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Asia Pacific Family Medicine 2002; 1: 59–60

REGIONAL ROUNDUP

Primary health care in FijiNeil SHARMA

Department of Primary Care/General Practice, Fiji School of Medicine, University of South Pacific, Suva, Fiji

Fiji is an archipelago of some 300 islands in the tropical South Pacific. Some 240 islands are still un-inhabited. Being centrally located it serves as a hub for the various groups of other island countries. Tradi-tionally a trading post, it boasts an agricultural basedeconomy. There are rich deposits of gold, fish and oilin our trade and economic zone. Fiji today, is also an important trade, telecommunication and tourism destination.

The population is approximately 800 000 with 60%urban based. Great cultural diversity, tourism, travelexposure, turbulent politics and rapid urbanizationpose new meaning to the planning and delivery ofprimary health care.

The primary health care system Primary care is provided by the Fiji Ministry of Healthand is modeled on the World Health Organizationthree tier system of primary care aimed to provide divisional, sub divisional and area based health carefacilities. This is complemented by the urban basedgeneral practitioner community under the aegis of theFiji College of General Practitioners.

The three tiered system is manned by specialist,generalist and primary providers. The latter includebasic medical graduates, medical assistants, nurse prac-titioners and nursing graduates. The aim was to keepmedical care decentralized and primary focused.

Problems and improvementsThis well intended strategy has produced practical difficulties due to a centralized administration. Poorlogistical support, inadequate pharmaceutical suppliesand manpower shortages have resulted in inadequateperipheral care. Limited financial resources and lack of health planning are contibuting to deterioratingprimary health care delivery. The need to upgradeequipment plus basic and technological supplies is a

constant need. The rural dwellers and periurbaniteshead to the base hospitals, perceiving them as centersof excellence, while the primary health centers remainunder used. At the base hospital, elective work be-comes almost impossible and effective primary care,mere wishful thinking.

Nonetheless, Fiji improved in areas of child andmaternal health. Morbidity and mortality statistics arebetter. Immunization, nutrition, contraception usageand longevity statistics improved. This is a direct resultof the contribution by the three tiered health caredelivery. Greater strides are needed to control the non-communicable diseases including diabetes, cardiovas-cular disease and cancer quality of life issues for thepatient, their family and the community in general.

The Fiji College ofGeneral Practitioners This was established in 1993 and still awaits formalrecognition as an act of parliament. It remains a voluntary, primary health care organization aimed atproviding ongoing vocational education and trainingfor the general practitioner community. This involvesjournal clubs, peer groups, clinical audit groups, miniseminars, and annual conferences for the 100 oddmembers. Well over 200 professional developmentand continuing medical educational activities wereorganized in the last fiscal year. A bi-monthly news-letterkeeps members intouch, while a quarterly journalprovides an avenue for publishing local research.

Accreditation and reaccreditations of college membership is currently continuing medical educa-tion based and plans are in place to establish a voca-tional career pathway for new graduates. The Collegeof General Practitioners is affiliated to the Fiji School ofMedicine, which is the Regional Medical TrainingInstitution. Three members are senior honorary lecturers in primary care/general practice. Four othershave been appointed lecturers for undergraduateattachments throughout the academic year. Theundergraduate program is now fully established andstudents receive an improved bird’s eye view of generalpractice.

Correspondence: Dr Neil Sharma, GPO Box 1297, Suva, Fiji.Email: nsharma@is.com.fj

Accepted for publication 18 March 2002.

N Sharma

Developing a postgraduate program is an importantaim of the college. In striving for excellence in primaryhealth care training, education, research and servicedelivery, a localized program of study is being formu-lated in affiliation with the school of medicine and theregional university of the South Pacific. Franchising apostgraduate study program and making sure it staysinternationally recognized will need collective input.Attracting the current lot of general practitioners willbe another task as interest levels vary due to work andpolitical pressure.

The ministry of health’s recognition of the FijiCollege of General Practitioners’ international links,outreach community programs and undergraduate/vocational ongoing training schemes have paved theway to a formal memorandum of agreement for settingup a computerization program in general practice. Thisexercise will assist in bilateral transfer of statistics andsurveillance data, as well as placing the Ministry ofHealth in a better position for fund sourcing.

Practicing in primary care Most general practitioners are urban based, initiallyworking in the public system as a registrar in one of the hospital based disciplines. They are mostly in solopractices. Newer developments see integrated practiceswith various practitioners with postgraduate diplomasin dermatology, pediatrics, obstetrics and gynecology,travel, aviation and dive medicine. There is a sprin-kling of specialists in the private sector too. Theseinclude anesthesia, obstetrics and gynecology, cardiol-ogy, internal medicine and surgery. A fee for service,capitation, integrated capitation and a mixed paymentsystem renumerates the general practitioner.

The public sector physicians are salaried, althoughspecialists in the public sector are allowed some afterhour consultation. Well over 65% of hospital basedand public primary care doctors are expatriates fromChina, Cambodia, India, Nigeria, Pakistan, UnitedKingdom, New Zealand and Australia. Expatriates anda small number of locals provide the teaching staff atthe regional medical school. The general practitionercommunity are largely locals with a few expatriateswho have taken Fiji citizenship.

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Dealing with a changing medical workforceThere has been a massive loss of manpower followingthe coups (see Viewpoint, this issue). Over 30 generalpractitioners and a sizeable number of teaching staff at the school have left. This is all to the detriment of primary health care. We are also losing well-trainednurses to New Zealand, Australia, England, MarshallIslands and Palau. A small outflow of technologists isanticipated as well.

With the Australian based (Mayne–Nickless) spon-sored Suva private hospital, we see the entry ofmanaged care in Fiji, although not everything appearsas it should. Monopolies have resulted in unilateral fee hikes within a year, unscrupulous over servicingand competition with the general practitioners hasbecome an issue, which needs the attention of bothmanagement and the College of General Practitioners.Suva private hospital, a 40 bed establishment, doeshowever, provide a breath of fresh air for the commu-nity. Local inpatient care for those who can afford ex-ecutive health schemes, against overseas evacuationsmay be of great benefit. However, a national healthscheme remains a major missing link in the chain ofsocial development.

A challenging future The Fijian political instability has resulted in increasedpoverty. Over 50% of the population now lives belowthe $6000 per annum income (Fijian dollars). There ischanging diseases patterns in primary health care. Weare seeing more internal displacements in the commu-nity; periurban squatter settlements; anemia’s; andwater, contagious and air borne diseases. There is anincrease in sexually transmitted diseases. Social prob-lems associated with political instability are moreobvious. The most vulnerable in society suffer themost – woman, children and the elderly. Primaryhealth care providers suffer with them.

The challenge to primary care is to continue pro-viding quality care in the face of a rapidly changingdisease profile with increased professional attritionand still be astute enough to keep focusing on primaryprevention.