A CONTEXT-SPECIFIC APPROACH TO PRIMARY CARE STRENGTHENING IN FIJI
Two separate attempts at decentralising Fiji’s health services, each employing a different strategy, indicate that a context-specific, incremental approach has been more successful than a prescribed approach to reform. This paper book chapter discusses Fiji's context-specific approach to strengthening primary health care.
WAVE UPON WAVE: FIJI’S
EXPERIMENTS IN DECENTRALIZING ITS
HEALTH CARE SYSTEM
Decentralisation in the health sector has been widely implemented since the 1970s as a reform mechanism with mixed results. This study describes Fiji’s two attempts at decentralising its health sector and examines the implications they have had for the functions of planning, financing, and delivery of health services. The first wave attempted a major restructure by devolving Fiji’s health system. Political instability, along with a lack of acceptance, stalled its implementation resulting in a delegated system. While the functions of planning and financing remained centralised, the function of delivery was delegated to geographic regions. The second wave was a more focused effort that targeted the deconcentration of outpatient services in one division. This attempt also decentralised the delivery function while keeping the other two functions centralised. Fiji’s incremental approach to decentralization could provide lessons for Asia-Pacific countries that have had failed attempts in large scale decentralisation efforts.
DECENTRALISATION OF HEALTH SERVICES IN FIJI: A DECISION SPACE ANALYSIS
Decentralisation aims to bring services closer to the community and has been advocated in the health sector to improve quality, access and equity, and to empower local agencies, increase innovation and efficiency and bring healthcare and decision-making as close as possible to where people live and work. Fiji has attempted two approaches to decentralisation. The current approach reflects a model of deconcentration of outpatient services from the tertiary level hospital to the peripheral health centres in the Suva subdivision. Using a modified decision space approach developed by Bossert, this study measures decision space created in five broad categories (finance, service organisation, human resources, access rules, and governance rules) within the decentralised services.
DECENTRALISATION; THE QUESTION OF MANAGEMENT CAPACITY: A RESPONSE TO RECENT COMMENTARIES
Whilst decentralisation as an instrument of healthcare reform remains popular, commentaries to our paper titled “Decentralisation of health services in Fiji: A decision space analysis” highlight the complexity in understanding decentralisation, with the significant body of research on decentralisation lacking consensus on its definition, differing on what constitutes decentralisation, emphasising different theoretical underpinnings and frameworks, and reporting varying applications and outcomes of decentralisation. This is reflected in the commentaries to our paper. This article responds to the commentaries.
FIJI LIVING HIT UPDATE CHAPTER 6: PRINCIPAL HEALTH REFORMS
Fiji made considerable progress in advancing health outcomes of its citizens from the 1950s to 1970s. However, this progress has been stalled since the 1980s with little or no headway being made in improving health outcomes (World Health Organization, 2013). Additionally, a series of reports outlined growing user dissatisfaction with health services (Coombe, 1982, Dunn, 1997, The Government of Fiji, 1996, The Government of Fiji, 1997, The Government of Fiji, 1979, World Bank, 1993). As a result, Fiji attempted two waves of reforms: the first between 1999 and 2004; and the current from 2009. This section provides an overview of the two waves of reform and describes their impact on service organisation and planning, financing, human resources, and service delivery.
HEALTH SYSTEMS IN TRANSITION
VOL. 1 NO.1 2011 THE FIJI ISLANDS
HEALTH SYSTEM REVIEW
This Health System Review provides an overview of the health system of Fiji, one that faces many challenges in order to meet increasing demand for health care from a highly dispersed but rapidly urbanizing island population during a time of slow economic growth.
TRANSNATIONAL DISTANCE LEARNING:
A STUDENT PERSPECTIVE
This chapter describes the online educational experiences of students in both emerging and developed countries around the world. The authors are from France, Japan, India, Cyprus, Canada, the United States, and Fiji. This cross section was chosen to present a global view of student needs for transnational education. The chapter presents personal vignettes of the online educational experiences, as well as the authors’ views of student needs in the future. The authors also describe how they used technology to coordinate writing this chapter from six countries around the world.
INVESTIGATING THE IMPACTS OF DECENTRALISATION ON ACCESS TO PRIMARY HEALTH CARE IN FIJI: A QUALITATIVE MULTIPLE-CASE STUDY
Globally, since the 1970s health sector decentralisation has been widely implemented as a reform mechanism, particularly by developing countries. With the aim of improving access to health care, in 2009 Fiji initiated decentralisation in one administrative division. This research set out to answer the following question: What are the impacts of decentralisation on access to adult outpatient health services in the Suva Subdivision?
Using a qualitative multiple-case study design, semi-structured interviews were conducted across seven study sites (three decentralised health centres, a non-decentralised health centre, a divisional hospital, a private general practice, and the Ministry of Health central office) in 2014. Reflecting a triangulated approach, interviews were conducted after informed consent with patients, providers and administrators. Supplementing those data, utilisation and expenditure data before and after decentralisation, and policy documents concerning the design and implementation of the decentralisation initiative were analysed.
Implementation of decentralisation was rushed, with administrators having to make decisions ‘on-the-run’. Rushed implementation meant that extended hours and expanded scope of service were not matched with increases in health professional staffing, and diagnostic and pharmaceutical services were not similarly extended. Although workload was moved from the centre to the periphery, decision-making remained centralised. Providers were faced with increased and changing utilisation patterns and shortages in staffing, equipment, medicines and consumables. Providers struggled to deliver quality health services, and actively ‘worked the system’, often outside of formal structures, to provide health care. Patients were positive about the extended hours, but access was negatively affected by lengthy wait-times, brief engagement with doctors, out-of-stock of medications and a lack of basic and diagnostic equipment in decentralised health centres. Patients described having to ‘run-around’ between health centres and divisional hospital to complete their treatment, entailing increased costs, time and travel in seeking health care.
All three groups of participants regarded decentralisation favourably. However, there is much scope to further improve access through strengthening decentralised health centres. This research has implications for advancing understanding on models and implementation of decentralisation, and frameworks of access. The importance of transferring decision space as well as workload in decentralisation initiatives was highlighted. Theories of access emphasise provider and patient characteristics in shaping access, but the role of policy and its implementation are not adequately reflected, although they are central to improving access. Finally, existing frameworks on access can be enhanced by understanding the interactions between the dimensions of access and drawing out supply and demand aspects of each dimension.