the evolution of primary health care in fiji: past, present and future

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KNOWLEDGE HUBS FOR HEALTHStrengthening health systems through evidence in Asia and the Pacic

The Nossal Institute

for Global Health

www.ni.unimelb.edu.au

HEALTH POLICY AND HEALTH FINANCEKNOWLEDGE HUB

WORKING PAPER SERIES NUMBER 6 | MAY 2010

The Evolution o Primary Heath Care in Fiji:Past, Present and Future

Joel NeginSydney School o Public Health and Menzies Centre or Health Policy, University o Sydney, Australia.

Graham RobertsFiji School o Medicine.

Dharam LingamFiji School o Medicine.


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WORKING PAPER SERIES HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB

The Evolution o Primary Heath Care in Fiji: Past, Present and Future NUMBER 6 | MAY 2010

ABOUT THIS SERIESThis Working Paper is produced by the Nossal Institute or Global Health at the University o Melbourne,Australia.

The Australian Agency or International Development (AusAID) has established our Knowledge Hubs or

health, each addressing dierent dimensions o the health system: Health Policy and Health Finance; HealthInormation Systems; Human Resources or Health; and Womens and Childrens Health.

Based at the Nossal Institute, the Health Policy and Health Finance Knowledge Hub aims to support regional,

national and international partners to develop eective evidence-inormed policy making, particularly in the eldo health nance and health systems.

The Working Paper series is not a peer-reviewed journal; papers in this series are works-in-progress. The aim is

to stimulate discussion and comment among policy makers and researchers.

The Nossal Institute invites and encourages eedback. We would like to hear both where corrections

are needed to published papers and where additional work would be useul. We also would like to hear

suggestions or new papers or the investigation o any topics that health planners or policy makers would ndhelpul. To provide comment or get urther inormation about the Working Paper series please contact; [email protected] with Working Papers as the subject.

For updated Working Papers, the title page includes the date o the latest revision.

The Evolution o Primary Health care in Fiji: Past, present and Future

First drat April 2010

Corresponding author: Joel Negin

Address: Sydney School o Public Health and Menzies Centre or Health Policy, University o Sydney,[email protected]

Other Contributors: Graham Roberts, Fiji School o Medicine and Dharam Lingam, Fiji School o Medicine.

This Working Paper represents the views o its author/s and does not represent any ocial position o TheUniversity o Melbourne, AusAID or the Australian Government.

ACKNOWLEDGEMENTSThe authors would like to acknowledge the assistance and guidance o Josaia Samuela o the Fijian Ministry o

Health and o Alvaro Alonso-Garbayo o the World Health Organization throughout the research and drating.

Erica Mayer provided excellent research support and Anne Marie Thow assisted in the development o thehealth policy analysis ramework. The authors would also like to thank the various interviewees or their time

and candour in contributing to the research.


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HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB WORKING PAPER SERIES

NUMBER 6 | MAY 2010 The Evolution o Primary Heath Care in Fiji: Past, Present and Future i

ABSTRACTHealth policy development is under-analysed globally and in the Pacic region. Understanding how healthpolicies develop and evolve is a rst step towards improving the quality and appropriateness o those policies.

Through a document review and key inormant interviews, this study examines the evolution o the concepto primary health care in Fiji rom 1975 to 2009, ocusing on priority-setting, unding, implementation, politicaleconomy, the cultural context and interactions between communities, government and donors. Lessons rom

more than 30 years o experience with community health are highlighted, revealing high levels o contestation

over health policy. The study identies actors or inclusion in any renewed primary health care intervention andcalls or greater government ownership o priority setting, more clarity on the links between policy and unding,

greater awareness by development partners o the risks o imposing policy and a deeper analysis o political

economy and culture in relation to health policies.


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ii The Evolution o Primary Heath Care in Fiji: Past, Present and Future NUMBER 6 | MAY 2010


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NUMBER 6 | MAY 2010 The Evolution o Primary Heath Care in Fiji: Past, Present and Future 1

INTRODUCTION AND METHODS

Purpose o the Case StudyThe overarching objective o the research is to understand better the evolution o primary health care in Fijiand, through it, the policy process in the Pacic. Carden (2009) asserts that in order to maximize the infuence

o development research on public policy and action, the best rst step is to assess how that policy is actually

made. Despite its importance, health policy analysis remains neglected, under-researched and under-unded(Gilson and Raphaely 2008). This is particularly true or the Pacic: while many agencies ocus on infuencing

development, there has been a paucity o analysis o regional health policy and the development o national

strategic and operational plans.

A 2008 review o global literature, which identied 391 health policy analysis articles concerning low and middle

income countries over a 13-year period, noted that none ocused on the Pacic (Gilson and Raphaely 2008).

Globally, evidence-based policy making is becoming more complex. The World Health Organization (WHO

2006) highlights the strength o development partners, asserting: [N]ot only do these partners have the powerto und, or not to und, given projects, they also have the power to infuence, i not control, policy-making

agendas. Reich and Takemi (2009) note: [P]olicy making in global health has become a multistakeholderprocess with competition and conusion both globally and nationally. The act that the Pacic is the mostheavily aid-assisted part o the world per capita only adds to the challenge and importance o health policy

analysis (AusAID 2009).

A recent overview o the health sector in Fiji cited the need or [a] stronger evidence based approach to policyand planning (Sutton, Roberts et al 2008). This study investigates the evolution o primary health care in Fiji

rom 1975 to the present. It aims to understand how health policies develop over time, noting how various

actors infuence policy and the dynamics between national and international stakeholders. The purpose is:

ToinformpolicyactorsinFijiandtheregiononthepolicydevelopmentprocess;

ToinformcurrentdebatesinFijionthedirectionofprimaryhealthcarepolicy.

MethodsThe case study was conducted through a thorough document review, including bilateral and multilateral

agency reports and Ministry o Health documents, a review o the published literature and semi-structured keyinormant interviews.

Empirical data were gathered through historical documents and reports. A search o the PubMed literature

database using search terms including Pacic and islands and primary health care and Fiji and primary healthcare revealed a limited number o peer-reviewed articles, demonstrating the relative lack o published analysis

o primary health care in the region. To complement the literature review, the research included telephone and

in-person interviews with representatives o government agencies, multilateral organisations, donor agencies,academic institutions and experienced health consultants to the region. Interviews o approximately one hour

each were conducted using a semi-structured questionnaire. In total, 14 interviews were conducted, including

10 with national actors and our with representatives o bilateral or multilateral agencies. The ocus was how theinterviewees perceived changes to primary health care over time, emphasising infuences, language and socialconstruction o ideas. Ethics approval was received through the University o Sydney.

The study used Walt and Gilsons (1994) health policy analysis triangle to structure the interviews and analysis

and particularly ocused on decision-making processes and relationships between key actors. However, theWalt and Gilson ramework does not suciently capture some o what Pollard (2008) calls the Pacics below

the iceberg actors, including: belies, culture and values; power, authority and politics; organizational culture

and norms o behaviour; and social patterns and relationships. Thereore, in looking to develop a ramework orhealth policy analysis or the Pacic, we have sought to integrate key themes rom other rameworks, including

Howlett and Rameshs (2003) policy cycle, Bowen and Zwis (2005) policy and practice pathway and cultural

and contextual issues specic to the Pacic (Capstick, Norris et al 2009). Based on these themes and global,

regional, local and national infuences in the region, a health policy analysis ramework was adapted rom that

o Walt and Gilson (1994). Figure 1 illustrates the ramework. During analysis, inormation was organised


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2 The Evolution o Primary Heath Care in Fiji: Past, Present and Future NUMBER 6 | MAY 2010

Figure 1. Health Policy Analysis Framework

in each component o the ramework and at the various geographic levels beore movement between levels

or interaction between components was assessed. While the ramework does not clariy all possible policyinteractions, it serves as an initial tool or conceptualising policy components and interactions.

Such qualitative research has its limitations. The limited number o interviews, covering more than 30 years o

history in Fiji, is insucient to grasp the ull complexity o the evolution o primary health care. A number o the

key actors in the 1970s and early 1980s are no longer in Fiji or no longer living. Additionally, those willing to beinterviewed were more likely to be interested in the topic generally, thus representing some level o bias. Lastly,

there is certainly a sense o nostalgiasome interviewees recalled the good old daysand their recollections

o health policy development might not represent the ull spectrum o issues o the time. These limitations havebeen taken into account as much as possible in the analysis.

The Global ContextPrimary health care (PHC) has been a central concept in global health or more than 30 years, since its

inception at Alma-Ata in 1978, although the implementation o PHC principles has varied. Over the past twoyears, however, there has been a renewed interest in PHC, as evidenced by the 2008 World Health Report,

Primary Health Care: Now More Than Ever (WHO 2008), and the prominent Lancetseries on PHC (Arenaissance in primary health care 2008; WHO 2008; Lawn, Rohde et al 2008; Lewin, Lavis et al 2008; Rosato,

Laverach et al 2008; Rohde, Cousens et al 2008).

Margaret Chan, Director-General o the WHO, has noted with regard to Alma-Ata that there is much that can

be gleaned rom the experiences o a movement that ailed to reach its goal (Chan 2008). This is particularly

relevant or the Pacic, where, perhaps more than most regions o the world, some countries implemented PHCand realised real benets (WHO 2001; Jacobs 2002) some o which were subsequently lost. Recording the

lessons rom the PHC experience in the Pacic can thereore support policy making in the region.

The International Conerence on Primary Health Care was held in September 1978 at Alma-Ata in the thenUSSR. The conerence, jointly sponsored by the WHO and UNICEF, was attended by 600 representatives

o 150 WHO member states. The attendees rejected the inequalities in health care o the time as politically,

socially and economically unacceptable and proposed comprehensive primary health care as the undamentalmeans or improving health (WHO 1978).

GLOBAL

REGIONAL

LOCAL

CONTEXT &

CULTURE

EVIDENCE &

PRIORITIES

ACTORS &

CAPACITY


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The Alma-Ata Declaration dened primary health care as the rst level o contact o individuals, the amily and

community with the national health system bringing health care as close as possible to where people live and

work, and [it] constitutes the rst element o a continuing health care process (WHO 1978). The Declarationarmed health as a undamental human right and strongly linked it to national development. Importantly, a

central tenet o the Alma-Ata Declaration [was] that progress in health [would] depend on many actorsi.e.,

economics, education, nutrition, health system and cultureand [would be] closely linked to governance,social justice and changes in other sectors (Rohde, Cousens et al 2008).

In essence, the Alma-Ata Declaration expanded the scope o health care by presenting health not merely as

a result o biomedical interventions but also an outcome o social determinants (Lawn, Rohde et al 2008). Forthe rst time, prevention was equally as important as cure and there was a shit in attitude rom a ocus on ill

health and hospitals, to a ocus on communities and amilies controlling their own health, putting the public

into public health (Lawn, Rohde et al 2008). The Declaration emphasised greater equity in access to care,

community ownership and eciency in service delivery. There was consensus on the need or a country-by-country approach based on sound epidemiological analysis that would be relevant to [each] countrys state

o development (High Hopes at Alma-Ata, 1978). All o this was intended to lead to the ultimate goal o health

or all by the year 2000.

Alma-Ata emphasised community-ocused health, calling or a system that addresses the main health

problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly

and initiatives that require and promote community and individual sel-reliance and participation in theplanning, organisation, operation and control o primary health care (WHO 1978).

The necessary components o PHC as dened by the Declaration included education concerning prevailing

health problems and the methods o preventing and controlling them; promotion o ood supply and proper

nutrition; an adequate supply o sae water and basic sanitation; maternal and child health care, includingamily planning; immunisation against the major inectious diseases; prevention and control o locally endemic

diseases; appropriate treatment o common diseases and injuries; and provision o essential drugs (WHO

1978).

Some, however, saw this approach as overly ambitious, unrealistic and unattainable (Brown, Cueto et al 2006).

The move to selective PHC and then the implementation o structural adjustment policies in many developing

countriesaccompanied by budget cuts and reduced social spendingmeant that the original conceptiono PHC was, in the main, not ully implemented. Some outstanding local health development programs did

demonstrate that a strong commitment to PHC principles could decrease deaths and reduce chronic disease

morbidity, in both government and non-government settings with examples in South and Central America

(Perry, Shanklin and Schroeder 2003), South Asia (Arole and Arole 1994), and South-East Asia (Perks, Tooleand Phouthonsy 2006). These were, however, rarely scaled-up to a national level, with some exceptions such

as Thailand (Rohde, Cousens et al 2008).

Nonetheless, the idea has remained alive and there is now a return, in dierent orms, to the Alma-Ataprinciples. In 2002, the Western Pacic Regional Oce o WHO made a signicant evaluation o the experience

o national health programs (including Fiji) o 25 years o PHC, nding success in a limited number o areas(Jacobs 2002). The ormer director-general o WHO, Lee Jong Wook, used this and other regional evidenceto promote the vision o a health-care system based on primary health care (Lee 2003), leading later to the

stronger declaration o Primary Health Care: Now More Than Ever(WHO 2008). In 2009, the American Public

Health Associations working group on community based primary health care systematically reviewed health

delivery mechanisms underpinning PHCs success in promoting child survival. This made a strong case orcommunity-oriented interventions such as home visits by health motivators, group meetings or education and

support, outreach services and community-based care o high priority diseases (Freeman, Perry et al 2009). An

examination o the history o PHC in Fiji helps to locate it in these global movements and also determine howPHC principles and mechanisms can best inorm uture health policy in Fiji and similar settings.


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THE ORIGINS OF PHC IN FIJIAs the global community declared its ambitious health goals at Alma-Ata in landlocked mountainousKazakhstan, the newly independent Pacic island nation o Fiji was responding to its own health challenges,

already beginning to practise much o what the Alma-Ata Declaration proposed. Interviews with key inormantsor this paper reveal a commitment among Fiji health planners to many o the principles o the Declaration.

PHC Has Always Been HereDuring interviews, now retired Ministry o Health (MOH) ocials described a newly emerging health system in

the 1960s that showed eatures similar to some central PHC components.

One interviewee described his work starting in 1962 in the interior o Vanua Levu, Fijis second largest island,where, as a medical ocer (MO), he conducted outreach, oten on horseback, to remote villages to discuss

hygiene and health issues with the community and even to set up a de acto village dispensary by training the

headmans wie and giving her some basic medication to treat minor ailments. While these activities were not

dictated by MOH directives, the intervieweewho noted that many others provided these types o services

toojust did these things based on intuition, responding to a need to reach dispersed populations in morethan 130 inhabited islands.

Similarly, in interviews, nurses who were working at that time conrmed they were doing outreach, holdingvillage clinics and training traditional birth attendants and traditional medicine practitioners. From the early

1970s, they were working with communities because domiciliary visits and demographic inormation collection

were part o the position description along with their responsibilities at their posts. They would visit every homein their catchment area, discuss health issues with community members and come up with collaborative ways

o overcoming challenges, such as protecting water sources or building latrines.

One interviewee who worked in remote areas in the 1970s said, We started PHC even beore Alma-Ata. Mostdoctors, ater their internships, served in rural health centres and nursing stationswhich were built throughout

the country in villages o more than 200 peopleproviding services close to where people lived (Sutton,

Roberts et al 2008). These nursing stations provided amily planning inormation and services, maternal andchild health services, rst-aid and health education and also conducted outreach. Fijis communitarian cultureacilitated a high degree o community engagement and participation. Indigenous Fijians place a great deal

o emphasis on village lie and the hierarchy o chies and traditional clan roles. Doctors and nurses active at

that time stated that they were able to work within this community culture, building partnerships with chies, toensure that communities took an active role in their own health status.

Following Alma-AtaBased on the research interviews, however, it is unclear how widespread these positive PHC experiences

were in the pre-Alma-Ata phase. Reports o the outreach work by doctors and nurses might be biased by bothmemory and the selection o interviewees. Despite these caveats, there was a consensus that at least some

elements o PHC did exist in Fiji beore 1976 even i they were not institutionalised, unded or ormalised.

In 1976, even beore the conerence at Alma-Ata, the World Health Organization held a regional meeting onPHC to introduce the concept. The government o Fiji ollowed in 1977 with the First National Conerence onPrimary Health Care (Asuzu, Ram et al 2004), and in the same year the WHO started providing substantial

unding or PHC in Fiji. Interviewees who were then working in the health system remember hearing about PHC

or the rst time during that year. One interviewee noted that she rst heard o PHC in 1978, as a doctor in arural health centre, noting that doctors were already doing much o what the MOH was pushing them to do.

In 1986, the development o primary health care in the South Pacic region was assessed by the World Health

Organization and the United Nations Development Programme (WHO and UNDP 1986). PHC has variouslybeen understood as an overarching health system philosophy (based on attaining health or all), as a level o

care (rst point o contact with the health system) and as a health systems approach emphasising a horizontal

manner o acing challenges (Lawn, Rohde et al 2008).


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Meanwhile, the emphasis on PHC was less as a how to manual than as a philosophy o holistic health (Lawn,

Rohde et al 2008). As a result, Fiji had to adapt the concepts to suit its system and health challenges and

chose to pursue a village-based approach to primary health care in line with its existing rural health program(WHO 2008). The 1978 MOH Annual Report described PHC as a concept that was being tested (Asuzu, Ram et

al 2004).

Even with an existing health system structure that incorporated a number o PHC concepts, a majorreorganisation o the administrative structure was made to the health system in the build up to and the period

immediately ater Alma-Ata. At the national level, a new division o Primary and Preventive Health was set up

with all community based health institutions placed under its jurisdiction (Waqatakirewa 2001). According tointerviewees, the Fijian version o PHC was embraced quickly by health workers. With WHO unding provided to

divisional and subdivisional health teams, the new approach became more ormalised.

With signicant unding, Fiji implemented a broad-based PHC approach ater 1978, highlighting a ew

pillars: expanded access to health services, community engagement, environmental health, multi-sectoralengagement, establishment o village health committees and village health workers. Subdivisional health

workers started organising more community workshops as part o a more explicit aim to get community

members to see health as their own responsibility. In a 2001 review o PHC in Fiji, Lepani Waqatakirewa (2001)refected on the years ater 1979 and noted that the conduct o subdivision and community workshops was the

most memorable activity ollowing the introduction o the PHC concept, when there was more integration o the

various programme areas in one sitting.

The major achievement made possible by the WHO unding was the marketing o the Alma-Ata Declaration

and community awareness building regarding health. For example, water and sanitation were an area o

major concern because o water-borne diseases, so communities were advised and assisted to ocus on the

construction and maintenance o water and sanitation resources.

However, some components o the emerging PHC concept were new to Fiji. Under the new model, the health

sector subdivisions collaborated with representatives o other ministries, including Agriculture, Education and

Lands. One interviewee lauded this huge and rich multi-sectoral approach as one o the dening elements oPHC, although other interviewees cast doubt on whether this rhetoric was ever achieved, noting that separate

budgetary provisions remained during this era and still do.

Another major component o Fijian PHC was the training o community health workers (CHW) in mixed Indo-Fijian communities and village health workers (VHW) in every Fijian village. 1 Communities nominated a local

member who would become the CHW/VHW, and that individual would be trained by the MOH through an

intensive six-week program ollowed by organised in-service training (MOH 1994). The MOH would provideequipment and drugs, the community would provide a working location (sometimes building a CHW/VHW

dispensary rom scratch) and, in many cases, the community committed to supporting the CHW/VHW either

with cash or with in-kind contributions such as planting or shing or them. The CHW/VHW was the rst contact

point or community members and provided basic drugs and treatments. The CHW/VHWmostly womenreerred patients to nursing stations and reported to the area nurse. Interviewees armed that the CHW/VHW

were the backbone o PHC, the interace between health and the community.

Interviewees highlighted the strong community culture at that time, there being an infuential villageheadman in Fijian communities and strong Advisory Committees in Indo-Fijian communities, acilitating PHC

implementation. Planting, cultivation and shing were seen as communal activities, and neighbours supported

one another. However, interviewees noted that it was ar more dicult to implement PHC in the heterogeneousIndo-Fijian communities than in the homogeneous Fijian villages, where community action was more likely.

PHC was a dening element o the Fijian health system or many o the nurses and doctors who entered the

system in those years, and who are now senior ocials in the MOH. One noted that PHC was part o our

training and another that we came into the ministry at a time when we heard lots about PHC. During this time,

1 In the literature o Fijis primary health care initiatives, the terms village health workers and communit y health workers are used interchangeably. CHW generallyreers to those who worked in Indo-Fijian or mixed communities and VHW to those rom ethnic Fijian villages. This report uses the term CHW/VHW predominantlyunless one or the other term is explicitly used in a quotation or document.


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PHC became entrenched in educational acilities. The Fiji School o Nursing established a compulsory three-

month rural attachment or medical students, and the Fiji School o Medicine introduced the Primary Care

Practitioners (PCP) program (Waqatakirewa 2001).

The government, with cabinet approval, strongly endorsed the PCP program and appointed Dr Timoci Bavadrao the MOH to direct it. Interviewees suggested that Dr Bavadras leadership o the PCP program contributed

signicantly to his popularity as a champion o the people, contributing to his eventual election as PrimeMinister and highlighting the widespread appeal o PHC values in Fiji.

Challenges and Successes in PHC ImplementationAlong with a generally positive experience in the early days o PHC, a number o challenges arose. One nurse

said, PHC is doing seminars in villages, suggesting how shallow the absorption o key PHC concepts wasamong some health workers. Many interviewees suggested that the implementation o PHC had been largely

top-down, but also thought this may have been appropriate because, at the time, there was very low awareness

and understanding o health issues in rural Fijian communities.

This top-down approach, in which health proessionals took the main role, meant that PHC was successul

mostly where the subdivisional medical ocer pushed it. Tembon (1988) identied that the training o CHWs

depends on the enthusiasm and energy o the medical ocer (MO) o that area. While one MO stated, At the

time, I would eat and sleep PHC, one might expect that this level o commitment was not true o all doctors andnurses working in rural areas.

Another interviewee noted that while implementation o PHC was successul, it required a lot o sacrice rom

the health workers o time conducting outreach and working with communities. The personal commitmentneeded to push PHC orward was perhaps unsustainable on a wide scale without continued external unding.

A similar sustainability challenge existed with CHW/VHWs. Although most agreed that the trained CHW/VHWs

did a good job, some volunteer CHW/VHWs were not supported with sucient basic operational costs by theircommunities, and clinics were not consistently supplied by the MOH, leading to declines in the numbers and

commitment o CHW/VHWs.

While the evidence suggests that the introduction o PHC in Fiji was largely driven by WHO and UNICEF

unding ollowing Alma-Ata, the model also had strong synergies with local cultures and health worker practicesin Fiji. This led to the airly seamless integration o PHC into the health system. PHC was seen as generally

successul by all interviewees. Most village health committees were engaged and involved in PHC, CHW/VHWs

were initially warmly embraced by communities, and outreach activities were common. Interviewees lauded theprogram as really good or Fiji while it lasted and noted, We had people who mastered it PHC specialists

and had great impact.

Asuzu, Ram et al (2004) report that, based on the progress during the rst decade o PHC, many thought thatFiji could be the rst in the developing world to achieve health or all. Key indicators support this attitude.

Critical measures improved signicantly rom 1975 to 1986: the inant mortality rate and maternal mortality ratio

declined dramatically and immunisation coverage increased rom below 50% to over 80% (Asuzu, Ram et al

2004). Figure 2 illustrates the improvements. A number o interviewees asserted that communicable diseasessuch as diarrhoea and scabies were reduced during this time (although, as one interviewee who was working

as a rural MO at this time noted, there were no lab tests to conrm this reduction). Waqatakirewa (2001) noted

that, while it is true that other positive actors aecting the health system could claim credit or the improvement the single most important event happening around that period was the introduction o the PHC concept.

In some respects, the positive impact o these early years o PHC has persisted in dierent orms or 30

years, including the existence o nursing stations throughout the country, nearly universal use o skilled birthattendants (99% o all births, according to AusAID 2009) and the continued presence o VHWs in many

communities (which interviewees placed at approximately 70% o all villages). During the rst ew years o

PHC, interviewees stated that many latrines were built, the water supply was improved, and monthly checks

were conducted by health inspectors. The visits o health inspectors became well known to the point that one

interviewee recalled, My mum used to clean up the house and yard when the inspectors were coming.


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Figure 2. Key Primary Health Indicators in Fiji, 1975-2008

Notes: Inant mortality rate per 1000 live births; maternal mortality ratio per 100,000 live births; amily planning protection rate as a percentage o women. Data or someyears were not available and were estimated.Sources: World Bank 1994; MOH 1994; 1996; 1998; 1999; 2000; 2006; 2008; Sutton, Roberts et al 2008.

Interviewees noted high levels o community participation, outreach activities and communities taking

responsibility or their own health. Some communities embraced PHC thoroughly and provided unds to scaleup the community dispensary and pharmacy and to support CHW/VHWs. In act, in 1991, one community won

the WHOs Sasakawa Health Prize, which acknowledges outstanding innovative work in health development

or notable advances in primary health care (WHO 1998). Overall, PHC was seen as a powerul and positive

orce or better health, leading one interviewee to note that PHC became a phenomenon in the eld. It was

generally agreed that through the 1980s, the PHC approach became entrenched in MOH health system policyand implementation.

THE SLOW DECLINE OF PHCDespite the prominence o PHC in the late 1970s and the early 1980s, all interviewees agreed that this

momentum did not last, a judgment conrmed by Waqatakirewas (2001) review o PHC. From the 1990s, PHCin Fiji suered a steady decline.

The decline o PHC is refected in declining use o primary care acilities. Data rom MOH annual reports

indicate a marked drop in per capita health centre outpatient utilisation rates rom 1989 and, up to 1994, aslight increase in hospital outpatient utilisation (Figure 3). Although some o the observed change in utilisation

patterns may be explained by urban migration and the expiry o native rural leases (a orm o rural land

ownership), interviewees conrmed that villagers began to bypass lower level services to attend generaloutpatient departments o urban hospitals.

A number o dierent reasons were posited as the cause o this decline in PHC and diminishing use o village

clinics. Each o these reasons will be outlined; the variety o explanations demonstrates the multi-aceted

and contested reasons or the waning emphasis on PHC. This contestation o explanations is importantand instructive o health policy challenges and will be discussed in more detail later in this section. These

explanations are by no means mutually exclusive, but most interviewees highlighted only one explanation as

dominant (while acknowledging that others might have had a more limited role). While all the actors should beseen as contributing to the decline o PHC, the act that most interviewees stressed the primacy o one reason

demonstrates the contestation over the decline.

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Infant Mortality Rate

Maternal Mortality Ratio

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Figure 3. Per Capita Outpatient Utilisation, by Facility Type and Total

Note: Data or 1992 and 2001 to 2005 were not available and were estimated. Population data rom SPC 2009 and United Nations Population Division 2008.Sources: World Bank 1994; MOH 1994; 1996; 1998; 1999; 2000; 2006; 2008.

Explanation #1: SuccessSome interviewees suggested that there was a general eeling that PHC had been accomplished successully

and it was simply time to move on. PHC had been pursued or a number o years, communicable disease rates

were down, workshops had been held, CHW/VHWs had been trained and it was time or the next thing.

Explanation #2: The End o WHO FundingThe end o WHO unding or community seminars was cited by a ew interviewees as the primary reason or

the decline o PHC. 2 For approximately ve years rom 1979, the WHO had provided FJ$200 or each two-dayand FJ$120 or each one-day community seminar on PHC, or travel and meals or participants and health

workers. One interviewee noted that he and colleagues ran 14 seminars in one year, with the unding covering

ood, transport and expenses. The money was substantial and allowed communities to get well prepared to the

point that most seminars ended up being easts o prawns, sh and crabs. The WHO also provided unding orortied milk, cooking demonstrations and nutrition inormation to supplement the PHC sessions.

Ministry o Finance budget reports show donor assistance to the health sector. From 1981 to 1985, donors (the

exact donor is not specied) provided a total o FJ$863,800 to rural health services (World Bank 1994). Thisunding abruptly disappeared in the 1986 budget. When the unding ended, interviewees stated, many ewer

seminars were held and the push on PHC died out as subdivisional health teams made many ewer trips to

villages. Counterpart MOH unding was never provided and was not allocated to replace the WHO unds.

Explanation #3: Lack o Explicit Government-Driven PHC Policy and BudgetingBesides a lack o unding, there was also a lack o a clear written policy rom the MOH to guide PHC and a

lack o strategic and corporate business planning. Despite a great deal o training o community and village

health workers, Tembon (1988) reported that there appears to be no national policy paper on training CHWs.

Together with the lack o a PHC policy, PHC activities never had a separate line in ministry budgets nor anallocation in budget estimate documents. PHC was an idea rather than a program and, while unds were

allocated in the early 1980s, that unding declined by the latter part o the decade.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Hospitals

Sub-Divisional & AreaHospitals

Health Centres

Total

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2 One interviewee doubted that the unding came directly rom WHO, citing the act that WHO is not a unding agency. Despite this, the majority o intervieweesbelieved that the unding came rom WHO.


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Table 1. Percentage of Government Spending for Health by Category, Selected Countries and Years

Fiji 1986 Fiji 1991 Samoa 1992 Marshall Islands 1992 Tonga 1993

Hospital services 71.1 67.0 53.6 48.2 61.6

Rural health acilities 8.7 5.2 22.5 15.4 14.4

Public health programs 3.1 2.7 7.0 23.2 14.4

Source: World Bank 1994

In addition, overall real per capita government health expenditure peaked in 1984 and has declined since. Per

capita spending was FJ$25.80 in 1962, rose steadily to FJ$51 in 1984 and then declined to FJ$35.10 in 1992

(prices at 1985 FJ$, World Bank 1994). By the early 1990s, Fiji government expenditure on rural health andpublic health was markedly lower than that or other Pacic islands countries (Table 1). While Samoa, Tonga

and the Marshall Islands all contributed more than 28% o the health budget to rural and public health, Fiji

allocated less than 9%.

A World Bank (1994) document asserts that Fiji had been the most successul in grating primary health care

acilities and outreach activities on to its existing system, with spending on rural services averaging more than10 percent o total recurrent health outlays in the early 1980s. But the report states that the budgetary share

allocated to rural acilities ell by hal, while per capita real spending on rural acilities and preventive servicesdecreased rom US$6.69 in 1983 to US$2.25 in 1991 (World Bank 1994). By the late 1980s, sucient budget

unding was not provided or continued outreach services, community seminars, transport and the like.

Interviewees asserted that with this unding decline, health inspections by ministry ocialsto veriy waterquality, latrines and cleanliness in communitiesbecame considerably less requent by the early 1990s. PHC

activities such as outreach and community seminars, which were once seen as part o Fijian public health

culture beore Alma-Ata, were supported by the WHO rather than being integrated into MOH unctioning.

Explanation #4: Domestic InstabilityA number o interviewees stated that the decline o PHC started with the 1987 coup, ater which a large number

o skilled health workers who were instrumental in the development o PHC emigrated. Government positivediscrimination towards ethnic Fijians and the waiver o minimum qualications or senior positions contributed

to migration. Health workers rom Burma and the Philippines lled the gapby some counts 50% o doctorswere expatriates at this time. The coup also led to an economic downturn, which, as noted above, was refected

in the health budget. The World Bank (1994) noted: [T]he Ministry o Health had a strong health education unit

until it was disbanded in the budget cuts ollowing the political upheaval and economic downturn o 1987/88.The coup also resulted in restrictions on internal movement o people, and meetings were not allowed, urther

hampering village and community engagement in their own development.

Explanation #5: Cultural Changes in Fijian VillagesA number o interviewees cited changes in community culture as leading to the weakening o PHC incommunities. The village structure started to weaken in the 1980s, and the chies and leaders were no longer

as well respected. As Roberts (1997) writes, [W]hile a strong tradition o communal action exists in Fijianvillages, systems or mobilising it have partly broken down with the introduction o Western values centred

on improving the lot o the individual. As a result, there was less community engagement in both Fijian andIndo-Fijian communities. Interviewees suggested that this trend may have been strengthened by the 1987

coup, which eroded chiefy authority in the public mind. One interviewee noted that, whereas beore i a village

headman called a meeting, there would be 100% attendance, now (in 2009) he would expect around 20%attendance. A ew interviewees suggested that doctors and health workers were no longer being listened to in

the same way as in the early 1980s; they ound community work less rewarding and more dicult and thought,

We might as well head back to Suva and ocus on clinical medicine.

Explanation #6: Short Attention Span o Global ActorsOne interviewee noted that the concept o PHC itsel was diluted by the global community in the middle to late

1980s, and this dilution trickled down to Fiji. While the original notion comprised comprehensive PHC, by the


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mid-1980s a selective approach to PHC had emerged globally, or example in UNICEFs child survival revolution

and the application o the GOBI model (growth monitoring, oral rehydration, breasteeding and immunisation).

Various accounts describe this shit away rom comprehensive PHC (Hall and Taylor 2003; Brown, Cueto et al2006; Haines, Horton et al 2007). Lawn, Rohde et al (2008) describe the selective approach as involving the

selection o the ew interventions most justied by epidemiological importance and technological aordability

and a more top-down management approach that was deemed to be more easible, measurable, rapid andless risky than really empowering communities to make choices. Some interviewees suggested that the dilution

o the PHC message weakened its implementation and unding in Fiji.

Explanation #7: The Emergence o Health PromotionAt the time selective PHC was being developed, another health concept was emerging. The new concept ohealth promotion was driven by the Ottawa Charter or Health Promotion in 1986 (WHO 1986). The infuence o

this changes on the approach by WHO and others in Fijiand its impact on the emphasis on PHCwas noted

by interviewees. Several interviewees recalled a belie that health promotion would reduce hospital expenses

by ocusing on prevention, an idea that was current in the strategic plans o many Pacic health ministries. This

was a powerul idea during the emerging global era o neo-liberal economic policies coinciding with the WorldBanks 1987 report Financing health services in developing countries: an agenda or reorm and the Bamako

Initiative, both o which sought ways to reduce public expenditure on health (World Bank 1987).

HEALTH PROMOTION, HEALTHY SETTINGS AND HEALTH REFORMFrom the late 1980s through to the early 2000s, a number o dierent community health concepts wereimplemented in Fiji, including health promotion, the Kadavu and Taveuni models and decentralisation. These

were also impacted by other developments in the health system. Together, these aected the way that PHC was

conceived and implemented in Fiji over this period. These developments are addressed below.

Health Promotion

While the 1993-94 MOH annual report had a chapter on PHC, describing it as the ocus or the delivery ohealth care services, the 1995-96 report replaced this with a separate section on health promotion (MOH 1994;

1996). Some interviewees stated that they saw the emergence o health promotion in Fiji not as an imposedglobal model but rather as a response to shiting power dynamics between communities and health experts, as

strengthened communities showed more voice and agency in decisions and direction. The 2000 MOH annual

report states that health promotion aims to ensure that each village, each settlement, each school, each health

acility is trained to look at their own problems, issues and actors that infuence health, list down issues, look atwhat can be done, develop an action plan and implement it (MOH 2000).

Supporting the growing infuence o health promotion was the Yanuca Island Declaration, which resulted

rom the rst Pacic Island Ministers o Health Conerence, in Fiji in 1995 (WHO 1995). While the meeting hadthe objective o supporting the role o the Fiji School o Medicine in regional medical training, leading to the

beginning o the Master o Medicine program, Yanuca is remembered or its unique Pacic Declaration, which

proposed a truly ecological model o health promotion emphasising the environment and advancing theconcept o Healthy Islands (Nutbeam 1996). Fiji, as host country and primary driver o the conerence, quickly

endorsed the Declaration and sought to achieve healthy villages, healthy workplaces and healthy schools as

envisioned. Despite an emphasis on environmental health and integrated development, the language o PHC is

missing rom the Declaration.

By most accounts, health promotion has persisted in Fiji as the primary community health component. The

National Centre or Health Promotion retains responsibility or health education and engaging communities in

health activities and has been increasingly involved in addressing the growing chronic disease challenge, withactivities ocused on nutrition, smoking and exercise.


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Fulflment o, or Departure rom, PHC?Debate continues about whether the emergence o health promotion represented a weakening o PHC concepts,

the ullment o the PHC ideal, or simply the continuation o PHC. Some interviewees saw the Yanuca Declaration

as sounding the death knell or PHC as a guiding concept in Fiji, while others simply saw the Healthy Islandsconcept as a way o redirecting PHC. One interviewee asserted that the transition to health promotion was simply

an extension o PHC with healthy settings as the entry point ollowing the Yanuca Declaration; she noted that the

concepts were still very much the same and that health promotion managed to get the government machineryre-engaged with the core ideology o PHC. The new term and new declaration revived the multi-sectoral push by

establishing the Health Promotion Council with representation rom a number o sectors. Interviewees heralded

the health promotion model as emphasising community participation and community voice.

Many, but not all, interviewees asserted that health promotion in Fiji had weakened over time and had serious

aults. A ew interviewees asserted that, with the adoption o health promotion, the MOH had totally moved away

rom PHC. Contrary to other views, these interviewees characterised health promotion as being based on a

centralised, top-down structure and regarded health promotion as a shit away rom the core ideals o PHC. Intheir eyes, health promotion was less about community work and was instead more disease ocused.

Others highlighted the all in immunisation rates and increases in some mortality indicators as evidence that

health promotion was not working. Again, the causality is complicated by actors such as migration and politicalupheaval. MOH senior ocials noted that progress on amily planning, maternal health and water and sanitation

had stagnated in recent years. Although supporting data are lacking, interviewees suggested that the re-

emergence o some communicable diseases such as dengue and typhoid, which had been largely eliminatedduring PHC, refects the standard o public health out there in the community.

One interviewee noted that while health promotion generally continued the PHC concepts, promotion was

emphasised at the expense o health protection. The interviewee noted that health promotion ocuses mainly on

behavioural change and not suciently on such critical elements as building latrines and improving water supply.He asserted that the standard o sanitation and hygiene has dropped dramatically.

Similarly, interviewees noted that health promotion was but one piece o the whole puzzle and that health care wasneeded as well as health promotion. A number o interviewees criticised health promotion or being too passivein the ace o serious health challenges, describing the model as give them the message and then hopeully

theyll do it and we wait and wait. These interviewees noted that the broad health promotion approach, with its

ocus on individual responsibility and behaviour, is not our way o doing things in the Pacic. Health promotionwas regarded by these interviewees as lacking regulation and action and being too ocused on discussions with

individualsimposing a Western-oriented individual human rights approach to Pacic communities.

Funding or Community Health ActivitiesRegardless o the relative merits o health promotion and PHC, it remains true that public health programshave long been underunded. The World Bank estimated that in most Pacic island countries around 70% o

recurrent health budgets are devoted to curative care and treatment overseas, leaving little or preventative

services (AusAID 2009). This is conrmed by Fijian data, which show that the unding or public health hasbeen only 2-3% o budget provision since 1982 (Figure 4). Importantly, the budget item or rural nursingstations, which was included in MOH annual reports rom 1982 to 1996, was not included in subsequent years.

Despite the marked increase in unding or subdivisional hospitals between 1996 and 2000, utilisation rates or

those hospitals did not increase during that period (Figure 3). As noted above, unding or rural nursing stationswas cut in hal between 1983 and 1991.

The Kadavu and Taveuni Community Health ModelAnother element o the transition to health promotion was the commitment o additional external resources. In

particular, AusAID provided unding to support health promotion and community participation in health, mostnotably through health projects on the islands o Kadavu and Taveunithough the bulk o unding was or

hospital construction and biomedical equipment.


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Figure 4. Government Budget Provision for Health, by Category 1982-2000

Note: Data or 1997 were not available and were estimated.Source: MOH 1994; 1996; 1998; 1999; 2000

The Kadavu Rural Health Project ran rom July 1994 to June 1997 with the goal o developing an integrated

approach to rural health care delivery. The project included community participation, training o MOH staand community personnel and upgrading health care inrastructure and equipment (AusAID 2001). VHWs and

village environmental workers were trained. The director o the project has called the model a primary healthcare approach (Roberts 1997). The project devolved power and decision making to the community, andan AusAID evaluation in 2001 noted that public awareness o health issues had increased dramatically. The

Kadavu model, in which community development aspects were very prominent, in act emerged during the

projects implementation. Roberts (1997) writes that the project emphasised providing inormation to assist

communities to make sensible decisions to protect their own health.

One o the great successes o the model was its integration with provincial council decision making. The project

believed that success was more likely i activities were vested in local government rather than in the Ministry

o Health (Roberts 1997). With advocacy rom newly ormed village health committees, health became apriority o the provincial council and received greater allocation o time and unding (AusAID 2001). Utilisation o

health services increased signicantly, with VHWs conducting around 30-40% o consultations (AusAID 2001).

Environmental health was also emphasised and, over the course o the project, 576 toilets were constructed in

40 villages and water supply was improved in 39.

The project was widely seen as successul, and the model was picked up by NGOs, people in the education

sector and environmental health workers. Post-project interviews with senior MOH ocers indicated that

the project had infuenced MOH to place a greater emphasis on preventive activities (AusAID 2001). Criticalanalysis o the project revealed that its limited time span prevented the ull institutionalisation o the changes.

The AusAID evaluation also highlighted the lack o support rom the overcentralised health system, which

initiated the early steps towards decentralisation.

The Taveuni Integrated Community Health Model was unded by AusAID and implemented rom 1999 to 2004.

An end o project report written by the Taveuni Medical Sub-Division (Taveuni Medical Sub-Division 2004)

outlines the model: upgraded acilities, improved reerral system, sta training and supporting communityaction or health through a community-based health promotion program, the development and support o

0%

10%

20%

30%

40%

50%

60%

70%

1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

Urban Hospitals Sub-Divisional Hospitals

Rural Nursing Stations Public Health Services


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health committees and training and supporting a network o community health workers. This appears nearly

identical to the PHC model in Fiji in the 1980s.

The project established community health committees (CHCs) through consultation with local councils and

community meetings. The CHCs were tasked with promoting healthy liestyles, conducting village healthinspections, collaborating with MOH health workers and assisting with patient ollow-upactivities that largely

mirror PHC. The examples o activities given in the Taveuni report include rubbish disposal, building toilets,improving water sources and improving community cleanliness. In a post-project survey, 80% o community

members said that the CHC had made a positive dierence, noting social benets, improvements in

cleanliness, health education and improved sanitation (Taveuni Medical Sub-Division 2004).

Similarly, the Taveuni project revived the PHC concept by recruiting and training 91 community members as VHWs

or a population o less than 10,000. Based at community dispensaries, the VHWs conducted home visits and

reerred patients to nursing stations and health centres. They were also involved in health promotion on topics

ranging rom amily planning to non-communicable diseases to ood security to environmental health. By the endo the project, the percentage o community members who washed their hands increased, as did the percentage

using modern amily planning methods. Many households established backyard gardens, and knowledge o

sexually transmitted and non-communicable diseases increased (Taveuni Medical Sub-Division 2004).

The Kadavu and Taveuni community development models endorsed some o the core elements o PHC

community participation and o health promotion. While some project documentation (Roberts 1997) situates

the models in the realm o health promotion, most o the activities outlined hark back to the early days o PHC:environmental health, community outreach, training VHWs, and community health committees. Perhaps most

importantly, the projects placed a great deal o responsibility on communities, one commentator asserting,

[T]hese projects have resulted in the communities taking a more active role in health issues aecting them

(Waqatakirewa 2001).

One interviewee commented that the health and medical proessional world is based on selling inormation,

while the success o the Kadavu model required a willingness to give inormation and power away. Most

interviewees saw the Kadavu and Taveuni models as very successul, one noting that they should have beenscaled up. The AusAID evaluation (2001) armed that lessons rom these projects were eminently transerable

to other areas and projects. 3

Health Sector Reorm in the Early 2000sHealth reorm initiatives that began in 1999 have also had a signicant impact on community health care

which by this time was no longer called PHC. The health sector reorm program was nanced by AusAID

with A$9 million or the rst ve years. The reorm began with a ocus on devolving power and resources tothe divisions, but eventually ocused largely on the decentralisation o decision making rom head oce to

the our administrative divisions (Pande 2003). Decentralisation was a policy across all sectors o the Rabuka

government, but the Chaudhary government o 1999 reversed those policies or all other ministrieswhilehealth continued with decentralisation. Curative and preventive health services, which had been run separately

at Suva headquarters, were integrated at the divisional level. This broke down the division between curative and

public health programs.

A recent report noted that ater ve years, the decentralised model was well accepted and there were eciency

gains (Sutton, Roberts et al 2008). One interviewee noted that the decentralisation strengthened the PHC

concepts o moving power closer to the communities. Despite this, most interviewees suggested that the

act that unding and resource allocation decisions were not decentralised severely limited the eect o thedecentralisation and demonstrated the shallow commitment to changing ministerial unctioning.

In February 2008 the interim military government rolled back the decentralisation reorm and moved decision making

back to Suva. Additionally, curative services and preventive services were again separated, and the integrated linksbetween health centres and divisional hospitals were broken. Though the impact o these decisions has yet to be

ully elt, many interviewees considered that the change would likely weaken community health care.

3 Caveats on the success o these models must be added, however. The AusAID review notes that the cultural homogeneity o Kadavu simplies the implementation othis type o project , suggesting that operating the model in other par ts o the country might be somewhat more dicult (AusA ID 2001; Roberts 1997).


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A ew interviewees noted that the major donor partners support or reorm ran counter to the PHC approach.

Health reorm was consistent with the approach outlined in the World Banks 1993 World Development

Report, Investing in Health (World Bank 1993), which ocused more narrowly on delivering a cost-eectiveminimum package o services, omitted the term primary health care and neglected the role o other sectors

and communities (Lawn, Rohde et al 2008). In Fiji, the reorm was characterised by work on human resources,

health inormation systems and nancial management, activities that may be needed but that have beendivorced rom health service delivery.

During this same period, the global health arena became more crowded with a substantial increase in actors

and unding highlighted by the Millennium Development Goals, the Global Fund or AIDS, Tuberculosis andMalaria and many other disease-ocused initiatives. The signicant impact o these global health initiatives on

PHC and on national priority setting has recently been highlighted (Biesma, Brugha et al 2009).

For example, Das Gupta and Gostin (2009) attribute the decline in environmental health services in many parts

o the world, including Fiji, to a global policy ailure created by the international community. They argue thatthe intellectual shit away rom population-wide health services has become so extreme that interventions to

improve environmental sanitation have come to be classied as being outside the health sector. The authors

note that sanitation was even excluded rom the original Millennium Development Goals, and believe that bythis logic the health sectors response to diarrheal diseases is conned to treating cases or improving personal

health behaviors rather than reducing peoples exposure to ecally-transmitted diseases. They argue that a

core unction o public health agencies is, in act, to monitor the quality o sanitation services and pressure theproviders to improve them.

HEALTH STATUS AND SERVICE DELIVERYAs early MOH documents make clear, the main aim o health policy is to promote, protect, maintain, restore

and improve the health and well-being o the citizens o the Republic o Fiji (MOH 1994). However, the policy

changes during the last 30 yearsrom PHC to health promotion to Healthy Islands to health sector reormhave not been paralleled by a consistent improvement in health status. On the contrary, in some key areas

health status has declined. Progress against key health indicators has stagnated somewhat since the end o

the PHC era, and, in act, the maternal mortality ratio has increased since 1990. 4Figure 5 illustrates changes inindicators during the main periods o health policy change in Fiji.

Service Delivery ChallengesA number o challenges conront the Fiji health system. Interviewees noted that political upheaval had

weakened community leadership, while the old community structures were more encouraging o community

ownership. Others stated that, while Fiji used to have a strong whole o government approach at subdivisionallevel, communication between sectors was now weaker and activities more ragmented.

The political upheaval exacerbated human resource challenges. Again, ollowing the coup o 2000, 30 general

practitioners, who had been keeping the last remnants o PHC alive, let the country (Sharma 2002). By 2002,

well over 65% o hospital-based and public primary care doctors were expatriates, and private health serviceswere expanding (Sharma 2002). From 2003 to 2007, 160 medical ocers and 545 nurses exited the public

health system, going either overseas or into the private sector (Sutton, Roberts et al 2008; Negin 2008). By2008, 36% o senior medical posts were vacant, and 120 medical ocers (25% o the total medical workorce)

were in private practice (Sutton, Roberts et al 2008).

As a result, there has been a signicant reduction in services available in subdivisional health acilities over

the past decade. Specically, the lack o anaesthetists has orced surgical acilities to lie unused and patientsto be reerred to higher level acilities. Interviewees also agreed that VHWs were no longer very active, some

estimating that only 60-70% o communities have an active VHW, some o whom have not had reresher training

or years. While 15-20 years ago VHW training was a regular activity o the ministry, no one talks about VHWsnow in 2009, and turnover rates or VHWs, especially in peri-urban areas, are very high.

3 Caveats on the success o these models must be added, however. The AusAID review notes that the cultural homogeneity o Kadavu simplies the implementation othis type o project , suggesting that operating the model in other par ts o the country might be somewhat more dicult (AusA ID 2001; Roberts 1997).


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Figure 5. Primary Health Indicators in Fiji, 1975-2008

Notes: Inant mortality rate per 1000 live births; amily planning protection rate as a percentage o women. Data or some years were not available and were estimated.Sources: World Bank 1994; 1994; 1996; 1998; 1999; 2000; 2006; 2008; Sutton and Roberts et al 2008.

Health nancing also remains a challenge. Despite annual increases in health spending in dollar terms, the

proportion o GDP allocated to the MOH budget or the national public health system has allen rom 4%

to 2.6% over the last 15 years (Figure 6). This allocation is the lowest among regional neighbours. Annual

government budget spending or health in the Solomon Islands and Tonga is 5-6% o GDP, in Samoa 4-5% andin Vanuatu and Papua New Guinea more than 3% (Lingam and Roberts 2009).

Figure 6. Ministry of Health Budget as Percentage of GDP

Source: Fiji Bureau o Statistics rom Lingam and Roberts (unpublished).

The reerral system no longer operates in an eective way. Sutton, Roberts et al (2008) suggest that Fijiansare bypassing health centres to attend hospitals, indicating that health centres are not meeting community

needs or peoples expectations. In act, patients do not need a reerral or higher levels o service. Although this

is under consideration by the ministry, it will require strengthening o lower level acilities. Some interviewees

0

0.5

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1.5

2

2.5

3

3.5

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1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

0

20

40

60

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100

120

140

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1975

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Era of Primary Health Care

Era of Health Promotion

1987Coup

After-math

Health Reform /Disease Focus

Infant Mortality Rate

Maternal Mortality Ratio

Family Planning Protection Rate


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highlighted the re-emergence o typhoid as a sign that a revived PHC model is needed. And a recent report

highlighted the need or a new push on environmental health, noting: [M]any o the rural water supply systems

are now deteriorated to the degree that village water systems are sources o diarrhoeal diseases (Sutton,Roberts et al 2008).

Recognition o these health system challenges has led to some recent positive changes. Following the rst

stage o its health reorm project, AusAID initiated the Fiji Health Sector Improvement Program (FHSIP) during2004-09. The FHSIP has contributed to a recent strengthening o primary care delivery through an emphasis

on community development and outreach. When immunisation rates had declined by 2004 to just over 60%

coverage or measles vaccine, rom 86% in 1988 (AusAID 2009), FHSIP and MOH partners started working withnurses to get them back out into the communities (Sharma 2009). FHSIP interviewees asserted that immunisation

rates have now increased and that rates o diarrhoea and other maladies have likewise started to decline, in

part because the increased activity o nurses in communities allows greater health education and more prompt

treatment. Even so, FHSIP sta acknowledged that its Healthy Settings community development initiatives did notmatch PHC objectives and that a renewed push would be needed to strengthen peripheral care.

Revitalising Community Health CarePublication o the 2008 World Health Report indicated a return, in some orm, to the ideas o primary health

care and a new commitment by WHO to revitalising community health care. In a recent Lancetarticle, WHODirector Margaret Chan writes that it will not be possible to reach the health-related MDGs unless there is a

return to the values, principles and approaches o PHC. She says that when countries at the same level o

economic development are compared, those where health care is organised around the tenets o primaryhealth care produce a higher level o health or the same investment. As part o a preventive approach, primary

health care is people-centred, regards prevention as important as cure, and tackles the root causes o ill health

(Chan 2009).

The WHOs 62nd World Health Assembly, held in Geneva in May 2009, rearmed the Alma-Ata principlesalong with the MDGs and the importance o social determinants o health and called or a renewed push

on primary health care, including health system strengthening. The Assembly called or accelerated actiontowards universal access to primary health care by developing comprehensive health services and bydeveloping national equitable, ecient and sustainable nancing mechanisms, as well as putting people at

the centre o health care by adopting, as appropriate, delivery models ocused on the local and district levels

that provide comprehensive primary health care services. The assembly also called on countries to promoteactive participation by all people and re-emphasize the empowering o communities, especially women, in the

processes o developing and implementing policy and improving health and health care, in order to support the

renewal o primary health care (WHO 2009).

Reinorcing these sentiments, Lawn, Rohde et al (2008) write that it is understood that eective primary healthcare services [require] consistent political and nancial commitment, incremental implementation based on

local epidemiology, use o data to direct priorities and assess progress, especially at district level and eective

linkages with communities and non-health sectors. AusAID (2009) recently stated that involving communities

in service delivery can help service providers be more responsive and accountable to local needs and provideadditional resources or service delivery.

A number o issues emerge i a return to PHC principles is to be successul as a result o this ongoingdiscussion in Fiji.

Domestic Political OwnershipMost interviewees agreed that some return to community health principles was needed. One said that there

are lots o lessons we can learn rom PHC days and another noted the need to evaluate the strengths o PHCand understand what health promotion has achieved. Many interviewees emphasised the political aspects,

arguing that the MOH needs to drive the dialogue towards the model it wants rather than simply respond to

inappropriate external models. The Minister o Health held an internal meeting on PHC issues on returning rom

the World Health Assembly meeting in 2008 and emphasised the topic ater both the 2008 and 2009 meetings.


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Some interviewees, however, saw this as still responding without adequate thought to models imported rom

abroad. One said, Some decisions are picked up by politicians overseas and are put on our agenda without

discussion, as in 2008: when the Minister o Health returned rom Geneva with PHC, there was no discussiono strengths and weaknesses but rather more a directive to get PHC back. Some interviewees recommended

that a revitalised PHC approach should be adopted by Cabinet, endorsed by the Minister and/or supported

by legislation, in contrast to the PHC policies o the 1980s. The Public Health Act ocuses mainly on healthinspection, and other health-ocused legislation is almost exclusively curative.

Integrating Urban and Non-Communicable Disease IssuesA number o interviewees argued that the new approach to PHC should be adapted to changed disease

patterns and other circumstances including urbanisation, particularly the emergence o non-communicablediseases (MOH 2008). Interviewees understood that PHC and/or health promotion are important in addressing

risk actors such as obesity, nutrition and exercise. Many noted that supportive community- and home-

based care or amputees and stroke victims could be a core element o a resurgent 21st century version o

PHC (WHO 2002). Additionally, the new approach should move beyond the view o PHC as a rural health

mechanism to include urban issues. As one interviewee noted, This isnt just about village health care. In arecent document on the Pacic, AusAID (2009) acknowledged the challenge, noting that the level o poverty in

urban centres is considerably higher than in rural areas. In Fiji, there are high levels o poverty among the 52%o the population living in urban areas (including 100,000 squatters). While much o the rural health challenge is

about access and availability, urban challenges include access, quality, waiting times and opening hours.

This concern or attention to emerging diseaseswhile not neglecting long-standing communicable diseaseissuesrefects international opinion. Julio Frenk (2009) has highlighted how the new PHC needs to be able to

address not just acute care, as in the original model, but chronic care as well: Primary health care should also

move rom episodic to continuous care, going beyond the simplicity implied in the original notion o rst level

o care. Rohde, Cousens et al (2008) write: 30 years ater Alma-Ata, many countries still have a high burden odisease with inections and maternal and child health challenges, but also emerging chronic diseases. Primary

health care oers solutions and approaches to address these burdens but the increasing complexity threatens

to overburden the system. The design o the new PHC should ocus on the most critical components duringearly phases because with an ever increasing array o health service programmes, each a priority in the mind

o the designers, there is a danger o overwhelming primary health care workers with a massive menu (Lawn,

Rohde et al 2008).

Human and Financial ResourcesThis new approach to PHC will require additional resources, both human and nancial. One interviewee

stressed the implementation issues and lamented, We have been importing concepts that we have ailed to

apply. Despite the current human resources challenges, more health workers will be required or a revitalised

PHC program.

The Fiji School o Medicine and the Fiji School o Nursing are in a position to supplement training in PHC or

public health sta and through continuing proessional education. But curriculum changes will be needed. The2001 PHC review noted, [M]ost younger sta are unaware o the scope and dimension o PHC (Waqatakirewa2001). Asuzu, Ram et al (2004) reer to a study o medical students that shows a poor inclination to specialise

in community medicine/public health. More recently, both schools have emphasised rural placements and

community health in their curricula, and the School o Medicine has revitalised a year 3 community placement.Government-sponsored students are also required to do a rural placement ater graduation. As well, outreach

by nurses and MOs can be reinvigorated, and a renewed push to train and support CHW/VHWs is needed in a

manner already trialled by the Kadavu and Taveuni projects.

Sucient unding or PHC activities is needed and should be included in the preparation o national healthaccounts. Within the MOH, one interviewee noted that while there is the impression that curative is expensive

and preventative is cheap, this is not true any more preventative is also expensive. Within new health

project that may ollow Fiji Health Sector Improvement Programme (FHSIP) (scheduled to end in 2010), there is


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an opportunity or the MOH to request unding or priority areas such as PHC. Additionally, government unding

or health must increase. Signicantly, the new government recently issued a Peoples Charter, pillar 10 o which

calls or an annual increase o 0.5% o GDP in its allocation to health or the next 10 years.

New Political and Social ConditionsMany interviewees acknowledged that changes in community culture rom communalism to more individualism

would make implementing PHC harder now than in the late 1970s, but they remained optimistic. While

the nature o communities has changed, many o the biggest health challenges remain with the poorestcommunities, which are likely to benet most rom a new PHC approach. New issues are posed by urban

community structures in squatter areas, and as one interviewee noted, working through existing mechanisms

like NGOs and churches would be critical to success.

The new PHC must be accompanied by a clear and actionable divisional and subdivisional work plan, as

evidenced in the Taveuni Integrated Community Health Model. Some interviewees recommended that greater

decision rights and unding rights be provided to divisions and subdivisions to make the health system more

responsive to lower level needs, not only in the amount o choices but also in the types o choices and their

signicance. As one author lamented when writing about Pacic islands, [H]ealth systems are centrallydominated and controlled and there are ew local opportunities to infuence resource allocation (Newell 1983).

The new PHC must maintain a long-term vision. As one interviewee noted, One o the problems with PHC in Fijiis that we keep redening it. Another noted that Fiji has been bombarded by dierent models.

A New Terminology or Primary Health CareThere was signicant disagreement regarding the appropriate terminology or the new PHC. One interviewee

preerred to retain health promotion as the guiding term or community health, noting that while PHC seemsto ocus on care and the care-giver, promoting health is wider. Another interviewee noted that maintaining the

term health promotion would also cause less conusion among MOH sta and partners. Another noted that

PHC concepts o outreach, community engagement and environmental health were not owned by the term

PHC and thereore new terminology would be workable. Finally, one interviewee stated, The amily in the villagedoesnt care what you call it they want access to quality health services.


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RECOMMENDATIONS AND CONCLUSIONSRecommendations emerge rom this report, based particularly on the testimony o interviewees in Fiji who arenow looking careully at the process o revitalising the PHC approach. Interviewees agreed that a re-galvanised

community health model was needed, one that would learn rom past approaches and respond to currenthealth and political realities. The main recommendations include:

ImplementationofanewcommunityhealthmodeldrivenbytheMinistryofHealth(MOH)withsupportfrom

the Minister and Cabinet and ramed as a long-term vision rather than a short-term project;

Increasedfundingforcommunityhealth,publichealthandoutreachservices,followedbyanapproachto

AusAID and other development partners to support a new approach;

Arenewedpushfortrainingofdoctors,nursesandCHW/VHWsincommunityhealth;

Framingcommunityhealthasbothanurbanandruralapproach,withemphasisonimprovinghealth

indicators in squatter communities, leveraging existing strengths o churches and NGOs in these areas;

Anexplicitfocusonnon-communicablediseasesriskfactorssuchasobesity,nutritionandexercise;

Inclusionofsocialdeterminantsofhealthincludingeducation,housingandlivelihoodsintheapproach; Greaterdecisionrightsandfundingdecisionsfordivisionsandsubdivisionstomakecommunityhealth

more responsive to local needs.

This study provides important lessons or Fiji, the region and the wider health policy community on how health

policy develops and evolves over time. Global health policy is oten short-sighted and ocused on short-term

targets, and lessons rom past experiences are oten not ully considered in the development o new policies.This analysis o PHC in Fiji rom the mid-1970s serves as a microcosm o health policy challenges. It highlights

the importance o political economy to health policy development and emphasises a greater understanding

o community and political culture. It shows that there is oten a one-sided relationship between developmentpartners and national governments in which outside policies are oten imposed without due recourse to the

evidence and local country conditions. It also highlights the contestation over policy changes and the many

actors that infuence the evolution o policy.

The basic tenets o the Paris Declaration and Pacic Aid Eectiveness Principles (2005), which call or greater

government ownership o development priorities and place the impetus or decisions in the hands o domestic

government, need to be ully taken into account in developing a new model o PHC implementation in Fiji and

the region. Development partners and other international actors will thereore have to be more responsive tonational priorities in their planning, resource allocation and technical support.


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the evolution of primary health care in fiji: past, present and future

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