Diagnosing the state of Fiji’s health system

The Colonial War Memorial Hospital in Suva. Picture: ATU RASEA

Hospitals are the primary ultimate healthcare facility.

The anecdotal evidence suggests that Fiji’s health system and facilities are in pretty poor shape.

Drug shortages are commonplace, health infrastructure is in a deplorable condition in some places, and new hospitals that were commissioned years ago are either incomplete or still remain inaccessible to customers.

To add to the problem, constructive criticism by well-meaning health professionals are often dismissed by those in
authority.

Infrastructure

Regrettably, many Fiji hospitals are dirty and badly maintained.

The country’s main hospital is the Colonial War Memorial Hospital (CWM) in Suva, which was built in 1923, in memory of the Fiji veterans who served in World War I.

It was officially opened that year by the Governor of Fiji, Cecil Rodwell, and had a total of 108 beds and 27 staff, including two doctors.

The daily television reports of the COVID-19 pandemic often feature the “new” main block of CWM Hospital.

It is impossible not to notice the growth of mould on the hospital name board and also on the fascia board sloping down from the roof.

The government is responsible for the construction, management and maintenance of all public health infrastructure.

In many buildings, maintenance and upgrading has been non-existent or inconsistent and the same is true for buildings in the health sector.

In the last few decades, most major buildings in the health and health education sector have been funded by development assistance from the governments of China, Japan and the European Union.

The government has continued to fund the construction and renovation of health centres.

An old Suva resident told me: “I remember as a child when we had to go to hospital or the dentist at the CWM or the health office near the bus stand, we’d start shaking even before we saw these buildings as we could smell the disinfectant when climbing up Waimanu Rd. That smell has been replaced by urine. Sa boi riri dina!”

Surely the cleaning of health infrastructure and buildings to make them more welcoming and accessible does not require anything more than human effort, a water blaster, some detergent, mops and cleaning rags.

In March last year, the family of a woman who died complained that they had to provide the Savusavu Hospital mortuary with a generator.

There was a big hue and cry on social media with many Savusavu residents angry over the failure to properly maintain hospital and backup facilities in the town’s hospital.

Complaints about the hospital mortuary had been ongoing since 2014, when one Virendra Kumar of Daku expressed anger that it was not working. (FS: January 3, 2014).

Ministry of Health officials were defensive at the time and denied the deceased family’s complaints that the mortuary
was not in use.

Members of the public are able to enter and seek care health in facilities that are spick and span.

The Rotuma Hospital, commissioned in 2014, has not yet been completed.

A Rotuman professional who lives in Suva but who has strong links to the island told me that government removed a beautiful old colonial building which housed the hospital, to construct what he described as a “concrete monstrosity”.

Since then, however, the hospital has been confined to a few rooms at the Council of Rotuma.

There are reportedly flights every week to Viti Levu for medical emergencies.

In 2019, it was reported that the Minister for Health, Dr Ifereimi Waqainabete, confirmed that the Rotuma Hospital was nearing completion.

He said, “We are told that it should be ready by the end of the year, there are other things that we need to get ready, obviously it needs to have equipment that is already in the provisions of the budget, the Government has made,” (FS March 14, 2019).

The Attorney-General announced three years ago that land had been identified for a new Nausori Hospital (August 2018).

However, construction has not started.

One commentator was critical of the new Navua Hospital and said that the toilets were too small and frequently get blocked, tiles on the kitchen floor are too slippery, and basins are too shallow to clean medical instruments
(Brandt).

At the groundbreaking ceremony of the new Ba Hospital in August 2014, Prime Minister Voreqe Bainimarama said, “The new Ba Hospital will be constructed to World Health Organization standards and when it’s complete – in 2016 – it will serve as a bridge between the smaller Tavua and Rakiraki hospitals and the larger Lautoka
Hospital.”

The allocated budget for the overall project was over $23 million.

In November 2016, it was reported that the hospital was expected to be completed by March 2017.

The Ministry of Health project officer, Kamal Kapoor, said at the time that the project was in its finishing stages with much of the work achieved within the timeframe.

By that stage, the construction cost had apparently risen to $27.7 million. (FS November 13, 2016).

In March 2021, Health Minister Dr Waqainabete told Parliament the new hospital would open later this year.

It has still not opened, close more than 6 years after building commenced.

Anywhere else in the world, whoever was responsible for this state of affairs would have been sacked.

Equity in healthcare

According to the Institute of Medicine (IOM) in the USA, health equity means “providing care that does not vary in
quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.”

Equitable health care leads to a healthier population requiring less medical care, meaning fewer visits to the health centre or surgery, less healthcare spending for each individual and better health outcomes.

Equitable health care leads to socio-economic stability and ultimately economic gains for individuals, their families and their communities.

Fiji has a well-structured but also a diversified health system providing care to remote islands and communities in the remote hinterland of the larger islands.

Communities are served by community health workers, nurses and midwives, nurse practitioners and general and
specialist doctors.

When there is a need for urgent care or retrieval no expense is spared in transferring sick individuals to divisional centres by the quickest means possible.

No fees are charged for this service with medical need being the only criterion used to make the decision.

Most fees charged at Ministry of Health service outlets, are nominal.

A friend of mine recently went to the local hospital for dental treatment and was charged a tenth of what it would
normally cost to get the same treatment from a private dentist.

The increase in non-communicable diseases (NCDs), including obesity, highlights the need for Fiji to create policies that encourage individuals to adopt healthier lifestyles, while also meeting the needs of those whose illnesses become chronic.

The Fiji health system fares relatively well in this regard but faces significant challenges to adapt to changing circumstances in order to meet increasing demands and the needs of pressure groups, communities and of the
population.

A health policy that promotes a tall preventative fence at the top of the cliff rather than an ambulance at the bottom of it, makes a lot of sense.

Traditionally 70 per cent of the Fiji health budget has been allocated to curative services with 30 per cent for public health provision but perhaps this artificial division needs to be abandoned now.

Training, staffing and distribution

Fiji has been fortunate in its ability to train its own doctors and other health staff for more than a century.

Likewise nursing and midwifery training has a long history.

These members of the health workforce are being produced at two of three institutions: medical students are taken in at the Fiji National University and the University of Fiji while nurses and midwives are educated at the Fiji National University and the Sangam School of Nursing.

There were significant reductions in the numbers of doctors, nurses and midwives and other members of the health workforce in the country after military coups and also after Government enforced compulsory retirement at the age of 55.

In 1999, the ratio of doctors and nurses/midwives to 1000 head of population was 0.3361 and 1.9546 respectively.

By 2010, the ratios had increased to 0.426 and 2.242, and by 2015 to 0.86 and 3.0175 respectively.

The rapid intake in doctors and nurses became government policy to reduce skilled workforce shortages in the sector.

In 2014, Cabinet approved the absorption of 200 nurses per year for the next five years and to see a total increase in 1000 nurses.

While total staff number increases are welcome, Fiji’s 99 islands poses some problems with equitable distribution to
ensure the health needs of most of the population is met.

A paper published in 2017 showed there were greater inequalities in the densities of health workers at the provincial
level, compared to the divisional level in Fiji – six of the 14 provinces fall short of the recommended threshold of 2.3 health workers per 1000 people.

The presence of the three large divisional hospitals, providing specialist services, skews the health workforce in these locations.

Funding and international support

An examination of the level of funding for health in Fiji since 2000 shows the government only contributes between 2.9 per cent to 3.5 per cent of GDP to the sector.

This is amongst the lowest in the Pacific.

In contrast, according to the WHO, Marshall Islands, Micronesia, Palau and Tuvalu spend on average 14.5 per cent of GDP on health.

In 2018, healthcare spending by government was $450 per person.

A significant rise in the salaries for doctors in recent years has been long overdue.

It fairly compensates doctors for the length of their training and education, the obtaining of postgraduate qualifications and the long hours that they work.

The production of more doctors will lead to more reasonable work schedules and a healthier lifestyle for members of the profession.

As stated earlier, development funding from foreign governments has been a significant source of capital expenditure in the health sector.

Australia is the largest provider of development assistance to the Fiji health sector and has funded health sector improvement projects, including technical support for the upkeep and repair of many specialised equipment used for diagnosis and care.

Decentralisation of health services

The effects of health care decentralisation in the Suva-Nausori corridor, between 2009 and 2016, on patient satisfaction.

Due to overcrowding and long waiting times at the accident and emergency (A&E) department at CWM Hospital it was decided that primary care services would be diverted to the health centres in Valelevu, Makoi, Samabula, Raiwaqa, Lami and Tamavua (Nuffi eld Clinic).

Over time opening hours were extended (including weekends) and diagnostic, laboratory and pharmacy services were provided at some of these facilities.

Having local health services has made a big difference to utilisation by local communities.

The six health centres registered a 150 per cent increase in use while the A&E department at CWM showed a 21 per cent reduction.

As the workload for doctors at the health centres increased exponentially the average time spent per consultation has
dropped from 12.5 to 4.8 minutes.

Despite the health centres being opened up to 16 hours a day initially some of the support services such as pharmacies and ambulance carriage were not available for the entire time at all heath centres.

However, the majority of clients were reportedly happy that services were available locally and in terms of quality of care there was an inverse relationship between patient numbers and how people felt they were treated.

A significant complaint by the majority of clients was the poor level of cleanliness in the health facilities.

This seems to be a perennial problem, Fiji wide.

It might be a good idea to make facility cleanliness a key performance indicator for the person in charge of the health
centre or hospital.

Drugs

In December 2020, a row erupted when the highly respected retired surgeon Dr Eddie McCaig (a former professor of surgery) told a public forum that almost 60 per cent of essential drugs were not available.

In the same forum, Dr McCaig maintained that the health institutions and workers were “struggling” because of lack of essential medicines, high infection rates in surgeries and crumbling infrastructure.

In a recent interview, he told me that of the eight operating theatres, at best only two or three would be working at any one time.

Dr McCaig claimed that many health professionals worked under a climate of fear and were afraid to speak out on such issues due to possible victimisation.

He also said that he found the government pharmacist building to be in a filthy state on a recent visit.

Due to the unavailability of drugs, the majority of diabetics were being poorly controlled.

The Minister for Health rubbished Dr McCaig’s comments saying that he would not give credence to unsubstantiated
data.

However, the minister’s strident denial appears to fly in the face of evidence.

A 2017 paper published by Dr Betty Chaar, a pharmacist and an Associate Professor in professionalism in pharmacy at the University of Sydney, and others, concluded that “medicine shortages are a significant, ongoing issue within Fiji. [T]here is much that can be learnt from international solutions such as investment in logistics training and
human resources, the introduction to a nationwide reporting system, regional support, education and training.”

Following his retirement, Dr McCaig, after more than 45 years of practicing medicine, volunteered for a while at CWM, mentoring medical students, interns and young doctors.

Last year however, he received a phone call from a senior surgeon Dr Jemesa Turagava telling him he was no longer welcome at CWM Hospital.

Dr Turagava had been instructed by the Prime Minister and the Minister for Health.

Attempts to contact Dr Waqainabete for comments have been unsuccessful.

It is an unfortunate and a sad feature of this country that constructive criticism of government and government services is usually met with angry responses, rather than calm reflection.

It is a pity that retired health professionals who have so much to contribute and willing to do so without any charges, are dismissed and ignored this way.

It is either a sign of insecurity or arrogance, or both.

There is no need for this defensiveness, and much can be gained from public feedback.

Why is it so difficult to accept criticism?

It is part of being accountable.

The public have every right to comment on the standard of health care they receive from public hospitals.

They are taxpayers, after all.

Patient experience

Patients requiring treatment have complained that you have to be admitted to emergency at CWM before any medical problem is seen to, and the waiting is long and uncomfortable especially if someone is in pain.

Patients are usually required to bring their own sheets, blankets, pillows cases and toilet paper.

A former patient who preferred to remain anonymous told me: “Lying in bed is nerve-wracking as you stare at the extremely dirty and mouldy ceilings that leaks and have ants in the drier areas that fall onto your blanket or sheet. The toilet was used by both males and females and you passed the cleaning cubicle with plastic garbage bags full
of soiled bloodied cotton swabs, linen and buckets and dirty mops to get there.”

Another patient who had paid for a private room at CWM said: “The emergency button did not work and neither did the phone, so when I needed the nurses station which was 50 yards away, I had to use my mobile phone to ring the operator at CWM to connect me to the nurses’ station for attention.”

It’s a standing joke in this country that many people refer to the CWM Hospital as the vale ni mate (house of death).

It would be funny if it was not so tragic.

At one hospital, 172 patients acquired infections due to poor cleaning services; at another, poor services led to massive delays in transferring patients out of the Emergency Department causing bed block. (Public Service International – May 16, 2018).

While complaints about the standard of hygiene at Fiji hospitals are common, the medical staff including doctors and nurses, are invariably praised for being dedicated and hardworking.

Civil society

For reasons which are unclear, government seems to be unwilling to work with some civil society organisations.

Any hint of criticism from outsiders is quickly shut down followed by refusal to partner and receive help, even when it is needed.

One NGO which is committed to improving the welfare of women and children has had a negative experience trying to assist government.

The same NGO assisted with renovating the main doctors’ office, the children’s ward, the conference room at the CWM Hospital and installing an expensive conference call facility with all extended features including air-conditioning, only to be told officially by a senior government minister to stay out of the CWM Hospital.

In all likelihood this was “punishment” for a representative of the NGO publicising the fact that 12 bathrooms and toilet cubicles were available to 110 women at a time in the maternity ward with only three working cubicles!

The same NGO also provided breakfast for the new and pregnant mothers at the Makoi Centre as their breakfasts were being delivered at 3pm by the army from the main kitchen in Suva.

A spokeswoman for the NGO said she wished “If only leaders would take advantage of groups and civil society reaching out to help the people of Fiji and not feel intimidated by their assistance despite their incompetence. They should remember that it’s the people’s health first, and not the face of their regime.”

Conclusion

In some respects, Fiji has an adequate quality of health care provision for the public sector but there is definitely room for major improvements.

Keeping health facilities clean and tidy would seem to be a good place to start.

The state of some hospitals in Fiji is very poor – some would say abysmal.

Our citizens deserve a cost-effective, high-quality, public health care system, guaranteeing good health care to all.

It is after all, a basic human right (section 38 of the Constitution).

The majority of our people cannot afford to fly off to overseas destinations like Chennai for kidney transplants, or Singapore for heart valve repairs.

In this time of a global pandemic, a good health care system and facilities will be an important factor for those tourists wishing to travel to Fiji.

A “third world” health system will discourage health conscious and discerning visitors afraid of suddenly falling ill while o holiday in the country.

If government increases health funding as a percentage of GDP to reflect what WHO and others recommend, this would provide the funds needed to make improvements.

It has been estimated that up to 80 per cent of Fiji’s population is accessing health care, but only 40 per cent are receiving good quality of care.

Sound decision-making by government and public sector health professionals will only happen if those that are in charge are humble enough to take on the advice of others to arrive at the best decision.

Hubris and complacency will not help.

It is time politicians and senior health officials stopped being in denial and face the reality that Fiji’s health system is in dire straits.

Perhaps it is time for a review of the health system by a team of external independent experts.

Government has everything to gain from the findings and recommendations likely to result from such a review.

It may provide answers to how systemic problems in Fiji’s health system can be fixed.

 

  • GRAHAM LEUNG is a lawyer and former president of the Fiji Law Society. The views expressed in this article are his and are not necessarily shared by this newspaper.

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