A Fijian narrative

PRIMARY healthcare (PHC) became a core policy for WHO in 1978 with the Alma Ata Declaration. There have been rapid changes seen in health status and trends, demography, socioeconomic trends, governments and WHO’s priorities and their ways of working inclusive of guidance, technical and professional support while pandemics evolved.

Primary care by non-governmental organisations (NGO) and the private care (PC) have increasingly developed in the last three decades, to complement the original PHC model with additional service provisions, working within or outside State health jurisdictions, but under various State healthcare regulations, globally.

These private sector healthcare providers complement primary public health systems in various capacities, but there appear to be varied levels of knowledge gaps of the functions and capabilities of the private sector in many state jurisdictions, on the part of the two separate parties.

The World Health Organization (WHO) is calling on countries to adopt a whole-of-government and whole-of-society approach in responding to the COVID19 pandemic. This requires policymakers to include the private health sector in efforts to contain, control and mitigate the health impacts of the outbreak.

The Sustainable Development Agenda (SDA-2015-30), its underlying principle of Universal Health Coverage (UHC) and not leaving anyone behind is seriously being challenged by the COVID-19 pandemic.

The sudden and devastating impact of the COVID19 pandemic with its corollaries in global public health and the ensuring socioeconomic depression remains to pan out with third and fourth waves about 16 months into the pandemic. The global trajectory of SDA and its progress is under major duress with this pandemic.

The PHC profile of Fiji as part of a larger exercise involving six Asia-Pacific countries has been documented internationally.

Fijian healthcare service’s multifaceted and interrelated challenges are discussed in this presentation for the public’s consumption and knowledge.

Details on demographics, involvement of the various disciplines in PHC, training and registration of such disciplines, community accessibility to services, the intersectionality of the various PHC teams, health financing including barriers and challenges faced in-country were analysed.

The data analysis aims to highlight specific challenges to the delivery of PHC in Fiji.

 Population: 880,000 (2017);

 Distribution (e.g. urban / rural / remote); and

 > 55.9 per cent Urban > 44.1 per cent Rural > 15 per cent of rural in maritime.

 Indigenous: 65 per cent of total pop;

 Indo-Fijians: 30 per cent of total pop;

 Pacific People/Asian: 5 per cent of tot pop; and

 Unemployment rate cent.

Post-COVID19: 130,000 laid off tourism workers initially. three tier relief packages (personal superannuation released by government).

This was a short-term measure. When this fiscal support ceases more are expected to be unemployed or underemployed as the pandemic remain ongoing.

Long-term retirement funds are being released in this case. Small business closures are rising in urban areas.

People are now reconsidering other options to sustain their families’. Roadside stalls, flea markets, street sale of food items and vegetables have arisen.

There are more sexual services available on the roadside, unfortunately. A 10-fold increase in domestic violence is reported in the local media.

GP practices are affected with over 25-30 per cent reduced income as a result of downturn in “of the street” minor consultations, reduced scheduled attendances for non-communicable 7.8 per cent 2.9 per diseases, antenatal, maternal childhealth and aged care follow-ups.

PHC services in the already busy public system is challenged with greater workload.

Basic medication and supplies are in even shorter supply with difficulties in the international procurement of medical supply chain and ineffective local distribution.

 Life expectancy: 70 yrs. 64 yrs. The Fiji College of General Practitioners (FCGP) is accredited for obligatory Annual Continuing Professional Development and accountable to the Fiji Medical and Dental Council under Fijian Legislations.

Online registration/educational programs, intra and inter digital communication has been boosted by COVID-19 within the private health sector to maintain registration and serve as a source of vital information.

The Incident Management Team (IMT) in the Ministry of Health and Medical Services along with the armed services, police, boarder control units continue their sterling role, addressing the initial lockdown phase.

Screening, isolation and quarantining of in-bound passengers on freight flights to Fiji have been successful in new cases being identified in the quarantined phase without community spread.

Laxity, health worker exhaustion is evident and lapses in policy implementation by supervisory staff members need constant attention.

This will prevent community transmission, long-term. Structured policy and fore-planning for the next phase and triggered response need greater attention, practice runs and regulatory implementation plans in place.

The lapses in surveillance to date, has given rise to some near misses in the recent past and must be objectively addressed.

Fever clinics and triaging health facilities are now closed. The community has become lax and the health facilities are not separating respiratory type presentations from the general outpatient client. This could be a sticking point later, if horizontal transmission re-appears.

Monitoring and evaluation. This is the biggest tragedy when national data is not appropriately collected, analysed and researched.

Various digital formats are available yet under-utilised for long term research.

Although Communicable Disease Centre (CDC) surveillance systems and IMT have capabilities for data capture, human resources are limited and imputing remains fragmentary, as in most low and middle countries.

The pandemic outcomes will not be a true reflection of what really happened.

The gatekeepers to healthcare for rural and maritime residents remains the public health system under Ministry of Health and Medical Services. GP/family practitioners act as gatekeepers for paying patients mostly in the peri-urban and urban areas.

Some client/patients utilise both the public and private sectors, periodically and intermittently. Referral optional between public health and private practice system is manually managed: A digital system is not fully operational within the public healthcare system.

Health information links remains fragmentary as a consequence. No other specialties apart from the general practitioners work in the community with direct patient access.

Relationship of primary health care with other community services is on a voluntary basis especially with faithbased organisations is rudimentary.

These need to be developed further if the general population is to benefit. An “all of society” approach is needed.

GP practitioners: Solo and group practices exist. Some practices are developing capabilities with private diagnostic services: Corporatisation of private health care is taking root, at a cost.

The private care teams are affiliated on an ad hoc relation with these entities on a need’s basis for second opinions and diagnostics.

Health cost are prohibitive for the marginally poor and social/ health insurance is still in a rudimentary stage.

Universal health coverage has not been considered seriously following the WHOsponsored Social Insurance Study of 2011-12.

A modern, small (40 beds) private hospital is evident and has great potential, but without medical insurance, out of pocket expense for the average citizen remains prohibitive many a times.