidence seen at first hand during this mission indicates that 

some centres are overstaffed, while some are considerably understaffed. This has resulted in 

long waiting times at the general outpatient departments of divisional hospitals and some 

larger health centres. Equally important is the fact that many people are now bypassing 

nursing stations and health centres to go directly to divisional hospitals or other centres that 

are more convenient to them e.g. on a bus route or easy-access road. As a result the role of 

some centres may need to be re-assessed. 

Staffing the Health Service 

Within Fiji, this assessment mission found that workforce issues are of major concern to both 

curative and public health departments of the Ministry – although clinical areas are most 

acutely affected. In particular a shortage of key cadres of staff was reported to the team as 

being perhaps the single major issue facing the MoH – and it may worsen with the current 

directive by the PSC to reduce the workforce of the public sector by 10% . 

While there are adequate numbers of junior medical staff to fill the established positions 

(some would argue that these establishment levels have remained unadjusted for years despite 

workload increases), this assessment shows that, for all 4 levels of senior medical officers, 

including specialists, there is a serious shortage, with 36% of established positions being 

vacant. 

The continued shortage of specialist medical officers will, over time lead to a serious 

deterioration of service levels. At the divisional hospitals, waiting times for surgery are 

getting increasingly longer and the shortage of obstetricians and paediatricians is impacting 

on the care of mothers and babies. Furthermore, because of the lack of specialist medical 

officers and specialist nurses, the sub-divisional hospitals are functioning as little more than 

large health centres. Surgery, including caesarean sections, and other specialist medical 

services are no longer available at sub-divisional hospitals even though the hospitals may still 

have a functioning operating theatre and have provided these services to their communities in 

the past. 

There are shortages in other specialist areas. While there is now no shortage of generally 

trained nurses (there may in fact be a surplus within 2-3 years), there is a shortage of some 

cadres of specialist nurses, including those with specialist skills in intensive care and accident 

and emergency. Other areas of concern include biomedical engineering and IT support and 

specialist programmers. 

Funding the health service 

Financial constraints remain an ongoing problem facing the MoH. The figures presented in 

the report indicate that although there has been an increase in the size of health budget in 

recent years, the per capita health expenditure has declined from $176 in 2005 to $ 163 in 

2008. The MoH budget as a percentage of GDP was 2.57 in 2008, representing a continuing 

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and steady decline from over 4 percent in 1993. It remains the lowest percentage of GDP of 

all countries in the Pacific. 

While there is some level of cost recovery, charges are very low and the amount of revenue 

raised is negligible. Clearly public debate is needed to establish acceptable principles of 

revenue collection in the context of the political and economic state of the nation. Equally 

important there is a need for public debate on the erosion of public health financing in Fiji, 

with a view to generating commitment from successive governments to incrementally 

increase the share of GDP allocated to health to at least that of its Pacific neighbours. 

There is some level of private health insurance but this is limited to those in the workforce 

and provides access to Suva Private Hospital and, in most cases, covers offshore referral for 

medical emergency. 

The Health of the People of Fiji 

Key health indicators are presented in the report. Fiji made considerable progress in 

improving its key health indicators up to 1990, when they were seen to be excellent. During 

that period, life expectancy, and both maternal and infant mortality improved significantly, 

with MMR improving from 156.5 (per 100,000 live births) in 1970 to 53.0 in 1980 and 26.8 

in 1990. 

However since the mid 1990s, progress has stalled or deteriorated. Infant mortality rates were 

16.8 in 1990 but had worsened to 18.4 in 2007. Maternal mortality rates of 26.8 in 1990 had 

worsened to 31.1 in 2007. Both were well short of the MDGs of 5.6 for infant mortality and 

10.3 for maternal mortality. Clearly the MOH is not meeting these targets and data present in 

the full report show that under 5 mortality, infant mortality and maternal mortality are not 

only worse than the commitment given in the MDGs in 2000, but are considerably worse than 

the status in 1990. 

Particularly disturbing was a dramatic rises in the incidence of congenital syphilis to levels of 

162 cases in 5,635 lives births at the CWM hospital for the first 9 months of 2008. This also 

serves as an endpoint indicator of an antenatal care system that needs more support. 

Major causes of morbidity include infection and parasitic disease (including Dengue, TB and 

HIV), NCD, diseases of the circulatory system; accidents and injury and diseases of the 

respiratory system. Major causes of mortality include diabetes and other NCDs,diseases of 

the circulatory system, infection and parasitic diseases, neoplasms and diseases of the 

respiratory system. 

Issues affecting the health service arising from this assessment. 

Apart from financial constraints and staff shortages - especially of senior level medical 

officers - eight other important areas were identified. These include: 

1. A general poor perception of the health services by the public 

2. Changes in demographics and social behaviour require a rethink of the location, 

staffing and range of services provided by health facilities. 

3. Relatively poor progress towards the achievement of Fijis MDGs. 

4. Old or non-functioning equipment impacts on service delivery 

5. Stock outs of essential drugs are still occurring despite some progress over the past 12 

months 

6. There is a need for more focused planning and better use of management information 

systems – there appears to be a significant disconnect between the MoHs corporate 

plans and achievement of its KPIs 

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7. The health sector should be seen as being more than just the MoH – MoH should 

consider working more closely with its partners including the private sector, NGOs 

and the international agencies. 

8. There is a need for stronger evidence based approach to policy and planning and this 

will require a dedicated program or operational research 

Possible areas for future AusAID support. 

Eight possible areas of support are listed. However it is not recommended that AusAID try to 

address more than 3 of these areas - 1 or 2 would be preferable. In a review of the progress 

being made by the FHSIP that was carried out concurrently with this Situational Analysis, it 

was concluded that despite a number of important achievements no truly visible impact can 

be seen as judged by measureable progress towards the achievement of the MOHs own KPIs. 

In large measure this reflects the fact that the program’s activities are spread very widely, 

with little focus on a core set of activities. 

It is recommended that initial priority should be given by AusAID to assisting the MoH to 

achieve its MDG 4 (infant and child mortality) and MDG 5 (maternal mortality) targets. 

Although no design is included, the outline of a suggested approach to supporting this 

initiative is given in the full text. 

The eight areas identified for support by AusAID or other development partners are: 

i. Provide targeted support to the MoH to reduce its level of infant mortality (MDG 4) 

and maternal mortality (MDG 5). 

ii. 

iii. 

iv. 

provide support to address a limited number of the other national KPIs. These KPIs 

might include reduced amputation rates for diabetic sepsis (from 13% to 9%) , 

elimination of drug “stock-outs “ or reduction in teenage pregnancy rates (from 16% 

to 8%). Obviously the choice of which of the national KPIs (listed in Annex 11) 

would be a matter for the Ministry. 

Support to review the “framework” currently in place to ensure access to health 

services. This should take account of changes over the last 30 years. Such a review 

should ask the question “what do we want the health sector to look like in 2020” and 

begin planning for it now. 

Support a culture of evidence based policy. This would be done by providing support 

for key operational research projects aimed at making the sector more efficient and 

effective. 

v. A program of continued capacity development in key areas. This would include 

management and supervision; planning, monitoring and evaluation. The Project 

Officer and Performance Enhancing Projects “models” introduced through the FHSIP 

should be continued. 

vi. 

vii. 

There is a need to continue to upgrade PATIS and other Health Information Systems 

(including training). FHSIP will continue to provide some support in this area during 

2009. However it is recommended that further AusAID support beyond the end of 

FHSIP should not be continued until there is some indication as to whether the IGOF 

will provide the necessary ongoing financial and specialist staffing support to enable 

this to be sustainable. 

Continued support for NGOs, who need to scale up and widen their activities. 

Continued donor support will enable them to do this and to play a more positive role 

as “partners” of the MoH. 

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viii. 

Continued support for Regional Programs, especially in the area of disease control. 

What is proposed here is not a new program in this area but rather that the current 

regional disease control activities being supported by AusAID, and especially support 

for NCDs and diabetes prevention and control, should be continued and even 

strengthened. There should be an attempt when designing regional programs to ensure 

that activities fit within national plans and that there is greater ownership and 

understanding of the programs at the senior level within individual countries. 

Although shortages of senior cadres of staff, and especially specialist medical officers, is 

identified as a major issue impacting on the quality of health care in Fiji, no specific program 

of AusAID support is recommended here. However FSMed will need to increase its postgraduate 

output to begin to address this issue, recognising that the decision on the allocation 

of scholarships ultimately resides with IGOF. In addition the suggested programme of 

targeted support to address the MDG, by the very broad nature of the suggested approach, 

may address staffing issues in relevant areas. 

A list of recommendations made throughout the report follow. 

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Recommendations 

Recommendation 1 

Continued efforts need to be made to increase the number of medical post-graduates from the 

FSMed. With this in mind, the IGOF should continue to allocate priority for postgraduate 

medical training when it allocates scholarships, either those that are internally funded or 

funded by its development partners. 


The MoH should continue to work with the PSC to improve the salaries, allowances and 

incentives offered to specialist medical officers and specialist nurses with a view to reducing 

the level of outward migration and retaining their services within the Fiji health sector. 


The MoH should consider undertaking regular surveys at the major hospitals (and other 

centres) to determine waiting times for patients attending at different times of the day and on 

different days. Concurrently, independent patient satisfaction surveys could be carried out to 

explore other issues such as staff attitude and drug outages. The results from such surveys 

could guide the implementation of a Service Improvement Program. The FHSIP should be 

asked to include funding for such surveys within its workplan for 2009. 


The MoH should consider undertaking a review of the location, functions, staffing levels and 

operating hours of the current network of nursing stations, health centres, subdivisional and 

divisional hospitals to ensure that they better serve the needs of the people of Fiji. It is 

recognised that external assistance may be required for such a Review and development 

partners should look favourably on providing such support as it will offer the potential to 

significantly improve the efficiency of service delivery. 

The Clinical Services Planning Framework, developed with support of the FHSIP, should be 

a key tool in this exercise. 


A carefully planned study should be undertaken of antenatal care practices in Fiji, which 

should include women in both urban and rural areas. 


The MoH and its partners should consider developing “action” plans that focus specifically 

on reducing the levels of infant and maternal mortality. Such plans should cut across all 

departments of the MoH and engage with all relevant parties both within and outside of the 

Ministry. 

Recommendation: 7 

All options should be explored on ways to increase the level of funding made available 

through the national budget, and through development projects for the standardisation and 

procurement of essential biomedical equipment. 

Similarly, options should be explored on ways to increase the level of funding available for 

maintenance and repairs of biomedical equipment and to simplify the processes for the 

procurement of replacement spare parts and consumables. 

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Recommendation 8. 

Recognising the very critical state of biomedical equipment procurement and repair, 

development partners might consider a large scale biomedical equipment project that seeks to 

purchase standardised equipment for the divisional hospitals in order to bring equipment up 

to acceptable levels. Any such project should also review the processes required for the 

maintenance of equipment and purchase of spare parts. Such a project should work with but 

be outside of the current support that AusAID is giving to strengthening biomedical 

engineering departments within the region. 


Although access to essential drugs at the health facility level is improving and “stock outs” 

are occurring less frequently, more needs to be done, especially in the Northern Division. 

Any steps to improve the efficiency of drug supply should include a formal audit of the 

central pharmacy store , its processes and an assessment of the technical capacity of the staff 

to ensure that their skills match the needs of the job. FHSIP should be able to continue its 

support in this area during 2009, and include such an audit in its workplan 


The MOH should take the lead in recognising that the “health sector” consists of other 

partners besides the MOH. 

Working with outside support if necessary, it should explore ways in which it can work with 

these other parties, including private medical practitioners, to put in place more functional 

operational partnerships that better define the role of the respective partners in supporting the 

MOH to achieve the overall goals of the sector. 

It should also seek to obtain meaningful information on the range and volume of health 

services performed by these other parties. 


It is recommended that initial priority for any AusAID support beyond 2009, should be given 

to assisting the MoH to achieve its own MDG 4 (infant and child mortality) and MDG 5 

(maternal mortality) targets. 

Many of the issues raised in this set of recommendations are already known to the MoH. 

Indeed many of the recommendations take account of views expressed to the team by senior 

officials. However the recommendations themselves have not been discussed specifically 

with the Permanent Secretary and his Executive. 

xii


THE CURRENT SITUATION 

1. INTRODUCTION 

1.1. Background 

Australia remains committed to support Fiji to strengthen its health services. This reflects 

continuing support over the past decade including: community development projects in 

Kadavu and Taveuni (including the construction of new sub-divisional hospitals); 

strengthening the capacity of the National Centre for Health Promotion, support to the 

FSMed to introduce postgraduate medical training and more recently to strengthen the overall 

capacity of the School. AusAID has also sought to strengthen the capacity of the MoH to 

effectively manage its services and has provided support through the Fiji Health Management 

Reform Project (FHMRP) for management training, the introduction of the PATIS health 

information system (phase 1) and importantly to support the MoH plan for the 

decentralisation of health services. 

AusAID is currently providing ongoing support for the FSMed and the Fiji Health Sector 

Improvement Program (FHSIP), which supports the MoH to implement its own corporate 

plans across a broad range of public health, curative services and administrative services. 

In addition, AusAID has provided support to Fiji through multilateral programs, support for a 

number of NGOs and a range of major regional programs in the area of HIV/AIDS, noncommunicable 

diseases, support for equipment maintenance and biomedical engineering, 

visiting medical specialists and pandemic influenza preparedness. 

The sector remains a major pillar of Australia’s bilateral assistance to Fiji and AusAID now 

wishes to move ahead with planning for a new program of support upon completion of the 

FHSIP project. To make decisions on its future programs, AusAID now seeks to obtain good 

baseline data and analysis of the health sector and of the issues that it faces in the future that 

may impact on the effective delivery of services. This includes the achievement of the sectors 

goals, including progress towards achievement of the health related MDGs 4, 5, and 6. 

It has therefore commissioned this Situational Analysis (the assessment), which will inform 

scoping and design of a future assistance program in health for Fiji sometime in mid-2009. 

1.2. Objectives and Methodology used for this Situational Analysis 

The objectives for the assessment included in the TORs for the mission (see Annex 1) are as 

follows 

1. To provide a ‘snapshot’ of the current status of the health sector in Fiji from health 

service delivery and systems levels; 

2. To present and assess the state of health based on latest data and statistics, determine 

limitations of data and propose methodologies to enable tracking for MDGs and any 

future program support indicators; 

3. To identify opportunities and gaps for future AusAID programming, including 

strategic objectives and likely areas of impact. This assessment should be based on an 

assessment of the Fiji National Health Strategy and AusAID’s health sector programs 

in Fiji, including FHSIP, other bilateral, regional and donor partners’ programs. 

The Assessment was carried out in Fiji from 29 th October to 18 th November 2008 by a health 

development effectiveness specialist and team leader (Dr Ross Sutton); a health specialist (Dr 

Graham Roberts of FSMed) and a health data analyst (Mr Dharam Lingam – also of FSMed). 

The FSMed team members had recently commenced work on health financing and had a 

1


good level of local knowledge of the Fiji health system. Unfortunately, Dr Roberts joined the 

team late due to unforeseen family circumstances and could not participate in meetings 

during the first 5 days of the assignment. 

The team visited health facilities in the Central, Western and Northern Divisions. While in 

Suva the team met with AusAID and with officials from the MoH; CWM hospital, PSC, 

Ministry of Finance and National Planning (MF&NP), Consumer Council of Fiji, the FHSIP 

program, Attorney Generals Department, WHO, UNICEF, UNFPA, JICA and the EU. The 

team also met with a range of NGOs and community bodies including the Fiji College on 

General Practitioners (representing doctors in private practice). While in the Western and 

Northern Divisions the team visited a range of health facilities (nursing stations, health 

centres, subdivisional hospitals and divisional hospitals) and met medical and nursing staff in 

each facility. They also met with senior managers and their staff from the Community Health 

and Management Services areas. The team also met with managers and staff from PC&SS 

(an NGO providing counselling services) in Nadi. The list of Key Persons Met is in Annex 2. 

Data was collected using material available in the MoH’s annual reports and department of 

statistics, the Fiji Islands Bureau of Statistics, MoF&NP finance circulars and Fiji Budget 

Estimates, PSC, Land Transport Authority and from sources contacted during this mission. 

The analysis sought to provide a “snapshot” of the health sector and is not considered to be a 

full review. As such, the actual time allocated for the assessment was relatively short. In 

addition the team leader also undertook a “progress check” of the current FHSIP 

concurrently with the assessment mission. That report is not included here. 

2. THE FIJI SETTING 

2.1. Fiji - Demographic and Country overview. 

Fiji is a small island state at the hub of the south-west Pacific midway between Vanuatu and 

the Kingdom of Tonga. The population (2007) was 837,271 comprising 475,739 ethnic 

Fijians, 313,789 Indo-Fijians and 47,734 of other ethnic groups. Overall, the rural population 

was 412, 435 and the urban 424, 846. The average annual growth rate is 0.8% (the natural 

increase of 1.2% minus migration) with crude growth rates being higher in the Fijian than in 

the Indo-Fijian population. Areas with noticeably increased population over the past few 

years are the Western Division (55,266) and Central Division, where the population of the 

Suva and Nausori urban and peri-urban areas has increased by 32,300. Fiji’s population by 

age and ethnicity is shown in table 1. Thirty nine percent of the population is less than 20. 

Table 1. 2004-5 survey of population by age and ethnicity 

Age Group Fijian Indo-Fijian Others Rotuman All % by Age 

0-4 46,068 20,519 2,567 980 70,134 8.6% 

5-19 143,362 96,342 8,443 3,351 251,498 30.7% 

20-49 184,347 170,582 13,299 4,315 372,543 45.5% 

50-64 40,078 44,206 3,497 1,449 89,230 10.9% 

65+ 17,898 14,582 1,461 607 34,548 4.2% 

Total 431,753 346,231 29,267 10,702 817,953 100% 

% by ethn’y 52.8% 42.3% 3.6% 1.3% 100% 

Source: 2004-05 Employment and Unemployment Survey 

2


Fiji’s Economic Exclusive Zone contains 332 islands covering a total land area of 18,333 sq 

km in 1.3 million sq km of the South Pacific. It is a multi-cultural and multi-religious country 

where different cultures meet and to some extent merge. Literacy rate is around 94%, with 

English being the official language and Fijian and Hindi the languages of daily use. The 2007 

census indicated that 51% of the population is now urban with urban growth rate being 1.7% 

Fiji’s housing and employment crises are pervasive and will be compounded over time by 

high rates of school drop-out. As land leases expire and food costs rise, squatter settlements 

now number 200 with an estimated population of 100,000 people. Sixty eight percent of the 

workforce earns less than $7,000 per year. See Annex 3 for further information on income 

among different ethnic groups within Fiji. 

2.2. Economic and Political Situation. 

Main sources of revenue are tourism, sugar, mining, agriculture and bottled water. National 

GDP at constant price was $3.505 billion in 2000 and had grown to $5.826 billion in 2007. 

The country has a relatively good infrastructure to support its development but the overall 

standard of living is declining. It is rated on the UNDP Human Development Index (HDI) as 

being one of the medium developed countries, being ranked 92 nd among a listing of 177 

nations in 2006. However this represents a decline from position 46 in 1995. There is 

poverty, as reflected by the drop in ranking on the HDI, but it is not overtly apparent as seen 

in Africa, and some other Melanesian countries. However, poverty is increasingly becoming 

an issue that the present and future governments must deal with. Generally there is an 

adequate food supply for all although this should not imply that all have a well-balanced diet 

as indicated by the increasing incidence of NCDs. 

Despite its middle ranking status and the important role that Fiji enjoys as a regional centre, 

its development has been curtailed over the past 2 decades by political instability. The 

country has not attained the levels of development that were predicted for it in the early 

1980s. A series of 4 coups over the past 20 years has been a potential catalyst for an increase 

in migration from Fiji to Australia, New Zealand, the USA and more recently more selective 

migration to the Middle East. This is particularly apparent among the educated and 

professional groups which Fiji can ill afford to lose. Doctors and nurses have migrated in 

large numbers, as shown in this report. 

Thus Fiji’s economy has been repeatedly stressed by political changes since 1987 and 

subsequent fluctuations in the levels of private investment, fuelled in part by migration and 

the removal of preferential subsidies for sugar sold to the European Union, to reduce further 

by 35% in 2009. Increasing prices of oil and food imports have stressed the economy further 

while the decline in sugar production and in garments exports contribute more directly to 

poverty. The economy has become increasingly dependent on tourism, remittances from 

overseas, gold and forestry exports. 

The current Interim Government has been in place since December 2006. They have 

identified certain conditions to be in place prior to Fiji proceeding to a general election. 

These include adoption of the People’s Charter, within which Pillar 10 addresses issues of the 

health sector and proposes to ‘increase the proportion of GDP allocated to health by 0.5% 

per annum for the next 10 years to achieve a level of 7% of GDP’. The achievement of this 

objective would result in significantly increased funding for the health sector, yet in the 

current global and national economic climate achieving the increase will require continued 

advocacy for health developments in the face of competing demands; and the MoH to 

demonstrate that it uses its resources effectively. 

In the Reserve Bank Press Release (No. 30/2008 28 th November) the Governor of the RBF 

announced that “the domestic economy remained weak with growth forecast at 1.2 percent 

3


for 2008, a downward revision from the earlier forecast of 1.7 percent” and that “the balance 

of payments was still forecast to remain under pressure, underpinned by a wide trade deficit”. 

In October 2008 inflation was at 8.5% down from a 20 year high of 9.8% in September. 

3. ORGANISATION, STAFFING AND FUNDING OF THE HEALTH 

SYSTEM. 

3.1. Overview of the MoH, its structure and organisation 

The MoH is by far the largest player in the health sector. It provides health care services 

directly to citizens of Fiji and to a limited extent to tourists and persons referred from within 

the region. The MoH also serves a role monitoring compliance of outside bodies; issues 

permits, provides reports and regulates the functions of professional bodies. Basic health care 

is provided to all residents through a hierarchy of village health workers, nursing stations, 

health centres, sub divisional hospitals and divisional and specialized hospitals. This 

framework was put in place to provide access to all and has been functioning for many years. 

A more detailed discussion of this is given below at 3.2. The location of these health facilities 

is shown in maps at Annex 4. 

The Ministry underwent a process of reform commencing in 1999. Under the guidance of the 

GOF, and with support initially from the AusAID funded FHMRP, and later with support 

from the FHSIP, responsibility for much of the day-to-day operation of the health services 

was slowly devolved from the head office in Suva to restructured divisional offices in each of 

the divisions. While the head office was to retain responsibility for all policy, for national 

standards, for overall planning monitoring and evaluation of performance, the actual delivery 

of services would be the responsibility of the divisions. A feature of the divisional structure 

was the bringing together of public health and curative services under one Divisional Director 

of Health who would be in a better position to allocate resources across the two areas of 

health care within the divisions. This decentralisation process progressed steadily and after 5 

years was very widely accepted by the staff. This current assessment team heard many 

positive comments on the efficiency gains that were slowly being made through the process. 

However in 2008, subsequent to IGOF concerns to more tightly control limited government 

resources, senior staff and management functions were re-centralised into the MoH head 

office in Suva under the process of “roll-back of reform”. 

The assessment team heard many strong views in support of the original decentralisation plan 

as Divisional staff were empowered to make local-level decisions that was helping them to 

make local improvements. 

Following the recentralisation a new organisation structure for the Ministry is being 

developed with agreement of the PSC. However this has not yet been finalised. It is thus not 

possible to include an official organisation chart in this report as one has not yet been agreed. 

However, the organisation charts for HQ and sub-divisional level were recently proposed to 

PSC – but have not yet been approved (they are shown at Annex 5). 

The situation was further complicated when, early in 2007, the MoH was combined with the 

Ministry of Women and Social Welfare. 

3.2. The Service Delivery Framework – a traditional model 

The model of service delivery – from nurse to health centre, to sub-divisional hospital, to 

divisional hospitals and ultimately to the CWM as the central referral hospital, has served Fiji 

well. These different levels of the health system are defined in the Clinical Services Planning 

Framework (CSPF) as follows: 

4


Village/Community Health Service: Although not formally a MoH service, the 

Village/Community Health Service provides an important community link for MoH 

health services. 

Nursing Station Service: This is mainly a primary health care service, provided by a 

solo district nurse who is on call 24 hours a day. It caters for a catchment population 

range of approximately 200 to 5000. The average travelling time from a nursing 

station to the health centre by the most commonly used mode of transport is 1 hour 20 

minutes 

Health Centre Services: This facility provides Primary Health Care Services at a 

‘step-up’ from the nursing station as it is the first point of medical support for a 

number of nursing stations, which make up a medical area. The average travelling 

time from a health centre to a sub-divisional hospital by the most commonly used 

mode of transport is 2 hours 37 minutes 

Sub-divisional Hospital Service: General medical practitioners, midwives, registered 

nurses and assistants who work across inpatient, outpatient and community settings 

provide this service. This service operates on an on call service and is the first point of 

referral from health centre level. The average travelling time from sub-divisional 

hospital to divisional hospital by the most commonly used mode of transport is 4 

hours 20 minutes. 

Divisional Hospital Service: This service is provided by specialists, medical and 

nursing staff with a full range of diagnostic and allied health support services. The 

divisional hospital services also serve as a teaching institution for medical and nursing 

students. Divisional hospitals also coordinate visiting national and international subspecialist 

teams in Intensive Care, Cardiology and Cardiac Surgery, Plastic Surgery 

(Interplast), Neurosurgery, Urology, Vascular Surgery and Paediatric Surgery, while 

some patients are referred for overseas medical treatment. 

Specialized Hospital Service: This provides only selected specialty services namely 

psychiatry, rehabilitation and chronic infectious disease services (TB & Leprosy). 

These services are based in Suva, and act as a national referral service. 

A more detailed description of the different levels of health facilities is at Annex 6 

and table 2 shows the distribution of these different levels of care by Division 

Table 3: Distribution of Health Facilities by Division Source CSPF 2005 

Institutions 

Divisions 

Central Western Northern Eastern 

Total 

Divisional Hospitals 1 1 1 - 3 

Specialised Hospitals 3 - - - 3 

Sub-divisional Hospitals 4 5 3 4 16 

Area Hospitals 1 - - 2 3 

Health Centres 21 24 19 14 78 

Nursing Stations 17 22 20 24 82 

Community Nursing Stn 5 3 1 7 17 

Old People’s Home 1 1 1 - 3 

As stated above, this model has served the country well, but over recent years demographic 

and social change, improved transport and changing medical standards have meant that, while 

the framework is still relevant today, the location and size of the building blocks requires 

review. Evidence to this effect was presented to the assessment team and as this issue is 

5


considered to be particularly important to the efficient operation of the health system in the 

future, it is discussed in more detail at section 3.3. and especially at 5.2. 

3.3. Staffing the Health System 

3.3.1. Overview 

This continues to be a major issue in Fiji and indeed throughout the Pacific. The serious 

nature of workforce issues, and especially the shortage of key staff such as specialist medical 

officers, is reflected in the recent creation of the Pacific Human Resources for Health 

Alliance. The Alliance is a network of representatives from individual pacific island countries 

supported by regional training institutions and “interested parties” from universities and 

professional bodies in Australia and New Zealand. It aims to address continuing problems 

relating to human resource development in the Pacific. WHO currently provides the 

secretariat for the Alliance. 

Within Fiji, this assessment mission found that workforce issues are of major concern to both 

curative and public health departments of the Ministry– although clinical areas are most 

acutely affected. In particular a shortage of key cadres of staff was reported to the team as 

being perhaps the single major issue facing the MoH – and it may worsen with the current 

request to reduce the size of the public sector workforce by 10% . These Issues of the 

adequacy of staff establishments and the difficulties to respond to emerging needs, graduate 

numbers in all health cadres, emigration of health personnel, remuneration, job evaluation, 

performance appraisal and career progression have been discussed and disputed in the Fiji 

health system for many years but without a concerted and coordinated response. 

Unfortunately outward migration appears to have been accepted as an unavoidable 

phenomenon, resulting in the need to train more staff to fill vacant positions. However, the 

provision of newly trained staff to replace experienced staff is not an adequate response. 

Senior staff are leaving and are being replaced by less senior level staff, thus potentially 

putting at risk the overall quality of the workforce. Unfortunately in the current economic 

climate, the potential to increase staff establishments is unlikely, although within-budget 

changes to the mix of staff should be possible. This will be important to establish as it will be 

an unavoidable outcome of the review of the current service delivery framework referred to 

above at 3.2 and discussed in more detail at section 5.2. 

3.3.2. Service Delivery Staff 

Table 3 shows the number of doctors and nurses employed in each division. 

Table 3: Doctor and Nurse to Population Ratio by Division 2004 

Doctors 

Approved Popl’n Ratio 

Nurses 

Approved Popl’n Ratio 

Positions 

Positions 

Central/Eastern 159 1: 2704 890 1: 439 

Western 121 1: 3035 539 1: 516 

Northern 58 1: 3104 273 1: 586 

NATIONAL 338 1: 2896 1702 1: 532 

Note: These figures include only clinical posts and not senior administrators. 

Medical Staff 

Table 5 lists total medical staff engaged within the MoH. While there are adequate numbers 

of more junior medical staff to fill the established positions (some would argue that these 

establishment levels have remained unadjusted for years despite workload increases), the 

table shows that for all 4 levels of senior medical officers, including specialists, there is a 

6


serious shortage, with 36% of established positions being vacant. Clearly this has major 

implications for the delivery and quality of health services and for the supervision of medical 

students and interns within the public health system. 

Table 4. MoH Medical Cadre as at 31/10/08 

Post Grade Approved 

Establishment 

7 

Filled 

Vacant 

Consultant Specialist MD01 35 22 13 

Chief Medical Officer MD02 25 18 7 

Principal Medical Officer MD03 44 32 12 

Senior Medical Officer MD04 79 46 33 

Medical Officer MD05 168 170 +2 

Medical Intern MD06 35 49 +14 

Medical Assistant MD07 10 10 Nil 

Total 396 347 49 

Note: the surplus in ‘filled’ intern positions is of M.O.s held against those post. 

Shortage of Specialists and Senior level medical staff. 

The continued shortage of specialist medical officers will, over time lead to a serious 

deterioration of service levels. At the divisional hospitals, waiting times for surgery are 

getting increasingly longer (although an intense campaign of extended work-hours is 

currently seeking to address this); and the shortage of obstetricians, gynaecologists and 

paediatricians is impacting on the care of mothers and babies. 

This shortage of specialists has been felt for some years. For example, because of the lack of 

specialist medical officers and specialist nurses, the subdivisional hospitals have been 

restricted in the range of services they provide. The assessment team was continually told that 

surgery, including caesarean sections, and other specialist medical services are no longer 

available at subdivisional hospital even though the hospitals may still have a functioning 

operating theatre and have provided these services to their communities in the past. As 

examples, the subdivisional hospitals at Kadavu and Taveuni, constructed during the past 10 

years with AusAID support, have fully fitted-out operating theatres but do no surgery due to a 

lack of qualified surgeons. 

One factor associated with this shortage of specialists is the constraints on the FSMed to train 

enough medical officers – some of whom will go on to become specialists. A second reason 

for the shortage is the “pull” from countries both inside and outside the region who are 

offering much higher salaries but also, importantly, offer more attractive working 

environments. A third is what many have called the “push” being placed on doctors because 

of the stress they experience each day because of high workloads and poor working 

environments (lack of equipment, drugs etc). Together factors 2 and 3 result in a large level 

of outward migration as discussed at 3.3.3. 

General medical officers and private medical practitioners. 

Table 4 indicates that, compared with the establishment, there is no shortage of medical 

officers. Indeed there may be a slight surplus. However this may need to be interpreted with 

some caution as many of these positions are currently filled by foreign doctors from India, 

Philippines, Bangladesh, Burma, Nigeria, Pakistan and China on contract with the MoH. 

(Previously, in the 1980s Fiji sourced its overseas trained medical officers from Australia, 

UK and New Zealand). The cost of engaging these contracted doctors is higher than for 

equivalent local doctors and it is government policy to ultimately replace these doctors with 

locals.


When reviewing the medical workforce of Fiji, it needs to also be taken into account that 

there are currently approximately 120 medical officers in private practice (25% of the total 

medical workforce). In the main these are general practitioners; few are specialists and thus 

they will not help address the problem raised above. However, these general practitioners are 

providing a wide range of consultations, including antenatal care and childhood vaccinations. 

They are part of the health sector although the work they do is not included in the country’s 

overall health sector statistics. PSC mechanisms do exist to engage these doctors on a part 

time or locum basis within health centres and hospitals should this be needed in selected 

situations. These mechanisms have been tried on a small scale and there have been some 

problems but equally there have been some successes. However until this matter has been 

more fully explored, the role and use of private general practitioners in the public sector 

cannot be said to have been fully addressed. Using them more effectively will give the MoH 

greater flexibility in regard to medical officer staffing. 

In other steps to help relieve the shortage of medical officers: the FSMed has increased its 

intake of medical students from 70 to 80, of which 70 will be from Fiji. Another new medical 

school (under the University of Fiji) has just commenced in Lautoka, although its viability is 

still to be proven, and fifteen Fijian medical students have been selected to undertake training 

in Cuba where their tuition will be in Spanish. It will be another 5-6 years before a judgement 

can be made on the registration and value to the Fiji health system of the Cuban graduates. 

Nurses, allied health and paramedical staff 

A similar phenomenon exists in the nursing cadre, with vacancies in higher levels but 

surpluses (against establishment) in lower level positions. Whether the MoH actually needs 

more nurses will be better established by the review proposed at recommendation 4. Because 

of the current establishment levels, the MoH now has difficulty in employing the number of 

new nurses that graduate annually. Last year the graduates of the Sangam School of Nursing 

in Labasa were not absorbed – and it appears that some graduates from the Fiji School of 

Nursing (FSN) will not be absorbed in 2009. 

Tables listing nursing, allied health and paramedical staff are given in Annex 6 

While there is now no shortage of generally trained nurses at the staff nurse level, there is a 

shortage of some cadres of senior level nurses and importantly of specialist nurses including 

those with specialist skills in intensive care and accident and emergency. Nurses trained in 

these areas are in demand from the more developed countries. Many nurses are migrating to 

Australia, New Zealand and to Dubai and other destinations in the Middle East (see 3.3.3.) 

where high salaries are on offer. It is understood that a considerable amount of the resignation 

and outward migration of nurses shown in Table 8 below relates to these specialist nurses. 

The team was informed that in part this represents the attraction of higher salaries and 

working conditions but in part it is a reflection of the fact that promotion for nurses in Fiji is 

usually based on seniority and not necessarily on merit or special skills. As a result these 

specialist nurses, who in many cases have graduated in the last ten years, find that, despite 

their specialist skills, to get promotion they must move outside of their specialty or go 

overseas. 

Annex 6 shows that there is generally no shortage of established paramedical and allied 

health cadres in Fiji. Important however is the fact that there are no posts for cadres that are 

considered essential in many countries’ health systems – psychologist, counsellors, social 

workers, occupational health workers, podiatrists among others. As discussed elsewhere in 

this report counselling services within Fiji are now being provided by the NGO Pacific 

Counselling and Social Services (PICASS). 

Other Cadres of staff. 

8


There are two other staffing areas of concern, which are in biomedical engineering and IT. 

The MoH has had perennial difficulty in maintaining its biomedical equipment. AusAID 

support has previously been provided in this area but the problems remain as discussed in 

section 5.4. of this report. At the root of this problem is the ongoing difficulty of recruiting 

biomedical engineers. There is need both to increase the establishment in this area and have 

biomedical engineers in each of the three main hospitals and also create attractive salary and 

conditions to hold such people who otherwise will be attracted to other areas such as 

telecommunications, and airline equipment maintenance. The costs in external maintenance, 

transport of equipment needing repair, downtime of equipment and importantly in 

deterioration of patient care because of poor equipment, far exceeds the cost of employing 

specialist staff. See section 5.4 for further discussion on the poor state of equipment within 

the health sector. 

Similarly there is an acute shortage of IT specialists and the level of computer literacy is 

often low. Although FHSIP provides funding to support a full-time IT Specialist for MoH, 

the need for IT staff to maintain, extend and fully utilise PATIS was apparent to the team. 

The limited application of PATIS may undermine its success, while those who use it find it 

can provide valuable information. It is apparent that the additional workload placed on nurses 

to enter data into PATIS is a barrier to its success, and it would be wise for MoH to allocate 

resources and develop people and procedures to improve data entry and the use of PATIS as a 

management tool (see also 5.6). 

3.3.3. The Problem of Resignation and Outward Migration from the MoH 

The importance of resignation and outward migration has already been discussed. Table 5 

shows the ‘exits’ of staff from the public health care system between 2003 to 2007, through 

resignation, retirement, death or expiry of contract, revealing a high turnover in all cadres . 

In these five years the equivalent of 40% of the medical and 33% of the nursing approved 

establishments exited the public health system. 

Table 5: ‘Exit’ of staff from MoH over 5 years (2003-7) 

Cadre 2003 2004 2005 2006 2007 Total Av.p.a. 

Medical Officers 29 40 37 31 23 160 32 

Nurses 25 64 162 216 78 545 109 

Paramedical 15 15 19 19 13 81 16 

Dental 4 4 13 10 5 36 7 

Pharmacy 4 3 18 8 8 41 8 

Total 77 126 249 284 127 863 173 

This issue of resignation and outward migration of senior medical and nursing staff has been 

discussed earlier and remains a major problem for the Ministry and for the PSC. 

A recent study of specialist medical officer migration (Oman 2007) ‘Should I migrate or 

should I remain? Professional Satisfaction and career decisions of doctors who have 

undertaken specialist training in Fiji’ based on 3 elements of professional growth, service 

and recognition. Dissatisfaction was directed primarily at the MoH and the failure to reliably 

provide basic medications and supplies, as well as problems of career advancement created 

by bottleneck from limited numbers of senior postings. Oman’s also found a ‘centrality of 

the professional values of service, patient welfare regardless of ability to pay’ as a very great 

advantage from the standpoint of the MoH’ and goes on to propose 3 intervention areas to 

improve retention: supporting the work of doctors, supporting professional development and 

career advancement and valuing and supporting doctors as members of families, extended 

families and communities. 

9


3.3.4. Training the Clinical Workforce 

There are two major clinical training institutions in Fiji – the Fiji School of Medicine and the 

Fiji School of Nursing. Annex 7 shows the output from these two major training institutions. 

It must be remembered that FSMed also serves as a regional training centre and that only 

60% of medical graduates are from Fiji (64% in 2008). 

It has already been discussed that simply graduating new doctors or nurses will not address 

the immediate shortage of senior staff. As shown in tables 5 and Annex 8, the number of new 

Fiji medical graduates is almost matched by the number of doctors exiting the service. 

FSN and FSMed have consistently increased their intakes in response to the demonstrated 

needs arising from migration and high turnover – and the ever increasing need for Fiji to 

engage contracted foreign doctors. Unfortunately it is not possible to develop any specific 

“formula” to determine the number of staff that need to be trained to overcome losses. This is 

because the numbers leaving the services vary very significantly from year to year eg after 

political events such as a coup or after “recruitment drive”, by representatives from other 

countries eg the United Arab Emirates. 

Nevertheless this need to train more doctors should continue, even though data presented 

earlier in this report indicates that there is currently a slight surplus against establishment of 

the more junior levels of medical officer. This must be interpreted cautiously. There is a need 

to replace many of the lower level contracted foreign doctors in both Fiji and the PICs, and 

the need to consider contracting more senior medical staff at specialist, senior, chief and 

principle levels to improve the quality of health care services and also to support the training 

of local medical staff. 

Obviously the need to continue to train medical specialists through the Postgraduate Masters 

and Diploma level course at the FSMed should continue and indeed be given an even higher 

priority. 


Continued efforts need to be made to increase the number of medical post-graduates from the 

FSMed, With this in mind, the IGOF should continue to allocate priority for postgraduate 

medical training when it allocates scholarships, either those that are internally funded or 

funded by its development partners. 


The MoH should continue to work with the PSC to improve the salaries, allowances and 

incentives offered to specialist medical officers and specialist nurses with a view to reducing 

the level of outward migration and retaining their services within the Fiji health sector. 

3.4. Financing the health system 

From the outset it is important to note that the financial figures presented in this report have 

been vetted by the National Planning Office but there may be some discrepancies from those 

in the MoH accounts. 

3.4.1. Overview 

Health services in Fiji are primarily provided by government and financed almost exclusively 

through tax revenues. Other sources of funding for the MoH are donor assistance for service 

enhancements, a small cost-recovery program of user charges, a revolving drug fund account 

(from community pharmacies) and the government pharmacy’s bulk purchasing scheme. 

10


Government allocations to the MoH vary according to policy and fiscal priorities. Developed 

countries spend in the order of 7% to 10% of GDP on health). Fiji’s government allocation of 

2.6% of GDP is the lowest among Pacific regional neighbours (UNDP 2007/2008). The 

Solomon Islands and Tonga allocate between 5-6% of GDP to health annually, Samoa 

between 4-5% and Vanuatu and Papua New Guinea over 3%. Table 6 illustrates that in Fiji, 

the proportion of GDP allocated to health has fluctuated around 3% but has fallen below that 

since the year 2000, placing pressure on the capacity to provide a quality national health care 

system and to continually upgrade it. This ongoing financial constraint is of major concern. 

The collection of fees for services provided to patients and others remains a strategy for 

raising revenues, but the existing fee structure allows for only a token level of cost recovery, 

down from 14% in 1962 to less than 1% of expenditure since 1992. 

Table 6. GDP, MoH budget and MoH budget as % of GDP, 1993-2005. 

Fiscal Year 

GDP ($ MOH Budget MoH Budget as % 

millions) (Million FJD) of GDP 

1993 1707.00 68.57 4.02 

1995 2799.00 78.11 2.79 

1999 3662.00 107.90 2.95 

2000 3505.00 124.20 3.54 

2003 4245.00 136.88 3.22 

2005 4731.00 136.88 2.89 

2006 5032.00 147.06 2.92 

2007 5079.00 142.67 2.81 

2008 5826.00 150.00 2.57 

Source: Bureau of Statistics, Fiji and Fiji Budget Estimates 

All services provided at outpatient departments and the general public wards are free. 

Inpatient services are provided free of charge unless patients choose to be admitted to ‘paying 

wards’ where a range of fees are charged for diagnostic services in addition to the room 

charges. The ‘paying ward’ fees have not been subject to review since 1982 and are very low. 

As an example, civil servants in Fiji pay only $0.60 cents per day for the general paying 

wards (4 bed per room) and $1.00 for the single bed room ‘paying wards’, while non-civil 

servants will pay $6.00 per day for the ‘paying wards’ and outpatients referred by a GP to a 

specialist clinic will pay $8.00 per consultation. We understand that the MoF&NP is 

currently reviewing hospital charges and that new rates may apply soon, although discussion 

with important stakeholders, such as the Consumer Council of Fiji, has not yet taken place. 

Determining a level of fees that discourages frivolous use without discouraging essential use 

requires careful calculation and a degree of policy expertise and action that has not been 

evident in health financing in Fiji to date. Policy inactivity on this issue over recent decades 

may reflect political caution, but in an era of sharply rising costs it has inevitably propelled 

Fiji towards under-funded and limited services. 

The MoH has not attempted to compete with the growing private sector, yet it has the 

opportunity to partly privatize all three Divisional Hospitals by upgrading the standard of 

accommodation, by raising the fees in the ‘paying wards’ and establishing cost-sharing 

relationships with private health insurers. It is doing this in some places such as Nadi subdivisional 

hospital, where services to tourists are important. This approach is now practiced 

widely in some countries eg Indonesia where in some provinces, such as Bali, income from 

private ward patients in public hospitals is considerable and contributes to supporting public 

services. 

3.4.2. National budget 

11


Table 7 shows annual national budgets, health budgets and per capita expenditures from 1986 

to 2007. Despite the declining national budgets as a percentage of GDP (see above) there has 

been a relatively consistent proportion of government resources, and an increasing per capita 

expenditure, allocated to health. 

Table 7: Govt. budget, MoH allocation and budget share, MoH revenue, MoH revenue 

as proportion of expenditure and Per-Capita Health Expenditure 1986-2009. 

Fiscal 

Year 

Whole of 

Govt. 

Budget 

(Million 

MoH 

Budget 

(Million 

FJD) 

MoH Share 

of Govt. 

Budget (%) 

MoH 

Revenue 

(Million 

FJD) 

MoH 

Revenue as 

% of Health 

Expenditure 

Per capita 

Health 

Expenditure 

(FJD) 

FJD) 

1986 383.30 35.00 9.13 1.10 3.10 49.30 

1990 522.10 42.00 8.00 1.10 2.60 54.83 

1992 550.50 44.40 8.06 0.80 1.80 55.64 

1993 815.99 68.57 7.50 1.63 2.60 79.89 

1994 830.64 73.26 8.30 1.54 1.20 88.40 

2000 1,097.96 124.20 9.00 3.05 3.10 123.18 

2002 1,225.49 134.13 8.90 1.40 1.20 125.87 

2004 1,313.30 134.13 10.20 1.41 1.00 158.61 

2005 1,424.48 136.88 10.00 1.30 0.80 176.55 

2007 1,572.37 142.67 9.07 1.70 1.10 174.71 

2008 1,527.91 150.00 9.82 1.60 1.20 163.26 

2009 179.51* 

Source: Fiji Budget Estimates, Bureau of Statistics. 

* The announced 2009 budget includes an amount of FJD 27.445 million for Women and Social 

Welfare. 

Annex 9 provides further detailed information on the budget and illustrates how in the 15 

year period 1993-2008 the population of Fiji increased by 7.3% (56,096 people), Gross 

Domestic Product (GDP) more than tripled, the MoH budget more than doubled, the 

Consumer Price Index (CPI) increased by 48 %, the MoH Salaries and Wages bill more than 

doubled in absolute terms and averaged 53% of the MoH budget over the period. Salaries 

have increased to over 60% of the annual budget in recent years. 

3.4.3. Breakdown in expenditure by cost centres. 

Annex 10 gives detailed breakdown by cost centre of the MoH budget for two successive 

years. This provides the reader with some indication of allocation of funds across the areas of 

activities. Two specific areas are highlighted here: pharmaceutical and biomedical equipment 

procurement costs. Both have been identified by the team and by those interviewed during 

this mission as being “issues of concern” 

Pharmaceutical Costs 

Much has been said of the outages of essential drugs within the health system and this is 

discussed in more detail at section 5.5. The figures in table 8 below indicate that despite 

rising costs of drugs, expenditure remained constant from 2003 until 2006. It was not until 

2007 that there was a meaningful increase in this area. 

Table 8. Pharmaceutical Budget (millions FJD) 2003-2008 

2003 2004 2005 2006 2007 2008 

8.032 8.032 8.032 8.032 9.5 9.5 

Procurement of Biomedical equipment 

12


The budget for the purchase of biomedical equipment is given in table 9 below and these 

show that the situation is even worse in this area – with no increase in expenditure over the 

past 6 years. Indeed there has been a significant decrease in 2008. In large part this explains 

the ongoing problems now being found with the shortage of functional essential equipment. 

See section 5.4. for a detailed discussion of the problems occurring in this area. 

Table 9. MoH Biomedical budget allocations 2003-2008 

Type of Facility 2003 2004 2005 2006 2007 2008 

Urban Hospitals 700.000 500,000 700,000 700.000 700.000 500,000 

Sub divisional 700,000 700,000 700,000 700,000 700,000 500,000 

Hospitals 

H/Centre’s and 500,000 400,000 400.000 400,000 400,000 500,000 

nursing stations 

Total 1,900,000 1,600000 1,800,000 1.900000 1.800000 1.500.000 

3.4.4. Private insurance 

The feasibility of health insurance in Fiji is limited by poor economies of scale due to the 

high proportion of the population not formally employed, employed in low-paying jobs, or 

situated in remote geographical areas. Fiji has approximately 1.5 million outpatient visits and 

50,000 inpatient admissions annually. A government funded health insurance program such 

as Medicare in Australia does not appear to be feasible. While reviews of the feasibility of 

private health insurance schemes have been undertaken in the past, the growth in private 

practice may provide some justification for another review of the health insurance options 

available to Fiji and their potential impact on the relative rates of admissions to private and or 

public hospital ‘paying wards’ and redirecting some patients from the general outpatient 

department of the divisional hospitals to private general practitioners. At this stage prime 

responsibility should lie with the private health insurance companies to initiate any review. 

However if it is given priority by the MoH, a development partner such as AusAID or the 

ADB may support such a review – with a view to putting a proposal to government and the 

private insurance industry that takes account of the findings. 

3.4.5. Out of pocket expenditure 

National Health Accounts (NHA) show the community meeting 20% ($27 million) of all 

national health expenditure from its own pocket. Almost 3.5% ($4.8 million) is spent on 

health insurance premiums and 5.4% ($7.3 million) spent on pharmaceuticals at private 

providers. The true cost of health expenditure paid to private general practitioners is not 

reflected as there is no system in place for capturing the extent of these costs. 

Although out-of –pocket expenditure is high compared with other PICs it is not high by 

international standards. In many medium income Asian countries the private expenditure on 

health care is often of the order of 50%. In some countries e.g. Cambodia this may rise to as 

high as 80% of total health care expenditure. 

When all government and private costs are taken into account the total level of national 

expenditure on health is likely to be about 4% of GDP. 

3.4.6. Support from Development Partners 

Fiji is not a donor dependant nation, with development assistance to the health sector 

constituting less than 6% of the total health care budget in most years. However this may 

vary from year to year with some years seeing increased donor support through large 

infrastructure projects; the national pharmacy store, the Pasifika campus of FSMed and the 

new paediatric hospital being examples during the last 10 years. In terms of support for 

ongoing operations, AusAID is the major development assistance partner to the sector. 

13


Nevertheless development partners do play an important role in supporting the health sector. 

This support is given through four main pathways (a) direct bilateral programs/projects (b) 

assistance directly to NGOs/CBOs (c) regional programs in areas such as NCDs, HIV/AIDS, 

pandemic preparedness and (d) donor support to the international agencies and “funds” who 

in turn provide assistance to the sector. While direct bilateral assistance is, in most cases, 

captured through the national accounts, the monetary value of much of the assistance given 

through other channels is not shown in the national accounts. For this reason it has not been 

possible for this assessment mission to put a dollar value on total value of development 

assistance to the sector. However an indicative assessment over a 5 year period would be of 

the order of $6-10 million per year. Nevertheless Table 10 below gives an indication of the 

nature of the support going to the sector. It should be noted that there is some double 

counting in this table as partners such as AusAID and NZAID may provide funds to an NGO 

or international agency who, in turn provides additional funds from their own resources, to 

help implement a program. 

Currently AusAID and JICA are the only development partners with bilateral programs in the 

health sector. NZAID has a considerable regional program, as shown in the table below; the 

EU has no program in the health sector at the moment. The team were told that neither 

NZAID or the EU have any plans to change this position. JICA will continue with its current 

programs (support for EPI, middle level nurse supervision training and filariasis eradication) 

but have not made decisions on future activities in the health sector. 

Despite their current plans, all development partners met during this mission did express an 

interest in learning of AusAID’s plans for the future. WHO and UNICEF both indicated that 

they will give high priority to any approach to reduce the level of infant and maternal 

mortality and in this regard WHO advised the team that they shortly hope to appoint a 

specialist MCH adviser. 

It is therefore possible that, subject to the design of any future program, there may be 

opportunities for these partners to collaborate, particularly if any new program is in an area of 

high priority for them such as infant and maternal mortality. Increasingly development 

partners and the MoH have recognised the importance of donor harmonisation – in keeping 

with the principles of the Paris Declaration. This harmonisation of approaches among donors 

is likely to produce more partnership arrangements in coming years, as it has previously been 

identified that to do otherwise places too great a demand on counterparts; with MoH staff 

being asked to defer other important tasks to conform to donor processes and timelines. 

Table 10. Examples of main areas of support provided to the health sector through 

development partners 

Development 

Partners 

Areas they are supporting 

AusAID • Fiji Health Sector Improvement Program (multiple projects) 

• Support for FSMed 

• support visiting specialist program 

• support for Pacific Human Resources for Health Alliance 

• FSN curriculum development 

• Pacific Regional Influenza Pandemic Preparedness Project 

(PRIPPP) 

• Regional NCD 

• Regional HIV/AIDs 

14


• Regional biomedical engineering and equipment maintenance 

• ADRA Australian Development Research Awards 

• Support for a range of NGOs including 

• PC&SS training of qualified counsellors 

• Marie stopes 

• Fiji Red Cross Society 

• Fiji network for people living with AIDS and HIV 

• Femlink 

• Consumer Council of Fiji 

JICA • Support for Pharmacy and Consumables System 

• EPI Cold Chain System 

• Middle level nurse supervision -Protocols and Manuals etc 

• support for elimination of Filariasis 

NZ Aid • Support for tertiary health services in New Zealand 

• Support for a wide range of NGOs through relevant regional 

programs 

• Pacific Regional Influenza Pandemic Preparedness Project 

• International Planned Parenthood 

• Pacific Islands Aids Foundation 

• Marie Stopes 

• Foundation for Peoples of the South Pacific International 

• Pacific Disability Forum 

SPC • Adolescent reproductive health 

• HIV – regional coordination 

• Support to HIV/AIDS 

• PRIPPP (pandemic influenza preparedness) 

• NCD 

UNICEF • MCH/EPI 

• Immunizations/vaccines/ cold chain support 

• Promote life skills training in the community 

• Funding support to Peer Educators 

• Address non-nutritious food advertising 

• Promotion of Breast feeding through Baby Friendly Hospital 

Initiative 

• To increase the knowledge and understanding of sexual health 

issues 

• Integrated prevention of Mother to child transmission of HIV 

(PMTCT) 

WHO • Pacific Framework for Prevention and Control of Non 

Communicable Diseases (with SPC and AusAID) 

• Water Safety Plans (with SOPAC & AusAID) 

• Strengthening Specialized Clinical Services in the Pacific 

PHRHA (with AusAID) 

• Communicable Diseases Surveillance 

• Outbreak response Measles, Typhoid, Dengue Fever 

• International Health Regulations 

• HIV response 

• Pacific Human Resources for Health Alliance (AUSAID 

through WHO) 

• FSN post-basic program development 

• Pacific Elimination of Filariasis 

FSMed • Non Communicable Diseases/ Physical Activity 

• Accident and Injury Prevention 

15


UNFPA • Regional Reproductive Health Training program 

• Increase access to condoms.(commodity security) 

• Men as Partners in Reproductive Health (with ILO) 

• Adolescent training 

UNAIDS • Support to NACA 

• World AIDS Day 

NGOs • AIDS Task Force Fiji (VCCT and HIV testing) 

• Marie Stopes International (condom social marketing VCCT and 

HIV testing) 

• PC&SS Counselling training and service provision) 

• International Red Cross 

• Foundation of the Peoples of the South Pacific (youth mental 

health) 

3.5. Planning and Managing the Health Care system, 

3.5.1. The Planning process. 

Planning at the top level of the MoH HQ and Divisions has progressed well and well 

documented Strategic and Corporate (annual) plans appear comprehensive. However these 

plans are static and do not qualify as “action” plans which seek to address the national KPIs 

(Annex 11 provides a list of the national KPIs). 

Until recently, planning processes at the divisional level have integrated curative and public 

heath arms of the service, but these have recently been separated again during the ‘roll-back’. 

Comments most frequently made to the team relate to 

i. the need for plans to be inclusive of the activities of partner organisations; 

ii. 

iii. 

iv. 

plans have not been well communicated down through the organisation. 

activity plans created at lower levels lose the strategic focus of partnering and become 

internal; and 

that the planners are generally medical staff – not professionally trained managers. 

While some aspects of planning are sound, much more needs to be done. (See 5.6 for a more 

detailed discussion of this issue, along with a discussion on the use of health information 

systems, including PATIS, to monitor progress of the plans). 

3.5.2. The slow but steady development of a pool of trained managers. 

Recent years has seen little change in personnel at the higher management levels of the MoH. 

The senior MoH staff are predominantly medically qualified and with MPH degree in which 

they may have been exposed to basic management training. Various training programs have 

been conducted over the past 10 years, especially through the FHMR project and more 

recently through FHSIP to supplement their management skills. Comment made to the team 

(and a view supported by the team) is that, of all of these management training activities, the 

most effective appears to be the use of ‘learning by doing’ experience established by the 

FHSIP project officers “ model” where project officers were given a specific project task and 

the responsibility to carry them out. Supportive training was provided to these people, who, 

on interview, appeared to have learnt much from the experience which they will carry into 

their careers.. The Performance Enhancing Projects” model, also introduced by FHSIP is also 

proving to be effective - especially at the level of senior clinicians and managers. 

The postgraduate diploma in health services management at FSMed has recommenced, 

creating the opportunity for further development of management courses and short courses 

16


for MoH staff. It is acknowledged that creative management is difficult in the IGOF system, 

where much of the authority is centralised into the PSC or the MoF&NP. It was often stated 

to the team that policies of bodies such as PSC stifle the use of many management skills 

learned and replace them with a set of rigid rules that deny flexibility. We gained the 

impression however that, while this is true, a weakness in MoH management was in the 

capacity to prepare convincing, factually based management submissions to present to the 

PSC and MoF&NP to justify requests for procedural or distributive changes e.g. changes in 

staff establishment numbers. 

The quality of management within the health sector would also be enhanced by (a) creation 

by the PSC of formal classifications of professional health care managers and (b) the 

creation of a professional grouping of health sector managers with minimum accepted 

qualifications and experience modelled on similar groups in Australia and New Zealand. 

It needs to be accepted that organisations such as the CWM and the Lautoka Hospital are 

among the largest operations in Fiji and would best be managed by professionally trained 

managers. 

3.5.3. Health Legislation 

The MoH currently administers 17 pieces of legislation. Most of this legislation is now 

outdated and requires revision. There are some 140 plus pieces of legislation on the calendar 

for revision and enactment but most of the legislation under the MoH is not yet even listed 

for revision. The Public Health Act, Medical and Dental Practitioners Act have been revised 

but not enacted. 

4. THE HEALTH OF THE PEOPLE OF FIJI. 

4.1. Key health Indicators 

A comprehensive set of population health indicators is presented in Table 11. Overall the 

figures show no real improvement in the health status of the people of Fiji over the past 5 

years, although there has been some small improvements in areas of post neonatal mortality 

and contraceptive coverage rates 

Table 11. Fiji’s Key Health Indicators 

2003 2004 2005 2006 2007 

Population (Census estimates) 866,099 848,647 849,361 868,488 868,107 

Women in CBA (15-44) 180,555 167,810 183,295 186,803 185,328 

Total Live Births 17,910 17,714 17,826 18,394 19,298 

Crude Birth Rate/1,000 Population 20.68 20.87 20.99 21.20 22.2 

Crude Death Rate/1,000 Population 7.06 6.63 7.02 7.1 9.8 

Rate of Natural Increase 1.36% 1.42% 1.4% 1.4% 1.2% 

0-5Mortality Rates/1000 live Births 23.73 22.52 25.81 25.8 22.4 

Infant Mortality Rate/1000live Births 18.87 17.84 20.76 19.5 18.4 

Perinatal Mortality (stillbirth and early 16.4 19.3 22.05 19.4 15.8 

neonatal deaths/1,000Live Births) 

Early Neonatal Deaths (0-7days)/1,000 live 7.54 8.13 10.43 8.0 N/A 

Births 

Neonatal Mortality (Deaths 

9.27 10.05 15.37 11.3 11.9 

0-28days) 1000 Live Births 

Post Neonatal Mortality (Deaths 1- 9.6 7.79 5.39 8.2 6.5 

12Months) 1000 Live Births 

Maternal Mortality Ratio/100,000live births 22.3 33.9 50.5 43.5 31.1 

General Fertility Rate/1,000 CBA 99.2 105.6 97.3 96.9 104.1 

Family Planning Coverage Rate 42.0 45.9 42.3 49.1 43.1 

17


The Millennium Development Goals. 

The table shows no real progress by Fiji in reducing the level of infant and to a lesser extent 

maternal mortality (ie MDG 4 and MDG 5), with current performance generally being lower 

than the baseline figures of 1990. Because of the importance of this matter both to the MOH 

and to the support that AusAID and other donors may provide, it is discussed in considerable 

detail at section 5.3. of the report. 

4.2. Comparison with Pacific neighbours. 

Table 17 presents comparative indicators for pacific states and reveals that Fiji ranks 92 on 

the UNDP Human Development Index, trailing behind Tonga and Samoa. Fiji exhibits 

double the rate of urbanisation than its neighbours; its teenage pregnancy rate (15-19) is high, 

partly accounted for by the young age of marriage of Indo-Fijian females. 

Table 12: Selected regional comparative indicators 

Indicator Fiji Samoa Solomon Is Tonga Vanuatu 

Human Dev. Index Rank: 92 77 129 55 120 

% population urbanised 51 23 17 24 24 

Under 5 mortality rate 2006 18 28 73 24 36 

Life expectancy at birth 2006 69 71 63 73 70 

% of pop. using improved 

47 88 70 100 60 

drinking water sources 2004 

% of pop. using improved 

72 100 18 96 50 

adequate sanitation 2004 

Age specific fertility rate (15-19) 45 23 69 42 38 

births per 1000 women 

Contraceptive prevalence 44 43 7 33 28 

Sources: 1. UNDP Human Dev. Report 2007/08, 2. UNICEF: http://www.unicef.org/infobycountry 

4.3. Morbidity and Mortality. 

Table 13 reveals the triple burden of morbidity in Fiji as stemming from injury, infectious 

diseases and chronic non-communicable diseases. It also shows that non-communicable 

diseases account for the greatest part of mortality. 

Table 13. The Ten major causes of Morbidity and Mortality in 2007 

MORBIDITY 

MORTALITY 

No Cause No Cause 

1 Injury 1 Diabetes mellitus 

2 Influenza and pneumonia 2 Other forms of heart diseases 

3 Intestinal and infectious disease 3 Ischemic heart diseases 

4 Infection of skin and subcutaneous 4 Hypertension 

tissues 

5 Ischemic heart disease 5 Septicaemia 

6 Other conditions originating in the perinatal 

6 Cerebrovascular Disease 

period 

7 Chronic lower respiratory disease 7 Other conditions originating in the 

perinatal period 

8 Other forms of heart diseases 8 Chronic lower respiratory disease 

9 Hypertension 9 Renal failure 

10 Diabetes mellitus 10 Influenza and pneumonia 

Source: hospital admission 

Source: Death certificate 

Tables 14 and 15 show that the major causes of mortality in all years are disease of the 

circulatory system, which is reported to have increased by 14% in the past 20 years. 

Table 14. Major causes of Mortality by diagnostic group 1998-2001 and 2005 

CAUSE GROUP 1998 1999 2000 2001 2005 

18


% % % % % 

Disease of the Circulatory System 39.2 43.61 47.7 40.34 26.37 

Disease of Respiratory System N/A 7.51 6.1 8.1 8.55 

Infection and Parasitic Diseases 10.59 N/A 5.8 10.0 13.4 

Neoplasms 9.3 7.63 6.2 N/A 10.62 

Endocrine, Nutritional and Metabolic 

Disorders and Diseases of the Immune 

System 

7.27 N/A N/A 9.31 N/A 

Table 15 presents the major cause of morbidity for the period 1998-2001, and 2005 

presenting to hospitals and health centres. Infectious and parasitic diseases predominate in all 

years due to the high incidence of diarrhoeal disease, septicaemia and pneumonia. (Both the 

diseases of the Respiratory and Circulatory systems include NCDs). 

Table 15. Major causes of Morbidity by diagnostic group 1998-2001 and 2005 

CAUSE GROUP 1998 

% 

19 

1999 

% 

2000 

% 

2001 

Infection and Parasitic Disease 9.86 9.4 7.74 9.02 8.08 

Disease of the Respiratory system 9.14 8.6 7.74 9.02 8.08 

Disease of the Circulatory System 7.7 7.3 7.7 7.35 6.98 

Injury and Poisoning 6.82 6.9 7.4 5.9 N/A 

Disease of Genitourinary system 4.9 5.5 5.2 4.72 4.36 

Non communicable diseases (NCDs) such as diabetes, heart disease, high blood pressure 

and respiratory diseases have now replaced infectious and parasitic diseases as the principal 

causes of mortality and morbidity in Fiji. The NCD survey in 2002 showed that the 

prevalence of hypertension was 19.1% although this is not reflected in the table above as 

those patients who are “controlled” are not recorded as a new incidence. It also revealed that 

a third of all deaths and half of the deaths in the 40-59 years age group were due to 

circulatory diseases. In the year 2000 it was estimated that up to 70% of deaths in Fiji were 

due to NCDs (CSPF 2005). These diseases arise from the lifestyle factors of poor diet, lack of 

exercise, smoking, alcohol misuse and obesity. The revelation of the magnitude of NCD risk 

factors by the 2002 NCD STEPS survey highlighted some key reasons: 

• around 65% of population take one or less servings of fruits a day, 

• 37% currently smoke tobacco, and 

• there is a low rate of physical activity (25%) and 

• a high rate of binge drinking (77.3% of current drinkers). 

AusAID and other donors are providing support to Fiji to address its NCD problem through 

regional programs targeted at this area. 

Obesity: The Pacific Obesity Prevention in Communities study has recently released baseline 

findings for Fiji which include the statistics that “approximately one-quarter of students 

….were overweight (26% females; 20% males) and more than 10% were obese (12% 

females; 11% males)”.. 

Diabetes: The major cause of mortality in Fiji is Diabetes. The NCD survey in 2002 showed 

the prevalence of Type 2 diabetes in Fiji as 16% of the adult population, up from the earlier 

estimate of 12% (Cornelius 2002), reportedly the third highest rate per capita of diabetes in 

% 

2005 

%


the world. One out every seven person in Fiji has diabetes. The incidence of diabetes stands 

at 500 new cases per year. In 2005 187 amputations were carried out in CWM and one out 

every 7 died. 

Renal Dialysis: Until recently dialysis was not available in Fiji: consequently more than 95% 

of kidney patients died from kidney failure because of the lack of access to dialysis and 

support programs. The new Dialysis Centre in Suva opened in March 2008. 

Re-emerging and new viral diseases: Fiji is still dealing with outbreaks of re-emerging 

infectious and vector borne diseases (Typhoid, Tuberculosis, Leptospirosis and Dengue) and 

is potentially threatened by newly emerging viruses (SARS, HIV and Highly Pathogenic 

Avian Influenza). These threats present the risk of major socioeconomic impacts on Fiji and 

highlight the need for vigilance in surveillance, border control, detection capacity, 

investigation capacity and capacity to respond in a timely and coordinated manner. 

HIV & AIDS. While Fiji is still considered a low prevalence country for HIV, a rapid 

increase in sexually transmitted infections (STI) indicates a risk of increasing HIV 

prevalence. As at October 2008, there have been 271 HIV-positive individuals, a large 

proportion of them between the ages of 20 and 29. There had been 12 new cases this year 

which is an improvement on the past 3 years. A significant proportion of TB patients have 

tested HIV positive. 

Dengue Fever outbreaks of have been occurring across the Pacific in the last year and Fiji 

has had its first major outbreak for some years. Admissions to hospital continued beyond the 

53 cases reported in September 2008 to over 1531 cases in early October. Dengue fever 

remains a constant threat during wet periods in Fiji and constant vigilance is needed to reduce 

mosquito breeding sites. 

Nutrition: An impressive quantity and range of traditional food such as root crops, fruits and 

vegetables are grown throughout the country, and along with fish, and are identified as a 

“hidden strength” of the economy. However it is estimated that only 40% of energy needs 

come from locally grown food. Nutritional problems for weaning infants, undernourished 

children and adolescents remain. Kumar (2006) found that one third of teenage schoolgirls in 

the Western Division were anaemic and that many routinely miss breakfast. 

4.4. Key Lifestyle and other issues impacting on health of the people 

Lifestyle: The population of Fiji is becoming polarised between the employed and the 

unemployed, the former able to participate in the modern economy while the latter depend on 

subsistence agriculture, fishing and the sale of surplus produce. The social determinants of 

health, the migration to urban areas and the transition from the consumption of local produce 

to imported refined food items, has resulted in an increase in obesity and non-communicable 

diseases. 

It is generally believed that transition to the urban lifestyle has proceeded at a faster pace than 

Fiji’s neighbours. The introduction of television in the 1990s and the growth of the 

communications sector have connected Fiji to the lifestyles of western cultures. Secular 

fashion and behavioural trends are powerful influences on young people while the breakdown 

of traditional social controls have allowed behaviours such as binge drinking, cannabis 

consumption, an active nightclub scene, sexual promiscuity and commercial sex, the 

consumption of ‘fast foods’ and the increase in street kids and homelessness all of which are 

readily visible phenomenon of lifestyle change. The greatest challenge is youth 

unemployment. Young people of productive working age are commonly seen on the urban 

and suburban streets of Fiji during working hours. Protracted unemployment with little 

prospect of obtaining work contribute to social breakdown, violence and robbery. Other 

issues that impact on the health of the people are discussed below. 

20


Poverty: Estimates of poverty in Fiji are that 29% of the rural population and 40% of the 

urban population are poor; and that poverty (35% of the overall population) is distributed 

across the nation. The poor often live in unsafe and overcrowded houses in under-served periurban 

shanty towns where exposure to pollution and other health risks are greatest. They are 

most likely to indulge in risky behaviours out of circumstances rather than by choice, often 

going hungry or eating poor quality foods, living stressful lives, indulging in personal habits 

such as drinking of kava and smoking tobacco to obtain comfort and to socialize. 

Squatting: It is estimated that by 2006 the Suva/Nausori corridor will have 15,000 squatter 

households with a population of 90,000-100,000 people. This will place a large strain on the 

entire urban infrastructure, such as water supply, sewerage, electricity, roads, traffic 

congestion and social services. 

Water and sanitation: Many of the rural water supply systems built during the colonial 

period are now deteriorated to the degree that village water systems are sources of diarrhoeal 

diseases. It is understood that UNICEF will be giving particularly priority to the availability 

of safe drinking water in rural areas in the coming years and that the MoH will work with 

SOPAC to improve Fiji’s water and sanitation systems. 

The cost of food: Fiji is a net importer of food and its agricultural potential for food 

production is largely underutilized. Much of Fiji’s arable land has been devoted to sugar 

production, but as land leases expire land is left fallow without any plans for further 

development. For Fiji to develop a viable food export sector, the quality of food produced 

will need to be increased to meet the expectations of recipient markets. Many of the older 

sugar cane leases are now lying idle and potentially there is now more arable land available 

for food than in recent years. This is not to say that food prices will not rise. However in the 

current economic climate it is simply not possible for this assessment team to make any 

prediction and its likely impact on health. 

Global warming: There have been some suggestions that global warming could cause a shift 

in the epidemiology of some diseases (eg: vector borne diseases such as Dengue Fever, where 

increased rain fall has been associated with an increase in the number of reported cases). This 

has relevance to Fiji as dengue fever is a major risk to the community. The IGOF does have a 

strong mosquito monitoring program that can detect early increases in vector numbers. It is 

important that this service be continued. 

Suicide rates for the population as a whole are reportedly 26 per 100,000 and above the world 

average of 16 per 100,000 (WHO), however, the rates for Indo-Fijians (24 per 100,000) well 

exceeds that of Fijians (4 per 100,000). The suicide rate among Indo-Fijian females is 

reportedly among the highest in the world (Booth 1999). Anecdotally, these are due to family 

expectations of academic performance and young marriage, where the pressures associated 

with being a daughter-in-law are thought to contribute to stress. This situation illustrates the 

tensions between traditional family expectations and those of the modern world. 

5. KEY ISSUES ARISING FROM THIS SITUATIONAL ANALYSIS 

During the period of this short “snapshot” mission, a number of issues emerged that are 

discussed below. They include 

• Poor perception of the health services by the public 

• Changes in demographics and social behaviour require a rethink of the location, 

staffing and range of services provided by health facilities. 

• Relatively poor progress towards the achievement of Fijis MDGs. 

21


• Old or non-functioning equipment impacts on service delivery 

• Stock outs of essential drugs 

• The importance of more focused planning and better use of management information 

systems 

• The health sector should be seen as being more than just the MoH 

• There is a need for evidence based approach to policy and planning 

In addition financial constraints and staffing issues - and especially shortages of specialist 

medical officers - are recognised as very important issues but these have been discussed in 

detail at section 3 of this report and are not discussed further here. 

The issues listed above are perhaps best described as “big picture” operational or structural 

issues. Some have a bearing on the effective functioning of the health system (e.g. shortages 

of equipment, drug outages; financial and workforce constraints), others relate to such issues 

as equitable access and highlighted the need for a review of the location and staffing of health 

facilities to improve access, while others might better be described as the end results of 

problems that are occurring within the system. This latter group includes such issues as the 

failure to achieve the MDGs and a poor perception of the health services by the public. They 

are presented here in no particular order of priority. This is because they are all very closely 

inter-related and addressing some will have influence on the others. 

No attempt has been made to in this section of the report to discuss the importance of specific 

diseases such as HIV/AIDs and NCDs which are clearly a problem for Fiji. They have been 

adequately addressed in section 3.3. above. 

5.1. Perception of the health services by the public. 

The people of Fiji appear to be increasingly critical of the health care system. This is publicly 

reflected in current articles in the press and the electronic media. More privately, it is 

reflected by comments given by patients and from health care staff to the team that patients 

often complain to them. Some health care staff seen during the mission indicated that they too 

are concerned and now use the private system for their own family’s health care needs. 

5.1.1. Nature of the Public Concerns 

Based on media reports and a small number of interviews undertaken during this mission 

(and confirmed by local staff), public dissatisfaction appears to lie in four key areas: 

• Frequently long waiting times (> 4 hours) for treatment in general outpatients 

departments especially at CWM hospital (Suva) and Lautoka hospital. 

• The often lack of the essential drugs that the doctor wishes to prescribe – which 

becomes more frustrating if patients have waited several hours. This situation is 

improving in some Divisions (see 5.5.) 

• The breakdown of equipment, with the doctor telling the patient that they are unable 

to do important tests because the necessary equipment is not working. 

• Patients are charged for services at a hospital when they thought that it would be free 

(presumably doctors had rights of private practice). 

These comments are also reflected in comments and formal complaints to the Consumer 

Council of Fiji. They receive complaints in relation to both the public and private sectors. 

Press releases from the Consumer Council discussing the nature of these complaints are 

shown in Annex 12. Unfortunately the Consumer Council have not, in the past, maintained a 

data base of the number of each type of complaint. Trends therefore cannot be measured. 

22


However the assessment team was informed that a new data base has been installed and that 

this information should be available in future years. The MoH therefore may gain benefit 

working closely with the Council to monitor the level and nature of complaints and compare 

them with their own surveys. 

Despite these ongoing complaints, no recent surveys of waiting times have been carried out 

in general outpatient departments of the larger hospitals. Nor have customer satisfaction 

surveys been done throughout the hospital. At the CWM, the team were advised that 

management of the outpatient and accident and emergency departments would welcome 

assistance in carrying out such surveys and asked if FHSIP would include them in their work 

plans for 2009. Such surveys would provide more information on the level of dissatisfaction 

and whether it is reflected throughout the country or more likely to be associated with 

services in the divisional hospitals where workloads are highest –anecdotal evidence suggests 

the latter. 

5.1.2. Continuing Complaints lead to staff dissatisfaction 

Importantly these ongoing complaints, and the poor recognition by the public of the work 

being done by health care professionals is very demoralising to staff, who often make 

considerable sacrifice to provide the best service possible with the resources they have been 

given. This view was continually repeated to the assessment team. This dedicated 

commitment, under difficult circumstances, with lack of any real recognition, was often cited 

as a major reason for staff leaving the government system – either to go into private practice 

or to migrate. The evidence presented to the assessment team is that the current situation is 

not acceptable to a wide range of staff members, as reflected in the figures given in Table 5 

showing high levels of staff turnover. 

There are three key pillars for a successful primary health care service: (a) access, (b) 

affordability and (c) acceptability. The current health service in Fiji does not appear to be 

meeting the latter. Senior staff within the MoH are aware of this and expressed the view that 

they would like to see this issue addressed - especially the problem of long waiting times at 

general outpatient departments at the larger hospitals. 


The MoH should consider undertaking regular surveys at the major hospitals (and other 

centres) to determine waiting times for patients attending at different times of the day and on 

different days. Concurrently, independent patient satisfaction surveys could be carried out to 

explore other issues such as staff attitude and drug outages. The results from such surveys 

could guide the implementation of a Service Improvement Program. The FHSIP should be 

asked to include funding for such surveys within its workplan for 2009. 

5.2. Changes in demographics and social behaviour require a rethink of the 

location, staffing and range of services provided by health facilities. 

As discussed in section 3.2. the model currently in place in Fiji to ensure access to health 

services is a traditional one, based on providing easy access (usually within 1 hour) to a 

health facility, with provision for referral to more comprehensive services if required. The 

progression from community health worker to nursing station, health centres; subdivisional 

hospital and finally referral to a divisional hospital has served the people of Fiji well over the 

years – it is widely regarded in the region. It was developed to give substance to the long 

stated goal of providing access to a basic level of primary health care to all those living in the 

Fiji Islands. 

23


This model remains relevant today. However it was obvious to the assessment team that, after 

30- 40 years in many cases, the building blocks that go to make up this model urgently need 

review. This conclusion was supported by managers met by the team during this mission. 

There have been many changes during this period. These include (a) demographic and (b) 

social changes, (c) improvements in transport and (d) changes in medical practice and 

standards. These factors are discussed below 

Demographic changes. Demographic changes alone warrant a review of the location and 

staffing of health centres and nursing stations. Overall population in many areas has increased 

since most facilities were built. The 2007 census indicates that Central division population 

has increased 15% since 1996. Equally interesting is the fact that over the past 4 years, the 

annual average number of births at CWM hospital was 6,540. This represents a 10% increase 

over the average number of deliveries for the preceding 4 years. 

Importantly, there has also been a steady drift to urban areas that has accelerated in the last 2 

years following the termination of many sugar leases in the Western and Northern Divisions. 

See section 4.5 squatting. 

Improvements in public and private Transport. In recent years car ownership has increased 

and there has been an improvement in roads; bus services are now available in many areas of 

the country. The team heard that this has greatly influenced the mobility of patients and they 

are taking advantage of it. Patients are now (a) by-passing many health facilities and 

travelling to centres where they can see a doctor (not only a nurse) and have more chance of 

getting drugs and (b) some strategically placed health centres e.g. on main roads or bus 

routes, are receiving increased patient numbers while others have seen significantly reduced 

workload; However staffing levels usually remain little changed. One health centre, with a 

staff of one doctor/nurse practitioner and three nurses sees 10 patients per day (15-20 on days 

when antenatal or vaccination clinics are held) whereas in another centre one doctor saw in 

the order of 100 patients per day. The team was assured that such imbalance between staffing 

establishment and workloads is not rare. Clearly some centres have too many staff while 

some centres have too few. This is in stark contrast to the long waiting times being 

experienced in the outpatient departments of the divisional hospitals because of staff 

shortages. 

Social Changes. Fijians, and especially those in the larger cities, are increasingly travelling, 

watching television, reading magazines and using the internet. They are aware of modern 

trends in medical practice in other countries, especially in Australia and New Zealand where 

many have family members. As patients, they have increased expectations. There is an 

expectation that they will be seen by a doctor, have an X-ray and blood taken at the same 

time. They would like their health facilities to open for longer hours so that they can visit 

after work. There is frustration that most health facilities close at 4.00pm 

Patients are seeking to bypass smaller centres and go to the hospitals (where there are 

extended opening hours) and larger health centres where there is a doctor and other facilities. 

Improved transport links are making this possible. Unfortunately this results in the long 

waiting times at hospitals in the evening. 

Changing Medical standards. An increasing focus on improving the quality of medical care 

through the introduction of “best practice” has resulted in decisions that surgery must only be 

undertaken by qualified and registered specialist surgeons. This also puts increasing demands 

on improved diagnostic facilities. Because of the acute shortage of specialist surgeons, and 

the imposition of these more stringent standards, older established practices are no longer 

acceptable. This is especially noticeable in subdivisional hospitals where in past years 

considerable surgery was undertaken. Currently not one sub-divisional hospital routinely 

performs surgery although some occasionally host visiting surgical teams from the larger 

24


divisional hospitals or even from overseas. As stated earlier subdivisional hospitals provide 

low risk antenatal and birthing care for the subdivision and are functioning as little more than 

larger health centres. Their operating theatres lie idle. 

As a result of these demographic and social changes, together with improved transport links 

and stricter medical standards, the current service delivery model needs review. The basic 

framework is appropriate, but many of the building blocks require change. Currently staff are 

not always being utilised effectively and patients are not receiving the level of service that 

they are seeking. Without change this will prove to be a barrier to meaningful improvement 

in the health system in Fiji. 

1. There is an urgent need to review the location and function of current health 

facilities. Some may need their role re-assessed, or be enlarged and a wider range 

of services offered e.g. X-ray and laboratory services. In some cases, where a 

decision is made to change a role, additional vehicles may be needed to provide a 

more comprehensive home visiting service. 

2. Staff establishments levels will need to be reviewed 

3. There may be a need for new cadres of multi-skilled staff 

4. In some cases opening hours will need to be extended 

5. possibilities should be explored for making use of private GPs to support busy 

centres – especially after hours or as locums 

6. Consideration may need to be given to closing general outpatient departments at 

divisional hospitals and allow them to focus on genuine accident and emergency 

cases 

7. In such cases the size, location, staffing levels, range of services and opening 

hours of nearby health centres will need to be reviewed. New “hyper centres” may 

need to be created to offer services to out-patients who are now going to the 

divisional hospital. These would be larger than traditional health centres, provide 

a wider range of services including X ray, pathology and dental treatment and be 

open until later, perhaps as late as 8.00pm in the evening. 

These changes are apparent to managers within the respective divisions. Such changes have 

been occurring in many countries for many years. 


The MoH should consider undertaking a review of the location, functions, staffing levels and 

operating hours of the current network of nursing stations, health centres, subdivisional and 

divisional hospitals to ensure that they better serve the needs of the people of Fiji. 

It is recognised that external assistance may be required for such a Review and development 

partners should look favourably on providing such support as it will offer the potential to 

significantly improve the efficiency of service delivery. 

The Clinical Services Planning Framework, developed with support of the FHSIP, should be 

a key tool in this exercise. 

5.3. Relatively Poor progress towards Achievement of Fiji’s MDGs and other 

designated KPIs. 

5.3.1. The Current Position. 

As indicated in section 3.1. Fiji made considerable progress in improving its key health 

indicators during the period up to 1990, when its key indicators were seen to be excellent. 

During that period, life expectancy, and both maternal and infant mortality improved 

25


significantly, with MMR improving from 156.5 (per 100,000 live births) in 1970 to 53.0 in 

1980 and 26.8 in 1990. 

However since the mid 1990s, progress has stalled as shown in the table 17 below and in 

table 11 in Section 4.1. This is particularly disappointing in the case of Fijis targeted 

Millennium Development Goals (MDGs). In 2000 Fiji committed to its people (and to the 

World) that by 2015 it would achieve the targets for maternal and infant mortality and for 

control of HIV/AIDs and tuberculosis listed below in Table 16. 

Table 16. Fiji’s MDG Targets by 2015 

Target 

Reduce by 2/3 between 

1990 and 2015 the under 

five mortality rate 

Reduce by 3/4 between 

1990 and 2015 the 

maternal mortality rate 

Have halted by 2015 and 

begun to reverse the 

spread of HIV/AIDS 

Indicator 

1990 

Baseline 

2015 

Target 

Under-five mortality rate per 1000 live births 27.8 9.3 

Infant mortality rate per 1000 live births 16.8 5.6 

Proportion of 1 year old immunized 86% increase 

Maternal mortality rate per 100,000 live births 

26.8 10.3 

HIV prevalence among 15-24 year old pregnant 

women 0.00% 0.00% 

Data in Table 17 clearly shows that the MoH is not meeting these targets and under 5 

mortality, infant mortality and maternal mortality are not only worse than the commitment 

given in the MDGs in 2000, but are considerably worse than the status in 1990. The situation 

has been steadily deteriorating since that time, with the exception of maternal mortality in 

2007 when some improvement is noticed. In relation to maternal mortality the absolute 

number of deaths is relatively small and 1 or 2 extra deaths can significant change the MMR. 

Table 17 Progress towards achievements of MDG 4 and 5 

Year Child (< 5 ) 

Mortality 

Infant 

Mortality 

Maternal 

Mortality 

1990 Na 16.8 26.8 

1995 19.30 14.70 60.40 

2000 21.8 16.20 57.50 

2005 25.8 20.70 67.3 

2007 22.4 18.4 31.1. 

MDG 9.3 5.6 10.3 

As stated earlier HIV/AIDS cases continue to occur, although only 12 new cases were 

recorded so far in 2008. There were approximately 80 cases of TB last year – of which 84% 

occurred in the Central division, The majority were pulmonary TB. 

Childhood Deaths 

The main causes of death for children under 5 and immunisation coverage rates (another 

target within MDG 4) are shown in Annex 14. 

Clearly there has been variation from year to year in the causes of childhood mortality but the 

disturbing feature is the very high incidence of death due to peri-natal conditions. These perinatal 

deaths (200-275 per year over the past 5 years) are most associated with sepsis, 

congenital malformations incompatible with life, gross prematurity, peri-natal asphyxia, 

meconium asphyxia, severe HMD and more recently, a re-emergence of congenital syphilis. 

In general there has been little improvement in vaccination coverage rates except for measles 

in 2006. In this case coverage had dropped to 68% in 2005, resulting in a large measles 

26


outbreak in the country. This became the trigger for mass immunisation program with 

reported coverage of 100% in 2006 but this has slipped back to 80% in 2007. 

Causes of maternal mortality 

The main causes of maternal mortality from 2001 to 2007 (and number of deaths) are also 

shown in Annex 14. and include ectopic pregnancy, PET/eclampsia; PPH, cardiac disease 

and septicaemic( puerperal infection). Of the 68 maternal deaths during the period, 55 (85%) 

were classified as obstetric maternal deaths and 13 (15%) were classified as incidental 

maternal deaths. 

5.3.2. Changing patterns of antenatal care 

It is well established that timely and professional antenatal care is a key factor in reducing 

both maternal and infant mortality. Advice on lifestyle and diet during pregnancy, testing for 

infectious diseases such as HIV and STI and a physical examination to determine the 

likelihood of a regular or “difficult” delivery are all vital for safe motherhood and healthy 

child. The team was told that antenatal practice may be changing. In previous years it was 

practice for women to present for their first antenatal visit during the first trimester and that 

this is still current teaching in nursing school (< 12 weeks). However data presented to the 

team indicates that this is no longer necessarily the case and that women are presenting later 

for their first antenatal visit, although this may vary from area to area/hospital to hospital. 

Table 18 Trimester of First Antenatal visits 

CWMH (%) Lautoka Hospital (%) 

2006 2007 ) 2006 2007 

Trimester 1 833(17) 307(9) 370(18) 409(18) 

Trimester 2 2857(57) 4246(83) 1071(53) 1129(50) 

Trimester 3 1081(22) 493(9) 539(26) 674(30) 

Unbooked 167(3) 98(2) 27(1.3) 40(2) 

TOTAL 4988 5090 2007 2252 

This data for these two hospitals is subject to some margin of error as some cases may not be 

included although the trend is apparent. However, as discussed at 5.8, more detailed data is 

needed on antenatal care in Fiji. 

Congenital syphilis as an end-point indicator of antenatal practice. 

An indirect measure of the deterioration in this area is the striking increase in the number of 

cases of congenital syphilis among newborns. In CWM there were 132 cases in 2007 and to 

September 2008 there had been 162 cases out of 5,635 live births. In the period July- 

September there were 68 cases out of approx 1800 births. 

This high incidence of congenital syphilis is a concern in its own right but it is also an “end 

point indicator” of a potential quality decline in antenatal care in Fiji. More research is 

needed but key questions need to be asked 

• At what stage did mothers present for their first antenatal visit; were there follow up 

visits? 

• Was blood taken for serology at this first visit or were serology tests done at 

subsequent visits? 

• Were laboratory results relayed back to the doctor/nurse who saw the expectant 

mother? 

• Was there discussion during antenatal visits of the dangers of HIV and STI? 

27


Congenital syphilis is a very preventable disease and, as stated above, it can serve as an 

endpoint indicator of the quality of antenatal care. It can also serve as a measure of condom 

use. A decline in incidence of congenital syphilis may serve as an indicator of improvement 

in either or both of these areas. 


A carefully planned study should be undertaken of antenatal care practices in Fiji, which 

should include women in both urban and rural areas. 

5.3.3. Why has progress towards the achievement of MDGs 4 and 5 been so slow? 

The assessment team were advised by obstetricians, paediatricians, midwives and nurses that 

many of these infant and maternal deaths were preventable. If this is true the question must 

be asked “Why are these deaths still occurring and why is progress towards achievement of 

the MDGs 4 and 5 so slow?”? 

Some reasons for this have already been discussed and include poor equipment and 

consumables (including alcohol wipes, re-using disposable gloves etc) , shortage of specialist 

staff (e.g. obstetricians, paediatricians, experienced midwives, neonatal nurses), of general 

practitioners in rural areas; changing patterns in antenatal care as represented by women 

attending their first antenatal visit later in pregnancy. These represent technical/professional 

reasons that have contributed to slow progress towards achievement of MDGs. 

However, while a reduction of maternal and infant mortality are key performance indicators 

for the Ministry, the assessment team were informed that there is no focused plan of action in 

place that specifically addresses these problems. While areas within corporate plans for the 

public health department have relevance, as do plans for curative service department and 

individual hospital plans, a specific plan that addresses maternal or infant mortality must by 

necessity, cross both departments. The team was informed that no such focused plan exists. 

There is thus a need to bring more focus to these issues if the MDGs 4 and 5 are to be 

achieved. 

This must be reflected not only in stated goals or KPIs but in action plans that work to 

achieve these goals. Such plans need to bring to the problem the resources of both public 

health and curative (hospital) departments but also support of relevant NGOs, international 

agencies (WHO, UNICEF, UNFPA) and private medical practitioners. That is, it needs to 

engage the whole health sector and not just the Ministry. To a large extent this has happened 

in the area of HIV/AIDS, where there is a dedicated national strategic plan for HIV and the 

National AIDS Committee takes a cross sectoral approach. This need for more focused 

planning is discussed further below. 

5.3.4. Benefits will flow to the whole health sector. 

As discussed above, progress towards achieving the goals in the area of maternal and infant 

mortality involves improvements in both preventive health and clinical practice. It cuts across 

all areas of the health system. Thus any plan that targets a reduction in the levels of both 

infant and maternal mortality will, de-facto, go some way towards improving the health 

system overall. It will require improved antenatal care, improved vaccination coverage; 

reduction in incidence of STI, improved patient referral and transport services, fewer “stock 

outs” of drugs, more reliable, functioning equipment and improved cross infection control at 

all levels of health care. 

28



The MoH and its partners should consider developing “action” plans that focus specifically 

on reducing the levels of infant and maternal mortality. Such plans should cut across all 

departments of the MoH and engage with all relevant parties both within and outside of the 

Ministry. 

5.4. Old or non-functioning equipment impacts on service delivery 

A consistent problem presented to the assessment team was a shortage of essential equipment 

that was in good working order. The team heard that in some nursing stations and health 

centres, simple but essential equipment such as stethoscopes and sphygmomanometers were 

not functioning. In all facilities visited the team inspected essential equipment in key areas 

such as neonatal intensive care; obstetrics; accident and emergency; outpatient departments 

pathology, radiology and in health centres and nursing stations. Problems include: 

• Often essential equipment was very old. For example x-ray equipment in Lautoka 

hospital dates to 1986 (2 machines) and 1993 and 1996. The mammography machine 

was donated (as a second hand unit) in 1996. It is important for a successful 

replacement policy that the date of purchase (or date of manufacture for “second 

hand“ donated equipment) and the recommended replacement date should be included 

in the newly developed Asset Register. This should apply even for older equipment 

that was already in the facilities before the Registrar was put into use. 

• There is a shortage of funds to purchase new equipment or the processes required to 

purchase it were too bureaucratic even for small, inexpensive equipment. The 

biomedical equipment budget for the past 6 years is given in Table 9. It has not 

increased during the period 2003 to 2008. More strikingly the percentage of funds 

allocated in the biomedical budget was 1.7% of the total health budget in 2003 and 

had declined to 1.0% in 2008. To bring the 2008 biomedical budget back in line with 

the budget of 2003 would have required that an additional $ 1.05 million be allocated 

for procurement of biomedical equipment. Even the 2003 budget allocations are low 

when compared with actual needs. 

Repairs, maintenance and the supply of consumables are equally important. The team’s 

findings revealed that: 

• In many instances spare parts are no longer available as the type of equipment has 

long ceased being manufactured. 

• There were consistent reports of slow response from the biomedical department 

because they were simply overloaded with requests - the time taken was even worse 

for the smaller and more remote health centres 

• Very long delays in obtaining spare parts or vital consumables - putting essential 

equipment out of use for several months. This was not always a matter of the cost of 

the spare part - with delays often due to overly lengthy bureaucratic “processes” even 

for the smallest items. Examples include: 

o 

microscopes being out of use for 3-6 months because of delays in getting a 

bulb for the microscope lamp; 

o vital monitors in a neonatal intensive care unit being inoperable because of 

delays in getting replacement probes; with one probe being rotated between 3 

children even though each child should have been monitored 24/7 and 

importantly, with the added risk of cross infection. This is important because 

nosocomial infections have been a significant cause of neonatal deaths in Fiji. 

29


o in one obstetric department, the CTG (cardiotomograph) machine for 

monitoring foetal heart rate and maternal contractions, was new but no paper 

was available to record the charts so patients could not be monitored. 

• In many instances maintenance contracts with the supplier are relatively expensive 

and often no formal internal maintenance programs are in place. 

Recommendation: 7 

All options should be explored on ways to increase the level of funding made available 

through the national budget and through development projects for the standardisation and 

procurement of essential biomedical equipment. Similarly, options should be explored on 

ways to increase the level of funding available for maintenance and repairs of biomedical 

equipment and to simplify the processes for the procurement of replacement spare parts and 

consumables. 


Recognising the very critical state of biomedical equipment procurement and repair, 

development partners might consider a large scale biomedical equipment project that seeks to 

purchase standardised equipment for the divisional hospitals in order to bring equipment up 

to acceptable levels. Any such project should also review the processes required for the 

maintenance of equipment and purchase of spare parts. 

Such a project should work with but be outside of the current support that AusAID is giving 

to strengthening biomedical engineering departments within the region. 

5.5. Stock Outs of Essential drugs 

The often poor availability of essential drugs was frequently presented as a significant 

problem that contributed to sub-optimal patient care and to patient dissatisfaction and 

frustration with the system. As an extreme example the team was informed that some patients 

travel from Levuka (an eastern island) to CWM hospital primarily because they cannot get 

the necessary drugs in Levuka. 

Despite this concern, there is evidence that the situation is improving in most areas. The 

essential drug list has now been subdivided into (a) vital (b) very essential and (c) essential. 

Progress has been made in the past 12 months with support from FHSIP so that outages now 

occur very rarely in the vital drug category and on Viti Levu, where deliveries are made from 

the pharmacy store to the health facilities on a monthly basis, stock outs of other drugs are 

now occurring less frequently. 

However in the Northern Division, where deliveries remain on a quarterly basis, the team was 

informed that stock outs occur far more frequently. The team saw direct evidence of this, 

where only 50% of the quantities of drugs ordered by the facility had been delivered and a 

patient was not able to receive the necessary treatment for their hypertension. Apparently this 

is a regular occurrence. There is no good monitoring program in place to assess levels of 

drugs in the health facilities on a regular basis. 

There would be benefit if the FHSIP continued its work to strengthen the Fiji pharmaceutical 

store, including an audit of pharmacy, its processes and staff. 


Although access to essential drugs at the health facility level is improving and “stock outs” 

are occurring less frequently, more needs to be done, especially in the Northern Division. It is 

30


important that a system to monitor drug “stock outs” on a weekly basis in health facilities be 

instituted so that in future stock outs do not occur. 

Any steps to improve the efficiency of drug supply should include a formal audit the central 

pharmacy store, its processes and an assessment of the technical capacity of the staff to 

ensure that their skills match the needs of the job. If the charter board agrees, FHSIP should 

be able to continue its support in this area during 2009, and include such an audit in its 

workplan. 

5.6. The importance of more focused planning and better use of management 

information systems. 

In a dynamic management environment, business plans are developed that target the 

attainment of preset goals – with indicators being selected to guide progress towards these 

achievements i.e. they become stepping stones. Data that measures progress is collected and 

analysed daily; weekly or monthly depending on the targets e.g. data to review bed 

occupancy rates would be collected and measured daily so that staffing levels can be adjusted 

to match the occupancy rates and if necessary moved between different wards of a hospital to 

obtain best efficiencies and best care for the patient. In such a working environment plans are 

dynamic and are adjusted if necessary to take account of changing circumstances e.g. shift in 

target population; predicted shortages in drugs; changing community needs. The key 

elements of such an environment are (a) plans are focused on achieving defined goals e.g. 

MDGs; (b) good data is collected and acted upon in a timely manner and (c) plans are not 

static- they are not printed once a year and stored in a drawer for the remainder of the year. 

During this assessment the team found that few departments use plans as management tools 

in a way that guides their day to day operations towards achievement of objectives; no one 

indicated that they revise their plans if the need arises. 

Unfortunately the team observed that planning and management within many areas of the 

MoH is more static. Plans tend to be prepared annually and not reviewed on an ongoing basis. 

Such plans tend to be department focused e.g. public health; curative services; corporate 

services. The team was told that, with the possible exception of HIV/AIDs, broad crossdepartment 

plans were rarely prepared. As stated in section 5.3. there are few plans that might 

be described as “action plans”. They are rarely linked directly to achieving key performance 

indicators, and there appears to be a “disconnect” between corporate plans and the actions 

needed to achieve preset goals (KPIs). 

The fact that plans did not generally recognise the need to cut across multiple departments is 

unlikely to apply only to the MoH – it is common in many large bureaucracies. However if 

there is to be a greater focus on achievement of KPIs; it should begin with a review of the 

planning, monitoring and evaluation processes. 

Currently large volumes of information are collected throughout the health sector – as 

reflected in the various data sets presented in section 3 of this report. However much of this 

data is “static”. It is collected at all levels of the health care chain sent to divisional offices 

and on to head office in Suva. The collated data is used in annual reports and to some extent 

in planning. There needs to be developed a culture of performance management and 

monitoring that collects the type of data that can be used to make ongoing management 

decisions on a day by day basis. Examples might include collecting accurate data on waiting 

times in general outpatient departments on a daily basis and basing staff rosters on the 

anticipated waiting times; taking action to address causes of individual maternal and infant 

deaths on a “real time” basis, based on weekly or monthly data and adjusting overall plans 

accordingly; recognising a concerning increase in congenital syphilis and taking action “at 

the root cause’ level to address the problem. 

31


As stated above there is little evidence that data is being captured in a way that enables it to 

be used on a daily or weekly basis to improve quality and effectiveness of the health care 

system. PATIS, if used widely, can be used as an effective management tool. For example the 

hospital pharmacy is using it routinely to measure stock levels of certain drugs among its 

various wards so it is in a position to reallocate drugs from one ward to another if that is 

needed; it can also use it to monitor for theft of drugs; and - if there is a sudden increase in 

the costs of drugs within a hospital PATIS, can provide information to see if the cost 

escalations are due to one or two expensive drugs being prescribed by a new doctor. As stated 

above it is being used to monitor ward occupancy and allocate staffing hours and the 

radiology department is using it in many ways. However it has not been widely used outside 

of the hospital setting and its full potential is not being felt. PATIS is potentially an important 

management tool but it needs “champions” who understand the benefits that a “relational data 

base” can provide and staff need more training on how to use it effectively. 

The concepts of (a) the Project Officer (PO) and (b) Performance Enhancement Projects 

(PEP) introduced through the FHSIP are exceptions to the principles raised in the discussion 

above. In both cases the PO, or responsible PEP manager, set a target and develop a plan to 

achieve that target. If there is need for change in that plan, those changes are made. It is the 

achievement of the objective and not the original plan that has been the key to success of the 

project officers and PEP concepts. These “models” can serve as examples to be used more 

widely throughout the MoH. Improvements in the use of good management information will 

help. 

This report proposes that beyond 2009. AusAID may wish to continue to support a program 

of capacity development in key areas (see section 6.3.). The skills needed to develo more 

targeted “action plans”, to use management information to monitor progress towards 

achieving the objectives of these plans, might well be one such area of where capacity could 

be further developed. 

5.7. The health sector should be seen as being more than just the MoH. 

The health “sector” within Fiji is changing. Some aspects of these changes have been 

discussed above at Section 5.2. However significant changes are also taking place in the 

nature of the “partners” within the health sector. While the MoH is by far the major provider 

of services, they are by no means the only provider and many other partners are now making 

an important contribution. It is important that the increasing role that these “partners” are 

playing is fully recognised. This is especially so when (a) compiling statistics on service 

delivery –e.g. number of services, type and location of services; (b) estimating the total cost 

of health services in Fiji which should include out-of- pocket expenses – estimated to be 35% 

of government expenditure and (c) planning to address key national targets such as the MDGs 

and national health KPIs. 

5.7.1. Other Service Providers and Partners. 

Apart from the MoH, other key partners of the Fiji health sector include: 

A large and organised private medical sector. 

This consists of: 

• more than 120 private medical practitioners– including a small number of specialist 

medical officers. This represents some 25% of all doctors in Fiji. Although the exact 

volume of their work is not certain it is estimated to be of the order of 400,000 to 

600,000 consultations per year (approx 80-100/doctor/week). 

32


• One established private hospital with X ray, pathology, and other support services. 

Several specialists working within the government service have rights of private 

practice to operate within the private hospital on an out-of-hours basis. Others are 

from FSMed or are independent private practitioners. 

• One small private hospital/clinic with more limited services. The team learned that a 

private hospital was soon to be established in Lautoka. 

• 49 private pharmacies staffed by 50 qualified pharmacists. 

A growing number of NGO service providers 

While in the past the core business of most health sector NGOs was training, advocacy and in 

special circumstances support and relief (e.g. Red Cross), this position is changing. As an 

example the NGO Pacific Counselling and Social Services (PC&SS) currently provides a 

national counselling service. It has counselling centres in Lautoka, Nadi, Suva and Labasa, an 

operating budget of over $800,000 and employs more than 60 staff including 36 diploma 

qualified counsellors. Although it has a MOU with the MoH, it receives only minimal 

funding from them. PC&SS provides the majority of professional counselling services in Fiji 

- initially through specialised services to HIV positive patients and those being tested for 

HIV. However the range of patients is now very broad and includes hospital based 

counselling and social services work. PC& SS also provides training to others. 

Marie Stopes is another NGO that provides a wide range of services directly to the Fiji 

public. It operates a family planning clinic in Suva staffed by a doctor and outreach clinics 

staffed by 2 doctors and 2 nurses. It also distributes condoms directly and through a social 

marketing program. Their target client base is 16-29 year olds although they do service all 

groups. Further the team heard of an Indo Fijian registered nurse, recently returned from 20 

years in the USA, who has opened a clinic in Nadi providing free specialist services to 

women in the area of breast self examination, sexual health and offering a pap smear service. 

It is understood that she provides the services herself with the support of other local nurses. 

Visits by doctors from the USA may soon enable her to extend the range of services 

ultimately provided. The team were not able to meet with this nurse but this is mentioned 

here as an indication that there is the possibility of an increasing number of NGOs providing 

services directly to the people of Fiji in the future. Other NGOs, especially in the area of 

HIV/AIDS, are providing different levels of “service” to patients. 

The MoH will need to give consideration to developing working “Partnership Agreements” 

with these NGO and engage them more directly in planning of health services. This will 

better ensure that these NGOs contribute directly to the goals of the health sector. 

The International Agencies 

Although they are rarely involved in the direct delivery of services, they do provide high 

level technical expertise and can play a very important role in the planning and monitoring of 

progress towards the achievement of goals As .examples any focused “action plan” to address 

such areas as maternal and infant mortality should involve WHO, UNICEF and UNFPA as 

partners of the Ministry. 

5.7.2. The need for the MoH to engage with these other providers and partners to achieve its 

KPIs. 

There would be benefit if the MoH, working with external support if needed, could (a) 

explore ways in which the work of these different parties can be captured in health service 

statistics and (b) explore ways to best optimise the clear benefits that these other parties can 

bring to the health sector as a whole. 

33


In relation to engagement with the private doctors and hospitals, some issues will need to be 

addressed so that the public will have full confidence in the work that they do. This is not a 

criticism of the work of the private sector, but rather ensuring the pubic of the quality of the 

care they are receiving. In particular, attention should be given to addressing the need for 

minimum clinical standards for private doctors and guidelines for appropriate fees and 

issuance of formal receipts. While it would be inappropriate for MoH to actually set fees, it 

may be appropriate to make regulations that doctors fees must be on display in their surgery 

where patients can easily see them. Regarding this issue of fee levels, any move to set 

guidelines for fees for private doctors would, for purposes of equity, need to be extended to 

cover fees for doctors from the government system who have rights of private practice- and 

who charge patients directly for services provided within government facilities. 

In these areas the MoH and the Fiji College of General Practitioners may wish to work with 

the Royal Australian College of General Practitioners. 


The MOH should take the lead in recognising that the “health sector” consists of other 

partners besides the MOH. 

Working with outside support if necessary, it should explore ways in which it can work with 

these other parties, including private medical practitioners, to put in place more functional 

operational partnerships that better define the role of the respective partners in supporting the 

MOH to achieve the overall goals of the sector. 

It should also seek to obtain meaningful information on the range and volume of health 

services performed by these other parties. 

5.8. The Need for an Evidence based approach to Policy and Planning. 

While Fiji collects considerable and important data, as stated above, little operational 

research is being done to answer key questions that should guide future policy and planning 

decisions. Examples of 6 areas where such research is needed is given in detail at Annex 15. 

In summary this includes 

• Efficiency of Hospital outpatient departments 

• Change in usage patterns of health facilities 

• Patterns of Antenatal Care 

• The growing problem of congenital syphilis 

• Role of the private sector in Fiji 

• The adequacy and efficiency of mercy flights ambulance and patient transport 

services 

6. POSSIBLE AREAS FOR ASSISTANCE BY DEVELOPMENT 

PARTNERS. 

6.1. Overview 

As part of the assessment, the team was tasked to identify opportunities and gaps for future 

AusAID programming – including strategic objectives and likely areas of impact. This has 

been done and potential areas for external assistance are listed below. In general they are 

34


targeted to address the “ issues” identified in Part B, section 4 of this Situational Analysis, 

although some aspects of those issues may be addressed during the final year of FHSIP . 

Eight possible areas of support are listed. However it is not recommended that AusAID try to 

address more than 3 of these areas - 1 or 2 would be preferable. In a review of the progress 

being made by the FHSIP that was carried out concurrently with this Situational Analysis, it 

was concluded that despite a number of important achievements no truly visible impact can 

be seen as judged by measureable progress towards the achievement of the MOHs own KPIs. 

In large measure this reflects the fact that the program’s activities are spread very widely, 

with little focus on a core set of activities. 


It is recommended that initial priority for any AusAID support beyond 2009, should be given 

to assisting the MoH to achieve its own MDG 4 (infant and child mortality) and MDG 5 

(maternal mortality) targets. 

Such a recommendation is based on three observations: 

1. Fiji is significantly falling behind in its objective to achieve these important targets 

which are a key part of the MoHs own strategic plan and represent key commitments 

that the IGOF has given to its people. MoH would welcome assistance from AusAID 

and the donor community in general to achieve these. 

2. A co-ordinated and focused program to address these problems would serve as a good 

platform for other donors to join the program and for the MoH and these development 

partners to embrace the Pacific Principles of donor harmonisation (based on Paris 

Declaration). 

3. The impact of efforts to improve performance in these areas will be wide – and there 

will likely be improvements across many area of the health sector. 

Similarly the assessment team believes that the second priority should be to support the MoH 

to address a further 1 or 2 of its national Key Performance Indicators. These might include 

reduced amputation rates for diabetic sepsis from 13% to 9%, elimination of drug “stockouts 

“ or reduction in teenage pregnancy rates from 16% to 8%. Obviously the choice of 

which of the 12 KPIs listed in Annex 11 would be a matter for the Ministry. The extent of 

any further commitment beyond addressing MDG 4 and MDG 5 would be dependent on the 

level of support AusAID is prepared to commit. 

While no detailed design is given, an approach to achieving MDG 4 and 5 is discussed below. 

6.2. Highest Priority Areas for AusAID Support. 

6.2. 1. Provide targeted support to the MoH to reduce its level of infant and maternal 

mortality. 

This would require a strong focus on these two areas and would necessitate a recognition that 

such support will need to be provided across the sector including relevant secondary and 

tertiary areas. This issue of maternal and infant mortality has been discussed in some detail at 

section 4.5. 

While it is not the purpose of this “snapshot” to design any future program, some ideas are 

given here, because (a) it is felt that this area should be considered to be the highest priority 

for any new AusAID program and (b) if that principle is accepted some steps could 

commence within the framework of FHSIP, which still has one further year of operation and 

is currently finalising it workplan for 2009. 

35


In order to progress this concept in a planned way, such a program of support might have four 

phases – some of which could proceed concurrently and prior to the commencement of any 

new formal program of support that would begin in 2010. 

Phase 1: preliminary research to explore in more detail the issues affecting maternal and 

infant mortality, including the actual causes of each maternal and infant death; obtaining the 

type of information outlined in section 4.5. and 4.10. 

Phase 2: establishment of a sector wide management structure to guide the direction of the 

program and its ongoing monitoring and evaluation. This phase will also identify the 

“partners” who will work with the MoH as it seeks to address MDGs 4 and 5. These might 

include UNFPA, WHO, UNICEF, relevant NGOs and also a member of the private sector - 

recognising that there are over 120 private general practitioners who provide some level of 

maternal and infant care throughout Fiji. 

It would be an effective management strategy to include several project officers (seconded 

from MoH), of the type engaged within the FHSIP. They could play a day to day role in 

supporting individual key areas of the program and preparing reports for the management 

group etc. 

Phase 3: the MoH, working with its partners will prepare detailed “action plans” to address 

both maternal and infant mortality. While the outcomes to be achieved through such plans 

would be the attainment of the MDGs, it will be important that the plans include “stepping 

stones” that can be monitored on a monthly or quarterly basis. These “stepping stones” would 

need to be across many issues impacting maternal and infant mortality. including such areas 

as improved and more timely antenatal care; equipment needs for health centres and hospitals 

(neonatal units etc); improved transport (e.g. ambulances) within the framework of the 

referral system; addressing infection control within neonatal units; possibly the location and 

opening hours of health centres and nursing stations and reasons why people are by passing 

these centres to go to hospitals; steps needed to address the problem of neonatal syphilis. 

These action plans would need to be dynamic and be continually reviewed by the 

management group. 

Phase 4: ongoing implementation of the “action plans”. The program budget would need to 

be very flexible and not all committed upfront. This is because the success of such a program 

will be having available funds to respond to certain needs as they arise. 

It would also be important to have the PSC as an active partner in such a program as it may 

be necessary to respond to staffing issues in creative ways – and the PSC could give guidance 

on ways of doing this in a way that may constitute a “trial” without setting precedents or 

setting changes in concrete. 

It cannot be stressed enough that the success of such a program or activities will lie in the 

concept of focus and responsiveness – of addressing the problems in a timely manner 

and moving ever closer to the outcomes. It may prove to be a model for addressing the 

MDGs in other PICs. 

The Format for delivery of this assistance – a project, a model similar to that used in 

FHSIP or a model more similar to a focused SWAp would be a matter for AusAID to 

determine in conjunction with the MOH. 

6.2.2. Addressing other national Key Performance Indicators. 

A similar 4 phased approach could be used to provide support to a limited number of other 

national KPIs. The twelve national KPIs are given in Annex 11. As stated above, a program 

of support in this area might address KPIs such as reduced amputation rates for diabetic 

36


sepsis (from 13% to 9%), elimination of drug “stock-outs “ or reduction in teenage 

pregnancy rates (from 16% to 8%). Obviously the choice of which of the 12 KPIs listed in 

Annex 11 would be a matter for the Ministry. As stated above it is probable that a focus on a 

small number of areas would more likely have positive impact on the country’s health care 

system. 

In examples 6.2.1 and 6.2.2. the impact would be obvious – achievement of, or visible 

progress towards, attainment of the respective KPI 

6.3. Other Possible Areas for support by AusAID and other donors. 

6.3.1. Support to review the “framework” currently in place to ensure access to health 

services. 

The reason for such a review is discussed at section 5.2. and recommendation 4 of the report. 

It should take account of changes over the last 30 years and should ask the question “what do 

we want the health sector to look like in 2020” and begin planning for it now. 

It should have as its outcome a more efficient service model that better meets the needs of the 

people and the staff for the next 20 years. 

6.3.2. Support a culture of evidence based policy. 

This would be done by providing support for key operational research projects aimed at 

making the sector more efficient and effective. A strong interface between FSMed and the 

MoH is essential to ensure that donor supported research is targeted at key areas of need. 

Some areas that warrant research have been listed at 4.10. 

Such a program of support would provide a pool of information that can guide the 

development of meaningful policy – that experience from other countries has shown that 

policies supported by carefully researched evidence, are likely to be both more effective and 

less wasteful of resources. 

6.3.3.. Support a program of continued capacity development in key areas. 

Throughout this report the need to build capacity in selected areas has been highlighted. This 

will lead to a more skilled workforce. This would include management and supervision; 

planning, monitoring and evaluation; and the development of skills needed to prepare strong 

proposals in support of needs of the Ministry. 

The Project Officer and Performance Enhancing Projects “models” introduced through the 

FHSIP should be continued. Any support for program 6.1. above (MDG 4 and 5) would 

include a very large element of capacity development, including support for the Project 

Office and Performance Enhancing Projects model, and would largely negate the need for 

this to be a separate program. 

6.3.4. Upgrade of PATIS and other Health Information Systems (including training). 

Considerable work has already been done to support the development and roll out of health 

information systems in Fiji. This includes PATIS. More is planned by FHSIP during 2009. 

While it is recognised that good information systems are important tools to be used by the 

MoH, it is recommended that further AusAID support beyond the end of FHSIP should not 

be continued until the MoH, MoF&NP and PSC give some indication as to whether the IGOF 

will provide the necessary ongoing financial and specialist staffing support to enable this to 

be sustainable. 

37


6.3.5. Continued support for NGOs. 

NGOs play an increasingly important role in the health sector and should be supported. This 

especially applies to those NGOs that are providing services directly to the community. PC 

and SS and Marie Stopes International are such organisations but there are others. NGOs 

need to scale up and widen their activities and continued donor support will enable them to 

do this and to play a more positive role, and have a greater impact as “partners” of the MoH. 

PC & SS serves as a model for such a “scale up”. As discussed earlier, it started as a small 

NGO providing services to HIV/AIDS patients, but with increasing demand, it worked with 

The Australian Institute of Professional Counsellors to train more counsellors to meet a 

widening need. In time it began to train its own diploma level counsellors to Australian 

Standards and expanded its services from the initial 1 centre to the current position where it 

has counselling services in Lautoka, Nadi, Suva and Labasa. It now has an MOU with the 

MoH and provides routine counselling services in some hospitals as well as to the 

community, prisons and court work. AusAID has supported PC and SS throughout this 

scaling up. 

The format for continued support to health based NGOs (eg would it come from the health 

sector budget or from other NGO funding sources) would be a matter for AusAID 

6.3.6. Continued support for Regional Programs especially in the area of disease control. 

The above suggestions do not propose any new program in the area of Disease Control. This 

is because disease control activities are currently being well supported within Fiji by a range 

of Regional Programs including programs targeted at NCDs; HIV/AIDs; filariasis eradication 

and Emerging Infectious Diseases. In addition bodies such as UNAIDS, the Global Fund, and 

WHO are providing valuable support in key disease control areas. 

What is proposed here is that those regional disease control activities being supported by 

AusAID, and especially support for NCDs and diabetes prevention and control, should be 

continued and even strengthened. There would be benefit if there was also continued input to 

these areas from other donors. 

Such programs in many ways relate to “Pacific lifestyle”, and have elements that not only 

impact on Fiji but on other countries in the region. They are well suited to a regional rather 

than a bilateral approach. However it is suggested that, as AusAID further develops its 

regional strategy, it ensures that activities within its regional programs are clearly consistent 

with an individual country’s national plans and priorities. There would be benefit in having 

regional MoHs “sign off” on those elements of the Program that relate to their own country to 

ensure better ownership and understanding of what is available to them through regional 

programs. The review team found there was often poor understanding at senior levels of what 

the development partners were doing through their regional programs and how they can 

become part of their own national plans. 

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Fiji Health Sector Situational Analysis 2008 - Pacific Health Voices

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