«2.1 Section summary Fiji’s health system is based on a three-tier model that provides an integrated health service at primary, secondary and ...»
2 Organization and governance
2.1 Section summary
Fiji’s health system is based on a three-tier model that provides an
integrated health service at primary, secondary and tertiary levels. This
system was inherited from the British colonial administration and has
undergone several modifications over time. From 1999 to 2003, the Fiji
Health Management Reform Project introduced a more decentralized
approach to management of the system, but these changes were rolled
back in 2008.
While there are 17 pieces of legislation that govern and regulate the provision of health services, the health system is basically divided into two health programmes: primary and preventive health care services and curative health care services. These two programmes and their respective disciplinary areas largely determine the organizational structure and the modus operandi in the MoH. There are also various statutory bodies, councils and committees (such as the National Food & Nutrition Centre, the National Health Promotion Council, and the National Advisory Committee on AIDS) that provide supportive roles in the management and administration of specific health services.
The planning process for the MoH is based on the government’s national strategic planning process. Recently, the government has strengthened the intersectoral approach to project management and implementation to ensure effective resource utilisation and minimize wastage. The MoH Clinical Services Planning Framework also plays a key role in the planning process. Ongoing efforts to strengthen the Health Information Unit should improve the information available for planning.
2.2 Overview of the health system The MoH manages a comprehensive decentralized health system of integrated primary, secondary and tertiary care following the Fiji Health Sector Management Reform Project 1998–2002, although the administration of human resources, finance and supply remains centralized.
Primary health care and public health care services are managed and administered through four Divisional Health Services (DHS) offices: Central & Eastern combined in Suva; Western in Lautoka; and Northern in Labasa, each led by a Divisional Medical Officer (DMO) and responsible for providing public health services. There are five subdivisions in the Central Division, four in the Eastern Division, six in the Western Division and four in the Northern Division. The four DMOs are responsible to the Deputy Secretary Public Health who heads the Public Health Division in the MoH headquarters in Suva. Public health services are provided through 16 subdivisional hospitals (SDH), 77 health centres (HC) and 101 nursing stations (NS). The subdivisional hospitals, with an average capacity of 12-40 beds, provide inpatient care and outpatient services within each subdivision. Three area hospitals, smaller in capacity than a subdivisional hospital (usually with no more than 15 beds), complement the subdivisional hospital by delivering services in isolated populations.
Each subdivisional hospital supervises a designated medical area that includes a number of health centres and nursing stations. A health centre is managed by a medical officer or nurse practitioner working with one or two nurses. It provides the first level of referral for a number of nursing stations, and is generally staffed by one nurse who conducts outreach visits to communities in a designated nursing area. Community nursing stations complement and function like stations, except that they are built and funded by the community themselves, following approval by the government and according to government standards. In addition, MoH-trained community members serve as Village Health Workers (VHW) in Fijian villages and Community Health Workers (CHW) in Indo-Fijian communities.
20 Patients may first see a VHW/CHW or a nurse during an outreach visit or may go to a nursing station, health centre or subdivisional hospital. They may be referred to a higher level health facility: one of the three divisional hospitals (in Suva, Lautoka and Labasa) or the Colonial War Memorial Hospital (CWMH). All consultations, admissions and laboratory and radiological examinations are free to the public in public health facilities, except for some dental and special treatments or those in which patients choose to be admitted to a paying ward.
The sixteen subdivisional hospitals and the three divisional hospitals provide a comprehensive range of services, including core specialist services. The three divisional hospitals and several at subdivisional level also serve as teaching hospitals for nursing and medical students. The Colonial War Memorial Hospital serves as the national referral hospital for Fiji and is available to other countries in the region, as it provides additional specialized services, including renal, cardiac and cancer services.
There are three specialized hospitals: St. Giles Psychiatric Hospital; the P.J. Twomey Hospital for tuberculosis and leprosy; and the Tamavua Rehabilitation Hospital. Each divisional and specialized hospital is headed by a medical superintendent who reports to the deputy secretary for hospital services, head of the Clinical Administration Section in the MoH.
The Clinical Services Planning Framework developed in 2005 outlines the delivery of clinical health services at the various service levels within each specialty area, benchmarked against the MoH Strategic Plan.
A small private sector includes two private hospitals in Suva (and another under construction) that provide a range of specialized services, several day clinics and 130 private general practitioners located mostly in the urban centres of the two main islands, Viti Levu and Vanua Levu. There is a private maternity hospital in the Western Division (co-funded through government grants) and another one is planned.
In rural areas, traditional healers are visited for a variety of health problems, which can range from minor health ailments to more lifethreatening diseases like cancer and poisoning.
Source: Ministry of Health
2.3 Historical background Fiji gained its independence from the United Kingdom in 1970. It inherited a health care system in which provision of health services was subsidized;
although there was a schedule of hospital charges, there were also non-fee paying wards and a provision in the Hospital Act for a medical superintendent to waive fees. A user-pays system was implemented in 1978 for those who could afford to pay for private rooms. In 1970, revenues from fees comprised 10.5% of all health expenditure, but after 1973, this fell to between 2.5 and 3.5%. The population is accustomed to a high level of public funding for health services and any attempt to significantly increase revenues through user fees would represent a major change, with political and population health ramifications. In recent years, the potential to increase government health sector allocations has been limited by slow national economic growth and periodic austerity measures, compounding historic underfunding.
22 Fiji’s decentralized primary health care (PHC) system throughout the 1970s aimed to deliver good quality basic care to all. Fiji was implementing elements of primary health care well before the 1978 Declaration of Alma Ata made the concept internationally known. Negin et al (2010) identified that ‘some elements of PHC existed in Fiji before 1976 although not institutionalized, funded or formalized’. Home visits and village health days were part of health workers’ roles. Medical officers’ responsibilities extended beyond their clinical role to advising communities on public health issues, while Fiji’s communal culture facilitated a high degree of community engagement and participation. In practice, however, the centralized structure of the health system has tended to work against primary health care, with resource allocation tending to favour the maintenance and development of hospital services.
As primary health care activities declined in the 1980s, Fiji was beset by the now common Pacific experience of increases in non-communicable diseases (NCD). The imperative to sustain primary health care services remains, in particular, for preventive care. Health promotion activities, however, appear to be having little effect in producing healthier lifestyles, partly due to limited food consumption choices.
The Fiji School of Medicine, which celebrated its 125th year in 2010, was started by the Chief Medical Officer of the colony, Dr William MacGregor as The Suva Medical School in 1885. Its establishment was prompted by events and factors such as a devastating measles epidemic in 1875, fear of smallpox and cholera from indentured labourers from India and the acute shortage and high cost of European medical officers (Brewster 2009). The Suva Medical School progressively developed into the Central Medical School in 1928 and the Fiji School of Medicine in 1962. It now offers courses in medicine, dentistry, health sciences and public health. Fiji has a long history of training health professionals for the Pacific region, many of whom have become chief medical officers and national leaders.
2.4 Organization In the last two decades, the MoH has embarked substantially on the model of a three-tier system of primary care with the objective of providing divisional, subdivisional and area-based health care facilities. This threetier system is staffed by specialist medical and nursing staff, generalist medical and nursing staff and primary care providers, including MBBS graduates, medical assistants, postgraduate trained nurse practitioners and generalist nursing graduates, with the aim of maintaining a decentralized system with a strong primary health focus. The public system is complemented by approximately 130 urban-based general practitioners registered with the Fiji Medical Council.
The Minister for Health is a member of the Cabinet of Government of Fiji.
The MoH is headed by a Permanent Secretary for Health appointed by the Public Service Commission.
Permanent Secretary for Health The Permanent Secretary for Health provides overall leadership and direction for the MoH and is mandated under legislation to ensure the safe practice of health professionals and the provision of quality health services to the people. In doing so, the incumbent is accountable to the Minister for Health and the Prime Minister through the Public Service Commission for the attainment of health outcomes, as per MoH Annual Corporate and Strategic Plans.
Division of Hospital Services The Division of Hospital Services is the responsibility of the Deputy Secretary Hospital Services (DSHS) who provides policy advice to the Permanent Secretary on clinical services and related issues. Governed by the Public Hospitals & Dispensaries Act, the DSHS is responsible for the provision of clinical services, including the monitoring of health system standards in all health facilities, for the formulation and development of appropriate policies and for effective decision-making in resource management.
Division of Public Health Headed by the Deputy Secretary Public Health, the Division is responsible for services ranging from the development and formulation of public health policies and their translation into priority health programmes to the provision of primary health care to the population, as legislated under the Public Health Act 2002. It also includes the evaluation of various public health programmes under their national advisers, such as Family Health, 24 Non Communicable Diseases, Health Promotion, Control of Communicable Diseases, Food & Nutrition, Environmental Health and Oral Health, to ensure effective delivery of primary health care to the people of Fiji.
Division of Administration and Finance The Division of Administration and Finance plays a key service support role regarding asset and contract management, human, financial and physical resource development and information management. This division is led by the Deputy Secretary of Administration and Finance who reports to the Permanent Secretary for Health, and also provides policy advice on the implementation, monitoring and evaluation of civil service reforms in the MoH.
Division of Information, Planning and Infrastructure Led by the Director of Health Information, Planning & Policy, this division is responsible for co-coordinating the development, formulation and documentation of MoH policies, the National Health Plan, department/ section/unit plans, and medium-term strategies in alignment with the MOH’s long term mission and vision. It oversees the MoH Health Information System Development Programme, aimed at achieving a cost-effective and user friendly system that meets management’s timely reporting, monitoring, evaluation and information needs for decisionmaking, and is charged with strengthening essential health research activities.
Division of Pharmacy and Biomedical Services The Director of Fiji Pharmaceutical & Biomedical Services is responsible to the Permanent Secretary of Health for the provision of policy advice and management support in initiating and coordinating, formulating and implementing national strategies and plans in relation to pharmaceutical services and biomedical equipment. Technical matters related to medicine and therapeutics and their regulation, under the Pharmacy & Poisons Act 1997 and the Dangerous Drug Act 2004, are the responsibility of the Chief Pharmacist.
Division of Nursing Services (DNS) The Director of Nursing Services is accountable to the Permanent Secretary of Health for policy advice and nursing development. The Director holds 25 a statutory role as the Registrar of the Nurses, Midwives and Nurse Practitioners Board as mandated by the Nurses, Midwives & Nurse Practitioners Act 1999. The Director administers the Act in overseeing the functions of the Board in the registration of nurses, regulation of nursing practice and provision of nursing education, and liaises with the other directors and national advisers for the achievement of health outcomes.
2.5 Decentralization and centralization