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Fiji national health accounts 2005

31 décembre 2007 Organisation mondiale de la santé

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FIJI NATI ONA L HEA LTH ACC OUN TS Shaping Fiji's Health

200 5

The Fiji NHA Team

Septe mber, 2007

Osma tAZZ AM WHO Consullant West Pacific Regional Office

Fiji NHA Report 2005

WHOIWPRO LIB RARY MANILA. PHILI PPIN ES

o4 SEP 2008

Foreword I have great pleasure in presenting the Ministry of Health's first National Health Account for the financial year 2005. With limited available financial resources, providing universal access to health services remains a major concern for the Government of Fiji Islands. This was the major driving force behind the Ministry of Health and the World Health Organization to develop a National Health Accounts survey. The Ministry of Health is coordinating and managing a major part of the Health Sector with significant support from its key development partners such as the World Health Organization, AUSAID, JICA, NZAID and other donors The Ministry of Health had to find answers to basic questions such as: to what extent it succeeded in ensuring equity? At what price? And at what burden on households? In order to get a clear picture, the MOH had decided, in collaboration with the World Health Organization to conduct the National Health Accounts (NHA). A systematic effort was put by the WHO Consultant, Mr. Osmat AZZAM and the NHA team to collect information from both public and private sectors. The Statistic Department provided information on out-of-pocket expenditures and employment status in the country. Major surveys contributed to the finalization of this NHA report were The Providers survey, Employers survey, NGO survey, Donors survey, Private Insurance survey and Traditional Healers survey. National Health Accounts are designed to give a comprehensive description of resource flows in a health care system, showing where resources come from, and how they are used. This study would certainly have a great impact in shaping the health financing reform in Fiji. Most importantly, it constitutes an essential benchmark for assessing the health system performance and evaluating health policies in the future.

Permanent Secretary of Health

I 2

Fiii NHA Report 2005

FOREWORD .............•...•.........................................•..................................................................................... 2 INTRODUCTION ......................................................................................•.............••................................... 4 SOCIO-ECONOMIC AND HEALTH STATUS BACKGROUND ............•........................................•.... 5 FIJI BACKGROUND ...................................................................................................................................... 5 DEMOGRAPHIC AND POVERTY ..................................................................................................................... 5 HEALTH STATUS OF THE POPULATION ......................................................................................................... 7 MORTALITY AND MORBIDITY: .................................................................................................................... 8 EMPLOYMENT STATUS ................................................................................................................................ 9

HEALTH SECTOR .................................................................................................................................... 11 BACKGROUND ........................................................................................................................................... 11 FIJI HEALTH SECTOR ................................................................................................................................. 11 HOSPITAL SECTOR ..................................................................................................................................... 12

PROFILE OF HEALTH SUB-SYSTEMS IN FIJI ........................................................................•........• 13 NATIONAL HEALTH ACCOUNTS ACTIVITIES ................................................................................ 16 METHODOLOGY AND DATA SOURCES ........................................................................................................ 16 STUDY LIMITATIONS ................................................................................................................................. 17 GDP AND GOVERNMENT AND HEALTH BUDGET EVOLUTION .................................................................... 18 NATIONAL HEALTH BUDGET: PAST AND FUTURE TRENDS AND INDEX ................................ '" ................... 19

Use ofNHA ................................................. ...................................................... ................................... 20 NHA Main Findings ................................ ............................................................................................. 22 Health Care FinanCing in Fiji ............................................................................................................. 24 NHA MATRICES ....................................................................................................................................... 27 SECTOR ANALYSIS ................................................................................................................................. 29 MINISTRY OF HEALTH ............................................................................................................................... 29

Change in the MOH Budget ................................................................................................ ................ 30 Sources of Fundingfor MOH spending ............................................................................................... 31 MOH Functions by Subdivision: .......................................... ................................................................ 32 MOH Functions ................................................................................................................................... 33 MOH Expenditures by Providers ............................................. ............................................................ 34 FIJI NATIONAL PROVIDENT FUNDS ............................................................................................................ 35 THE MILITARY FORCES WELFARE GROUP MEDICAL SCHEME .................................................................. 35 PRIVATE PROVIDERS ................................................................................................................................. 35 HOUSEHOLD EXPENDITURES ON HEALTH: ................................................................................................. 37 PRIVATE INSURANCE MARKET: ................................................................................................................. 39 DONORS: ................................................................................................................................................... 40 Aus Aid Assistance: ............................................................................................................ ................. 40 Japan Grants: ...................................................................................................................................... 41 New Zealand Aids ................................................................................................................................ 42 Global Funds ....................................................................................................................................... 42 WHO Funds ......................................................................................................................................... 42 Other Donors ....................................................................................................................................... 43 NON GOVERNMENT ORGANIZATIONS ....................................................................................................... 43 TRADITIONAL HEALERS ............................................................................................................................ 44 CROSS COUNTRY COMPARA TIVE ANALySIS •........................................•.............................•........ 46 KEY HEALTH SYSTEM PERFORl\IANCE: ......................................................................................... 47 EQUITY: .................................................................................................................................................... 47

Discrepancies in physical access to health care ..... ............................................................................. 47 Discrepancies in financial access/ afJordability: .... ............................................................................ 48 SUSTAINABILITY ....................................................................................................................................... 48

Introduction The total estimated population for Fiji is 849,361 1 , with a population growth rate estimated at 0.1, and a total fertility rate of 97.25 per 1,000 population. The annual number of life births has remained at approximately 17,000 over the past five years or around 21 births per 1,000 populations. The majority of population resides in the central division, which account for 48% of the total. In the absence of a national health financing information, national health data in Fiji was usually obtained from studies done upon the need of certain projects; For example the WHO Social Health Insurance study undertaken in 2003 and the WHO health financing analysis undertaken in 2002. Those studies along with National Household Income and Expenditures Surveys (HIES) conducted in 2002-2003 were used in the preparations of this National Health Accounts. Most of the behavioral surveys (Knowledge, Attitudes, and Practices studies) on HIV are funded by Global funds or WHO under specific projects. More so, Data on Mortality causes of deaths and morbidity was done by the MOH and collected from the Annual Reports 2001-2005 and mapped with the western pacific country information profiles (CHIPS 2006 edition). Nevertheless, small scale studies, usually limited to certain population groups and most of the time to certain geographic are abundant. However, it is frequently difficult to use these studies and generalize the results to the population at large because of their poor representativeness, often poor reproducibility, and sometimes inadequate quality of the data. With the current information difficulties, this Fiji first National Health Accounts (NHA) exercise was carried out by the NHA team and The WHO Regional NHA expert (Mr. Osmat AZZAM) with the funding provided by the World Health Organization. The purpose was to present the results with the aim to contribute to the health care financing policy analysis and policy development process in the country. This Report also attempts to identify the major problems (logistical, methodological, and those related to data quality) faced during the NHA compilation in order to define those areas that will need to be addressed during the Future NHA process. Like many other countries in the Pacific, the government of Fiji faces a situation in which it is expected to meet a growing burden of disease, rationalize service delivery systems, regulate the quality and cost of services, and meets these demands despite declining public financing. As the economy continues to struggle, and the population keeps growing, the challenges of providing health care services increases. Government health budget continue to grow and reach an amount of F$ 137 million or 9.6% of the Government budget in the year 2005. This is an area of concern to policy-makers and maybe it is a time to start thinking of raising user fees and or develop some kind of an insurance scheme (social or National insurance). 1

MOH Annual Report 2005

Fiji NHA Report 2005

Socio-economic and health status background

Fiji Background Fiji has the largest population of the South Pacific islands countries. According to the Fiji National Millenium development goal report for 2004, the national economy is barely growing. It rests primarly on sugar production and tourism, but is becoming more diverse with manufacturing now an important employment sector. The shock to the economy delivered by the 2000 coup was minimized by the quick action of the central bank to maintain stability and sharply reduce aggregate demand. The Reserve bank of Fiji protected the value of the currency during the crisis and thus inflation was not a factor in 2000, coming in about 1%. The Government of Fiji faces a number of health challenges. According to the MOH, in addition to the continuing incidence of communicable diseases, they include an increasing prevalence of non communicable diseases such as diabetes and hypertension, due to lifestyle changes, poor diet, smoking, changing patterns of physical activity , continuing mulnutrition problems, particularly in schoolchildren and women. On disease conditions and status, NCO continues to be the major cause of of morbidity and mortality. Controlling diabetes and cardiovascular disease remains a priority focus of the MOH. Fiji faces a double burden of infectious and non-communicable diseases, which impacts on the health of individuals and populations and has the potential to affect broader social and economic development as well. The increase in the pattern of diseases, along with the political problems which considerably weakened the institutional and financial capacity of the government and public sector and the MOH role steadily declining.the private sector is expected to play a major role in filling the vaccum in capacity and numbers. Health care services have become increasingly oriented towards curative care but still not occupying the large size of provision. Today more than eighty percent of hospital beds are in the public sector. Tertiary health care services for complications of cardiovascular diseases is limited or restrictive and the MOH relies heavily on medical treatment abroad for identified disease conditions.

Demographic and poverty In 2004-2005 a household survey of employment and unemployment (EUS) aimed to obtain a comprehensive statistical data on the economically active population, comprising employed and unemployed persons, as well as on the 5

Fiji NHA Report 2005

inactive population of working age. While the general public perception is of considerable unemployment rate in the country, the official statistics out of this survey indicates that the stated unemployed rate is about 4.7%, and that there are extremely high levels of under-employment in several categories of workers, especially Family workers, self employed and Community workers. When taken this under employment into consideration, the effective rate of unemployment becomes considerably higher (over 20%).2 The population estimates from this report (817,952) is lower than what is projected by the MOH (849,361). The reason was that these estimations exclude institutional populations. The distribution of population by ethnicity and Divisions is detailed in table 1: Table 1: Population estimates, 2005 Ethnicity I Divisions Fijians Indo.Fijians Others Rotuman Central 194,234 118,439 13.152 3,951

Eastern 32,466 798 608 4.354

Northern 60,817 62,799 9.366 389

Western 144,235 164.194 5.540 2.008

TOTAL 431.752 346.230 29.266 10.702 817.950 100.0°/.

% per Ethnicity

52.8%. 42.3"1.

3.S·I. 1.3%

TOTAL 330.376 38.226 4.711'/9 p.r Division 40.4"1. ... Source: 2004·2005 EUS. FIJI Islands Bureau of Statistics ~.

133.371 16.3*/.

315.977 38.6%

100.0"1.

The 2002-2003 Household Income and Expenditure (HIES) and the Employment Unemployment Surveys (EUS) indicate that the average household size in Fiji is 4.9 persons, with an average 5.3 for Fijian Ethnic and 4.4 Indo-Fijians. The average income per household is F$12,753 per year with a higher estimates for the Fijians Ethnic (F$12,972). The interesting finding comes up from the surveys was the rate of unemployment which is defined as 8% for urban areas and 4% in the rural areas. The two surveys indicate that in aggregate, all the ethnic groups consume an average of 3.2% of their income on health expenditures, which gives us an estimation of an average out of pocket spending on health of F$408 per household per year. Table 2 indicates the indicator related to Ethnicity comparison and Table 3 related to Rural/Urban comparison. . b . 't v r.a ble 2: Househ 0 IdA na/ys/s t mel W Eh Ave Unemployed urban Ave HH size population 536 441 490

Ethnicity

tI/o ofHH 50% 46%

~/o

ofp?p

Ave Unemployed rural population

Income by Ethnic group 51%

AveHH income $, 12,972 00 1190200 19,105 DO

Ave Medical Exp ",sOlo of

Income 31%

Fijians Indo-Fijians Rotumans & Others Total Population

53% 42% 5%

17% 12% 18%

3% 5%

43%

35% 30%

1% 4<:>/<:>

7% 100%

Source. 2004·2005 EUS. FIJI Islands Bureau of Statistics 2002-2003 IHES. Fiji Islands Bureau of Statistics

...100%

100%

4.9

12.753

3.2%

22004·2005 Employment and Unemployment survey, Fiji Island Bureau of Statistics. May 2007

Fiji N HA Report 2005

Health status of the population The last population household Income and expenditures survey (HIES) was carried out for 2002-2003. Another recent survey, Employment and Unemployment survey (EUS) was carried out in 2007 for the year 2004-2005 and estimates the population size of 817,952. These estimates exclude institutional populations. Around 45 percent of households are living in urban area, while 55 percent are living in rural areas. The MOH Annual Report estimates a total population of 849,361 for 2005 and an increase of 0.1 % from 2004 estimates. As per the Employment and Unemployment survey (EUS) 8.6 percent of the population is under the age of 5 with a total of 39.3% under the age of 15, and 4% over age 65.

This pattern is typical in countries that experienced relatively high fertility rates in the past. The highest percent of population is in the age group 20-49 (reproductive age group). Population has been growing at 0.1 percent per year and Total Fertility Rate Vary between 92 per thousand population in 2001 to 105 per thousand in 2004.

Tables 5A and 5 8 show the key health indicators as per the MOH Annual Report 2005.

Fiji NHA Report 2005

Mortality and Morbidity: The main challenges faced by the MOH in Fiji, in addition to the continuing incidence of communicable diseases, there is an increasing prevalence of noncommunicable Diseases (NCD) such as Diabetes and Hypertension, due to life changes, poor diet, smoking, changing patterns of physical activity as well as the continuing malnutrition problem. NCD have become the principal cause of iIIhealth and death. The leading causes of death and serious illnesses in young children are acute respiratory infections, diarrhea, parasitic infections, meningitis and anemia. A rapid increase has been recorded in HIV/AIDS cases, where 158 cases were confirmed as at 31 December 2004, as well as sexually transmitted infections (STI). Despite the increasing burden of Chronic diseases, respiratory disease and infectious and parasitic diseases continue to represent the leading causes of admission to hospital. The MOH Annual indicates the top five major causes of hospitalization and death for the year 2005 as follow: Table 58: Five Major causes of Mortali!!t.. and Morbidity

Top Flv. MejQr Cau.!Jllf Mor:bldIY .•...••.. P.rc~.. Diseases of the Respiratory System Diseases of the Circulatory System Condition originating in perinatal period Infectious and Parasitic Diseases Diseases of the genitourinary system 8.08 6.98 6.39 5.91

4.36

Top Flv. Major CIIU8U or MOl'tajity Diseases of the Circulatory System Infectious and Parasitic Diseases Neoplasm Condition originating in perinatal period Diseases of the Respiratory System

Percentage. 26.37 13.4 10.62 8.91 8.55

I 8

Fiji NHA Repo>1 2005

Employment status The Bureau of Statistics in Fiji has conducted a survey on Employment and Unemployment in Fiji. The 2004-2005 EUS is intended to contain comprehensive national data on employment and unemployment. It includes a number of useful desegregations; rural/urban, divisions and districts, ethnicity, age, industries and occupations; as well as incomes, hours and days worked, major activities, industries, occupations .... This report will represent a good reference for any future feasibility study on Health insurance or policy on universal coverage. The report indicates that the bulk of the unemployed are mostly the youths between the ages of 18 and 30. While only 35% of the Labor Force, those aged 18 to 30 were 66% of the unemployed. Of note is that while those over 55 were 11 % of the Labor Force, they were only 3% of the Unemployed. Tables 7 and 8 indicate the unemployment rate in Fiji. Based on that survey, Table 6 below shows that the total unemployment rate (or not in labor Force) in Fiji represents 59% of the total population.

Most of the unemployed population falls in the age of 18-30. This category of the population is expected to be the most productive in the country. As shown in the tables 7 and 8 below, there seem to be an important portion of the population who are working. This means that an important number of dependent people rely on an active and working environment. It also should be noted that, ethnically all the Rotuman unemployed were between 18 and 30, while a slightly higher proportion 72% of the Fijians in this age group were unemployed. The eastern and western division of the country had higher rates of Youth unemployment too.

Fiji NHA Report 2005

Table 9 below shows the distribution of the workforce by employment status and Ethnicity. This distribution represents an important factor for the country feasibility study on any change in financing scheme or insurance mechanism to be proposed in the future.

Table 10 indicates the distribution of the workforce by income group in 2004-05. One of the most difficult definitions in the EUS was to differentiate between those who are in the formal sector employment and those who are in the informal sector. The EUS define the one in the formal sector as paying the Fiji National Provident Funds (FNPF) contribution. The EUS study resulted that 41 % of the employees (or 134,210 employees) are registered under the FNPF which is another good indicator for any future changes in Health financing mechanism.

40.0% 1U% 58.5% 12.8% 14.1% 26.9% .100,0%

10 Fiji NHA Report 2005

Table 11 indicates the average income per household as per the HIES 20022003, The average income of a household (of F$10559 for rural and F$15267 for urban) in this survey has been way overestimated, A simple calculation of this estimation and the number of household will indicate that total household income represents almost double the Government total budget and half of the GOP, Table 11: Average Household Income Average Household Income Number of Household Average HH Income Rural Urban Rural Urban 51,288 30,635 1,756 27,167 40,741 5,093 11,082 9,653 11,066 16,539 13,593 21,877

Ethnicity Fijians Indo-Fijians Others Average I Total

83,679

73,001

10,559

15,267

Source: 2002 2003 HIES, FJji 1.land. Bureau of Stati.tic.

Health Sector Background Fiji is faced now with an alarming escalation in health care costs, which is a burden for patients and for the MOH and its health care institutions, To address the most pressing issues, the Fiji health sector was transformed in 2003 from a highly centralized system to one that is decentralized within the MOH, This transition was slow and will continue to require substantial technical support and system development to put it in place, The Government health service is provided through divisional hospitals, sub divisional hospitals and area hospitals, Health Centers and Nursing stations, Government also provides assistance to community or village health worker clinics managed and staffed by trained Village Health Workers,

Fiji Health Sector The Fiji Ministry of Health is currently leading the financing and provision of the health services, It is indeed a need to redefine the role of government and health sector stakeholders in the financing, provision and regulation, To continue facing

Fiji NHA Report 2005

the challenges in the provision and financing of health services to the population, a new health sector reform is needed to be fused on funding; external development; health workforce; and ability and challenges of the MOH to provide accessible and quality health service. The agenda of such a reform need to address as well the issue of the other health related financing agents' responsibilities, contracting tertiary care provision and the continuous partnership with Donors for the sustainability of public health program.

Hospital sector As noted in table 12, there is a total of 26 public hospitals with 1,812 beds in Fiji in 2005. More than 90% of total Hospitals and beds are in the public sector. The private sector has the minority of beds. The predominance of the public sector reflects the major role of the government in term of financing and provision. A financing arrangement where the public sector purchases services from the private sector is minimal and is mainly for rehabilitation. Fiji has 2.2 beds per 1000 population making this one of the highest ratios in the pacific islands. However, the beds are not uniformly distributed. As example, for the referral hospitals there are 458 beds in Suva, 339 beds in Lautoka and 161 beds in Labasa. The three specialized hospitals are located in Suva. Most of the Hospitals have sixty beds or more with less than 50% occupancy, when only one has 27 beds. Thus this is considered a heavy workload and responsibility for the MOH to manage. able 12: Distribution 0 fF;acilttles and Beds by DIvisions H" " ,

Number of Bed,

Central Hospitals Di'<ision~1 Hospitals Specialised Hospitals Sub·Divlsional Hospitals Area Hospitals Old People Home

Weat.rn Northern Eastern ::: Total 1 5

%of "" Hospital

%of

Beds 53.5%

1 3

'!. 9S~

4 1 1

3 16 1 3

", 'ZT'T 533 33

11.5·~T 11.6% 61.6% 3.8% 11.6% 1(lO.O%

15.3"10

29A% 1.8%

Total Other Facilities Health Centers Nursing Stations Villaqe Hea~ Workers

10 18

5 18

4 14

:1,812

100.0%

20 5

24 26 3

21 2

33 7

In addition of the secondary care there is an overseas medical referral system maintained by the MOH through CWM Hospital and Lautoka Hospital for urgent and treatable medical conditions overseas. Main countries engaged in the referrals are New Zealand Australia and India.

I 12 Fiji NHA Report 2005

Profile of Health Sub-Systems in Fiji Following is a brief overview of the Fiji health sector in terms of health services coverage, sources of financing, prevailing provider-payer relationships, and the size of operation of each of the health care sub-systems. Table 13 : Pro i/e 0 fH ealth Sub-Systems in Fi"i Benefits by Health Subsystems Coveragel Special Categories Describes coverage and eligibility criteria, special programs for specific population groups AU citizens and

Principal Financing Sources

Provider - Payer Relationship

Percentage of Population Covered or Eligible No, of people covered or eligible by health system nation wide

Size of Operation

Describes types of services and benefits available.

Describes main sources of financing

Describes relationship between financing and service delivery functions Primary and Secondary services treatment as well tertiary treatment (available 2 overseas treatment scheme, a special budget item for overseas treatment out of the MOH and another scheme lunded by NZAIO)

As indicated by staff, beds, or number of facilities

Provides comprehensive public health services; primary, preventive and curative care services through its facilities. Free outpatient and low fees for inpatient. Minimal fees for Dentistry

residents in Fiji Highly subsidized care services for the entire population as well as Expiates

· ·

Ministry of Finance (general tax revenues) Household Spending (out·ol-pocket) Donors (through grants for vertical programs)

All Fiji citizens and expats are eligible.

· · · ·

Operates: 101 Nursing Stations 76 Health Centers 16 Sub Divisional Hospitals 3 Relerral Hospitals (CWM in Suva-456 beds, Lautoka Hospita1-339 beds, Labasa Hospital-161 beds) 3 specialized Hospitals (Main Centrally referral hospitals; St Giles in Suva136 beds, PJ Twomey in Suva -27 beds, T amavua in Suva-64 beds)

· Staff:

There are 4409 employees positions in the Ministry of Health, 3313 established staff and 1276 General wages earners. 3037 are the actual number of staff There are 15 SES Post ( Directors), 344 Medical Doctors, 1723 Nurses Personnel including midWives and specialized nurses, 197 Dental staff, 74 Pharmacists, 57 Dietitians, 119 Environmental Health staff, 133 Laboratories, 35 Physiotherapists, 63 radiologist technicians. 1 occupational therapist, 5 biomedical technicians, 4 supervisors hospital services, 20 institutional services staff, 61T, 2 legal officer, 4 librarians, 4 welfare staff, 20 Stores man, 10 telephone operators, 17 accounting officers, 138 Administrative Support staff, 4 statistical services staff and 42 reporting/typing staff. Doctors and nurses are salary paid.

Fiji NHA Report 2005

Benefits by Health Subsystems

Coveragel Special Categories All army and their family in Fiji Highly subsidized care services for the entire population as well as Expiates

Principal Financing Sources

Provider - Payer Relationship

Provides comprehensive public health services; primary. preventive and curative care services through the Military Hospital. Free outpatient, drugs and inpatient for Militaries and tehir family. Army had also private insurance scheme and overseas treatment through the Private insurance

. .

Percentage of Population Covered or Eligible All army and their family eligible.

Size of Operation

Ministry of Finance (general tax revenues) Household Spending (part of the premium paid from salary)

Primary and Secondary services treatment as well tertiary treatment (available overseas treatment scheme through private insurance scheme.

Operates: One military hospital in Suva with 7 beds has general health services. and can always refer their patients to specialized public hospitals

National Provident Fund (All government and non government workers retirement Scheme) NPF provides health Medical coverage for GOF via Ministry of Finance Paying Private and medical scheme for Employees and (general tax revenues) and Providers Elderly. Free services wages deduction 8% from pensioners (inpatient existed for patients and outpatients). Employees salaries and 8% treated at Private from Employers Hospital and Doctors.

Private sectors

Patients are treated at the Private Hospital and GPs

Non Government Oraanization Provides Health related All citizens programs mostly; some provides primary health care and first aid kids to village organisations such as Red Cross and Reproductive Health centers: Good number of NGOs are funded by the Ministry of Health Donors These are external governments and organizations that donate both cash (in form of grants) and inkind items for the health sector

Mainly from International Non-Government Organizations, Donors and Ministry of Health as well as fund raising organized by NGO's themselves

Delivering of Primary Health Care related activities, public programs and first aids

Approximately most of the population are eligible and can benefit from these programs

There are several NGO's in Fiji: 9 received grants from the MOH namely: Ra Catholic Hospital. Responsible Parenthood Council, SI John Ambulance Brigade, Fiji Red Cross, Channel Home of Compassion, Father-Law Home, Reproductive and Family Health Association, Family Support Association Group, and national Food and Nutrition Committee. World Health Organization, (WHO), AusAlD (Australia Agency for International Development), Global Funds, NZAIDS, JICA, UNFPA, UNICEF, Chinese Government Funds and Southern Pacific Commission (SPC).

Everyone are covered through these funded programs

Mainly from external governments and organizations

Providing funds for Primary Health, Health Programs and Overseas Treatment

All citizens are eligible for services delivered by various health care providers (for Primary& Secondary treatment); also eligible for OVT as well provided they meet the criterion

Private Sector Private Insurance Private or voluntary health insurance is a big industry in Fiji. One private insurance offered health for civil servants and a number of private insurance companies existed all over the country. All citizens are eligible to use this insurance provided they can afford the price; Civil servants are eligible for Marsh and McLennan insurance. Mainly Household out-ofpocket spending and employers Primary & Secondary Treatment (drugs, outpatient and inpatient) All citizens (100%) have a choice to access services provided that they can meet the associated cost. beneficiaries are covered through private contracts. Private insurance companies contract services to private providers.

Private Hospital There are two private hospitals in Fiji; one in Suva and one maternity All citizens are eligible to use these facilities All citizens are eligible

I Mainly Household out-of-

pocket spending and MOH for non profit hospital

Primary & Secondary Treatment

All citizens (100%) have a choice to access services

Suva Private Hospital has 40 beds. Ra maternity Hospital has 7 beds. It provides both outpatient

Fiji NHA Report 2005

Benefits by Health Subsystems

Coverage! Special Categories to use the Fiji hospital provided they can afford the price; user fees is expensive as compared to the free services at the public facilities. The Maternity hospital in Ra is a non profit organization and funded by a grants

Principal Financing Sources

Provider - Payer Relationship

non profit private hospital in Ra run by the Catholic church. they provide the public with Primary and Secondary Treatment both outpatient and inpatient services

(outpatient and inpatient) provided onsite with patient paying out-of-pocket

Percentage of Population Covered or Eligible provided that they can meet the associated cost

Size of Operation

and in-patient services on-site. The maternity hospital provides only maternity and postnatal services.

paid by the government (out of

the MOH budget) and the church provided

their staff.

Private Clinics These are physicians operating privately and independently providing general outpatient services, refer their operations and specialty to the public and facilities All citizens are eligible to use services provided by these private clinicians. User Fees is expensive as compared to the free public facilities services Mainly Household out-ofpocket spending Primary & Secondary Treatment All citizens (100%) have a choice to access these services offered by private clinics provided they can afford to meet the costs 110 Private Physicians existed in Fiji

(outpatient only) inpatient cases are usually referred to either one of the public facilities or the private hospital depending on the recommendations from physicians

Private Dentistry These are dentists operating privately providing almost the same services that public facilities provide All citizens are eligible to use services provided by these prvate dentistry User Fees is expensive as compared to public facilities All citizens are eligible to use services Costs of drugs is expensive as compared to the free services offered by Mainly Household out-ofpocket spending

Oral health treatment and

All citizens (100%) have a choice to access the services offered by private dentists provided they can afford to meet the costs

Private Dentists existed in XXXX

XXX PLEASE ADD

primary tooth prevention treatment

Private Pharmacies These are pharmacies owned by individual pharmacists and are operating in the private sector

Mainly Household out-ofpocket spending and donors

Selling medicine and drugs

All citizens (100%) have a choice to access these services offered by private pharmacies provided they can afford to meet the

43 Private Pharmacies existed in all urban areas ion Fiji

costs

the public hospKal pharmacies

Household (out-of-pocket) These are spending by people on health services provided by health providers for them All citizens Mainly from their disposable income Pay for primary and secondary treatment also tertiary care All citizens

Fiji NHA Report 2005

National Health Accounts Activities Methodology and data sources The Fiji NHA study followed the methodology provided by the Guide to Producing National Health Accounts prepared by the World Health Organization (WHO) in collaboration with the World Bank and USA/D. Needed adjustments were made to the classification schemes to bring them in line with Fiji national specifications. Several criteria were used to adapt the classifications: The transactions were grouped and partitioned so that they each represent an important, policyrelevant dimension. Partitioned transactions are mutually exclusive and exhaustive, so each transaction of interest is placed in one - and only one category. Efforts were made, to the extent possible, to consider existing international standards and conventions when placing certain transactions into groups to assure international comparability of the Fijian data. While preparing preliminary 2005 NHA tables, the NHA team relied on existing data sources and, where absolutely essential, additional efforts were made to compile the information. The following sources informed the report: }> The Ministry of Finance or Public revenues and expenditures; }> The Department of Statistics (SO), }> The 2002-2003 Household Income and Expenditure Survey (HIES) }> The 2004-2005 Employment and Unemployment survey (EUS) }> The Private insurance and Providers market; }> The Annual Reports of the Ministry of Health and the National Provident Funds were used to obtain details on public financing by functions and providers; }> The Army Medical Scheme was consulted to collect information about amounts disbursed by this agency to different providers and for different services; }> For donor financing and NGOs, special inquiries were made with the organizations active in the country to capture the size of donor assistance and purpose of funds/programs and projects. );> For Information about imported pharmaceuticals and other medical goods we consulted the custom department and other national experts and reports. Definitions used during NHA preparation were documented and also were subject to thorough review by the NHA team. After their revisions and approval, the required changes were made to the preliminary estimates and a final NHA for 2005 were produced.

16 Fiji NHA Report 2005

Study Limitations Preliminary NHA production revealed several strength as well as shortcomings of the existing systems and data. The main challenges faced were: ~ Household-level expenditure captured by the Household Income and Expenditures Survey was not enough for NHA purpose. ~ Significant variation from the Government Classification and the NHA Producers' guide classification which led the authors to question the quality of the available information. These concerns were shared by the NHA team and the MOH staff, and preliminary plans for future data quality improvement were identified. ~ Disaggregating spending by different Ministries and the armed forces medical scheme, other than the MOH, proved impossible, although in volume terms these agents manage less then 1 percent of Total Health Expenditure (THE) and services are provided at the MOH at no cost for the scheme, so this will not have significant impact on the findings. ~ Private insurance companies and private hospitals were not cooperative and data proved inadequate and sometimes not available. The NHA team used further analysis to extrapolate data from other researches and studies available. ~ NGOs expenditure data is of poor quality and what was available was on an aggregate level and not by functions and/or providers. ~ Household expenditure data was available only by broad expenditure categories, which did not allow the NHA team to disaggregate the data according to specific types of providers and/or functions. Considering the significant volume of private spending in Total Health Expenditure (THE) and the inability to disaggregate it by providers and functions places significant limitations on the presented analysis. ~ The quality of household level data, however, has been given prior attention, because it will help improving NHA estimates and will contribute to better Gross Domestic Product (GOP) estimation in the country and better health care financing policy development. Thus, presented data should be treated as preliminary that will be amended after data shortcomings will be improved in a follow up analysis and with the help of improved household medical expenditure survey tool. ~ Private market of Pharmaceutical was derived mainly from the custom department. NHA team has to analyze the volume of import and export and estimates private consumption accordingly. Finally, actual volumes of health expenditure described in this first ever NHA report in Fiji are reflected in the possible required format without adjustments, if not stated otherwise. These are the first NHA estimates. They attempt to achieve a compromise between timeliness and detail on one side and data quality on the other. As with any such estimation, revisions will be necessary to the methodology and numbers as new data sources become available, as improved

Fiji NHA Report 2005

estimation procedures are developed . Routine revIsions will therefore be necessary in future years in order to maintain and improve the quality and usefulness of the NHA, as well as update it.

GOP and Government and Health budget evol ution Actual total government budget has been increasing overall since 1996. Table 14 shows the gradually increase in the government expenditures on Health and Gross Domestic Product (GDP). Total Government Expenditures in Fiji amounted to F$1,424 millions in 2005 fiscal year, representing almost 30% of a GDP of F$4,775 million . Whilst there has been an overall increase of Government expenditure since 1996, the increase has not been uniformly steady with some fluctuations and slight decrease in financial year 2001. The greatest period of growth in government expenditure occurred in Financial Year 2002 and accounted to 14.5%, following a GDP growth of 11.1 %. It is no coincidence that this was the year in which the government introduced an affirmative action program AAP for indigene Fijian and the government back pay of the salary raise. Table 14: Gross Domestic ""!II Government and health I _~

_ _ i _ ......-f""l

II'""

.,,1'1

139

111

Health care in Fiji is financed mainly by general taxation. The Government has allocated a proportion varied between 9 to 11 % of its total yearly public expenditures on health care for the decade . Whilst there has been this overall increase of health expenditure as a proportion of overall national expenditure, the increase has not been uniformly steady with some fluctuations and a remarkable decrease of 16% in the financial year 2001 . The greatest period of growth in health expenditure as a proportion of total government expenditure occurred in 2004 equivalent to the decrease of the year 2001 (15.69% increase).

18 Fiji NHA Report 2005

Increased spending on health and the reduction in government revenues from taxes and other duties led to a steep increase in the balance of payment. Although the government budget on health has been increasing each year, the published total health expenditures in term of GOP have not increased . This NHA report highlight the issue that over the years , the declared Total Health Expenditures was underestimated and private share was more than it has been advised.

National Health Budget: Past and future trends and index The actual total government budget on health has been increasing overall since 1996. Figure 1 indicates the comparison of Health, Government and GOP in term of yearly percentage of increase. FIGURE

1- ACTUAL ANNUAL

INCREASE IN GOVERNMENT HEAL TH EXPENDITURES Cumulative Increase

r 50.00% 40.00%

Evolution GOP - Gov - MOH

(base year 1996)

60.00% ,....._ _ _ _ _ _ _ _ _ _ _ _ _ _ _. . , . , . _ - - - - - - - ,

30.00% 20.00% 10.00%

0.00%

-, 0.00%

1...!!! 1!!..l " 1i7 " 1..J1I!ll..~_i!I;.!!l!!l.....!!l!Ul!Lm~!l.dW; >!!m~!!£Z!Im..1!llI~~~~~

GDP ---- Gov!

MJH

Figure 2 shows that the highest increase in health expenditure over the past 10 years occurred in the year 2000. Overall health budget since 1996 effectively almost doubled in 2005. Because of this fluctuation in Health Budget, it is useful to compare three dimensions: the increase in Health Budget, the increase in Government Budget and the increase in GOP. Although the view of each comparison depends upon which dimensions and increases are being observed . The key finding out of this figure is that the rate of increase in Government budget and GOP evaluated like a horse and carriage, although the increase in health budget was faster than the government and the GOP, which explains the priority the Ministry of Finance provided to the MOH and thus to the health of population.

Fiji NHA Report 2005

FIGURE 2- INDEX OF ANNUAL INCREASE IN GOVERNMENT HEALTH EXPENDITURES (BASE YEAR 1996)

MOH , Government GOP evolution , 1996 base year 200 180 160 140 120

•

M 0 1-1 Budget Ind ex

100

_______ Govt Budge[ Index

80 BO

GOP Budget Index

40 20 1996 1997 1998 1999 2000 200 1 2002 2003 2004 2005

Although the government budget for health has been increasing each year, figure 3 shows that total health expenditures in term of percentage of GOP has not been increasing and maintained a constant share between 2.5% and 2.9%. FIGURE 3- ANNUAL SHARE OF MOH BUDGET OVER GDP

MOH over GOP (1996 -2005)

2.95% 2.90% 2.85% 2.80% 2.75% 2.70% 2.65% 2.60% 2.55% 2.50% 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Based on this analysis, running a National Health Account was a priority for the government in order to outline the health needs and measure the total health spending as well as the impact of the total public, private and donors spending on health .

Use of NHA National Health Account (NHA) is a widely accepted tool that is promoted by the World Health Organization to allow policymakers to understand and manage these health needs and systems used , and to improve system performance. It is a framework for measuring total - public, private, and donor - national health expenditures.

Fiii NHA Report 2005

Structured around a simple framework, the NHA methodology organizes, tabulates, and presents information on health spending in user-friendly format. It outlines some basic principles underpinning financial resource management and accounting rules that will be applied to monitor, mobilize and match resources to recognized needs. This 2005 Fiji NHA report provides a clear and transparent picture regarding the structure of the health financing system in Fiji and essentially measures the "financial pulse" of the national health system and helps policy makers making better-informed decisions by answering questions like: ~ ~

Who in the country is financing health services? How much do they spend in 2005? On what types of services? Who benefits from these health expenditures?

This NHA also intend to highlight the equity imbalances in the distribution of health expenditures as a valuable input into the financial projections of Fiji health system needs. The actual picture of how the fund is distributed among different groups, occupations and employment status are not available and approximations were made before. The distribution of population by occupation categories along with Health spending to Occupation NHA matrix can help to derive how much of resources can be pulled out from the government funding, currently being used to finance those who can potentially be financed by some form of insurance. Financial protection for everyone is a major concern of the government of Fiji. With limited government resources, the government has been debating to reallocate the government resources since 2001 to start some kind of Social or National health insurance to cover the population including those who cannot afford care on their own and depend on the government resources. Fairness in distributing health resources in a "Financial Protection" way is important. This can be understood by considering how the health care is financed. The Government has the following general aims in regulating health financing systems: ~ Raise revenue to provide individuals with adequate protection against medical expenses caused by illness and injuries ~ Manage these revenues to pool health risks equitably and efficiently ~ Ensure the provision and or the purchase of health services efficiently and effectively. From an expenditure point of view, NHA is built on four main classifications:

Fiji NHA Report 2005

Financing Sources (FS), Institutions or entities that provide the funds used in the system by financing agents, Financing Agents (HF), institutions or entities that channel the funds provided by financing sources and use those funds to pay for, or purchase, the activities inside the health accounts boundary, Healthcare Providers (HP), entities that receive money in exchange for, or in anticipation of, producing the activities inside the health accounts boundary, Healthcare Functions (Fe), goods and services produced by healthcare providers and by institutions and actors engaged in related activities to health care"

NHA Main Findings Summary Results (FY 2005) The main findings inferred from the three NHA matrices are summarized below: Table 15: NHA Summary Results

Summary NHA Results Population Exchange Rate $1= THE Tnt.)1 (invelilinellt BII.ItJet GOP Estlma_tes for FIJI

H 849,361 160 181,510,286 1,424,484,200 4, 774,559,000

usn

113,443,929 890,302,625 2,984,099,375

1,[lP Pel (')I)itol US "~

H 1,0'1 Exp Pel (.)pit.) US "~

$3,513 5,621

H Pel (:.)pit.) Expell.litules F$ US$ 'HI

$1,048 1,677 He.)lth 214 $134

P~Heelit Gnp Spellt "" He.)lth MOH ,)$ Pel cellt G.welllillellt Bu.ItJet THE .)$ Peleellt Gnvellllllellt Bu.I'Jet

3.8"", ~1.6""",

"12.8":-'

HH OOP

"15.06":-"" of THE

Fiji NHA Report 2005

Table 16- Sources of Funds:

Sources Millistry of FiJJ.1f1ce Priv.lte Employer FUllds Housellllid fll/rds NOli profit Illstitlltiolls Servill(l Households [lollors Fuwls- Gm!lts Tot.11 FS

Amount 131 ,036,450 4,072,534 27,447,216 3,525,000 15,429,086 181.51tl.28()

Percent 72.2% 2.2% 15.1% 1.9% 8.5% 1(lO''.,

Per Capita 154.28 4.79 32.32 4.15 18.17

213.7(1 US[I 133. 5()

Table 17- Total Health Care Expenditures by Financing Agents:

Financing Agents Millistry of He.llth Army Me<lic.ll Scheme Priv.1te IlIsl/(.11Jl'e Ellterj>tises Priv.lte HOllsehold' Oltt of p"diet NOli Govemmellt Oty.1I1iz,atiol/ [lollors Aqelldes TOt.11

Amount 136,880,800 900,000 8,936,950 21,682,800 3,525,000 9,584,736 181.510.28\\

Percent 75.4% 0.5% 4.9% 11.9% 1.9% 5.3% 1(l(l''',

Per Capita 161.16 1.06 10.52 25.53 4.15 11.28 213.7(1 I.lS[l1J3.S()

Table 18- Total Health Care Expenditures by Functions:

Functional classification of Health Jllp.ltiellt wf.1tive C.l/e B.lsk 01ltp.1tie lit Med /c.ll .111d Di.1l/llostic S elv ice Olltp.1tiellt [lel/t.ll C.lle All Otlret Sped.llized He.llth C.lle Tm(litioll.ll He-lltlr C.lle A IIdll.lry Selvices to He.lltlr C.lre PJl.1tllJ.lcelltic.lls .11111 Mher lIIe.Jic.lI11011 IiIll.li)les Repwtillftive He.1lth (M.1tent.11 ,111d Child Ire.1Ith. He.1lth Prolllotioll & Blood S.1fety Proqmlll Prevelltioll of ,'<11ll1l1llIlic.1"le (/ise.lses Prevellti01l "f 1I01l-COIll1l1lIllic.11>Ie liise.lses ElIviwlllllellt.ll He.llth. S.1I1it.1tioll & food 5.1fety Othel Miscell.ll1eolls 1'lIl>lIc He.llth services Gelleml Govetllluellt A.llllillistr.1tioll of He.llth He.llth Admillistr.ltioll & Health IIISIIt.1I1Ce Overse.1S Tre.ltlllellt C.lpit.11 Fotllmtioll of Ire.llth (.1101 plOviders EdllC.ltioll .111(1 tmillill(l of ire.llth persolllrel Rese.lrclr .1m! develol'lIJe!lt ill he.lltlr TOt.li

Amount 64,424,464 40 ,169 ,446 481,534 4,062,310 2,122,800 2,194,875 23,671,939 3,092,842 770,439 1,940,192 923,582 229,214 970,464 13,772,244 1 ,291 ,950 5,246,193 4,821,140 3,694,820 7,629,839 181.5W.28()

Percent 35.4% 22.0 % 0.3% 2.2% 1.2% 1.2% 13.0% 1.7% 0.4% 1.4% 0.5% 0.1 % 0.5% 7.6% 0.7% 2.9% 2.6% 2.1 % 4.2% 1(l(l''',

Per Capita 75.85 47.29 0.57

478 2.50 2.58 27.87 3.64 0.91 2.28 1.09 0.27 1.14 16.21 1.52 6.18 5.68 4.35 8.98 213,711

Fiji NHA Report 2005

Table 19- Total Health Care Expenditures bjfProviders: Providers of Health In Fiji Amount Percent Pl(hlk Go)lto)t.ll Hospitals PI(/>/ie [Jisttier Hospit.l/S Ptiv.lro) Hospit.ll PIrYSic;.lItS altd C/ilties (10) misrs Tradiriolt.ll Ho).l/o)tS Ho).llr/r Co)lt!O)IS Mtl,/k.l/.ll/(i [Ji.l'./Iwsrk L1I.oI.1rot/tlS PriV.1!tl,': Pltlolif Plwrtrr.1des Centt.ll Pltb/I<: Heal!/r Pwvido)ts Govetmrretrr A'/ruiltisrt.1riolt of Ho).llrlr Orlr"" (I'th'.lM) Admiltisrt.niotr <>f He.lltlr Iltsriwtiolrs ('lOviditry HRF 01l0)lse.ls Tle.ltlllo)trt PlovidO)IS 28.8~l1.(j.{~2

Per Capita 3402 36.20 5.63 6.92 0.57 2.50 40.74 2.58 27.87 13.23 16.21 1.52 19.53 6.18

J(I. 74!1.4!14

4.782,3\l!1 5.87~).~)nS

4$1.534 2.121.$(1(1

34. 5~)7 . ..l(~() 2.1!14.$lS 13. 671.\)3!1 11. H(;. 55t; 1J.772,244 1.2~}1.~)5t)

-H'.5~W.37S

TOt.11

5. 241•. 1!lJ 7$-".>'/(1.2$(.

15.9% 16.9% 2.6% 3.2% 0.3% 1.2% 19.0% 1.2% 13.0% 6.2% 7.6% 0.7% 9.5% 2.9%

'/(1(1'".

2H.71

Table 20- Household Out of Pocket Spending in 2005 Household Out of Pocket spending in 2005 Description 2,005 Percentages MOH cost recovery at public facilities Individual contributions/premiums to Private Insurance companies Armed F orees Contribution to Military F orees welfare group Payment to Pnv Providers (Hospital user fees) Paymentto Pnv Providers (user fees) Outpatient Dental Care Clinical laboratory Diagnostic Imaging Pharmaceutical spending at ~Jnvate Providers Reimbursement of Pharmaceutical by In~uranee Companies and Large Firms In kind contribution at Traditional Healers

Household Medical spending

1.336.000 4.864.416 900.000 3.696.000 4.862.000 275.000 836.000 550.000 7.351.580 653.420 2.122.800 27.447.216

4.9% 17.7% 3.3% 13.5% 17.7% 1.0% 3.0% 2.0% 26.8% 2.4% 7.7·/. 100%

Health Care Financing in Fiji Fiji has several different public and private financing schemes including a growing private sector. These include: • The Army employment-based social insurance schemes • The Ministry of Health financing that covers all Fijian citizen not dependent on the income of the beneficiary • A growing private insurance market • Out-of-pocket expenditures As indicated in the summary above, the NHA 2005 shows that the total National Health Expenditures in Fiji amounted to F$ 181,5 millions (USD 114 millions) in 2005 fiscal year, with per capita spending F$ 214 (USD 134). Health spending as

Fiji NHA Report 2005

a share of gross domestic product (GOP) came to 3.8% . This represented a low rate compared to other neighbors' countries. As per Figure 4, Th e NHA 2005 results show that almost 72% of the total funds (equivalent to 3% of GOP) originate from public sources, whereas 19% are apportioned private funds and the remaining 9% is contributed by international donors or other sources. Expenditure on health as a percent of total government expenditure in 2005 is 12.8% where the MOH budget over the government accounted to 9.6% . FIGURE 4· SOURCES OF HEALTH EXPENDITURES, 2005

Non profit Institutions Serving Households 2% Household funds 15%

Sources of Health Funds, 2005 Donors Funds· Grants 9%

Private Employer Funds 2%

Mnistry of Finance 72%

As per the figure 5, The Ministry of Health plays a major role in administrating the health fun ds in the country and manage almost 75% of THE, the household out of pockets accounts to 12%, Private Insurances market for 5% and Donors agents for the rema ining 6%. It is important to mention that it is the first ever estimation of the private sector at the national level in Fiji. FIGURE

5· ADMINISTRA TION OF HEAL TH EXPENDITURES, 2005 Financing Agents , 2005 Donors Age ncies 2%

Non Government

Organ ization Private Househo ld ' out o f pocket

12% Private Insurance Enterprises 5% ArmyMed i 1% 76 %

Fij i NHA Report 2005

A breakdown of total health expenditures by function indicates, almost 58% is spent on curative services out of which 35% spent on Inpatients care , 23% on outpatients including general and curative, 5% on preventive and primary and 8% on health administration and 1% on other health related functions . Drugs and Pharmaceuticals absorb a major share of 13%. It is important to mention that it is the first ever estimation of the functional classification at the national level in Fiji.

FIGURE

6· HEAL TH EXPENDITURES BY FUNCTIONS, 2005

Health Expenditures by Functions 2005 Capital Forrration of health care providers 3% Overseas Treatrrent 3% General Governrrent Adrrinislration of !-earth 8% A.Jblic Health Programs 5% Alarmaceuticals and other rredic:al non durables Ancillary Services to 13% Health Care 1% Traditionall-iealth Care Basic Outpatient fJedical and Diagnostic Services 22% AU Other Specialized Health Care 2% Outpatient Dental Care Education and training

of health personnel 2%

Research and devebprrent n health 4% npatient curative care

35%

Expenditure on health in Fiji is relatively higher than most countries in its It accounted for approximately USD 134 per Capita with a total Expenditures of USD114 million . Share of GDP is under 4% which need analysis at the National level. Next Chapter will highlight the analysis health sector.

region . Health further of the

Fiji NHA Report 2005

NHA Matrices

F I;,)

k .. , ~ j d,. \\'t .1I1

Finan cing

L1nent<>

to Providers

Malli x

•. ';: :::~; ;;.;~-

Fin_In" AVeni' 1 0 Proyk\fls

_ 1-=- '''.... ~ 1 --

~ -

lE ~ ,

";,;;;;;.;;r

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,.,~:. , ==- ~

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: :, :~:;;..;,

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;:--. ,""ot"''''_"""",,,"_ . - ...

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-=a

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~ 27

Fiji NHA Report 2005

,n t.nonl~.

to FL ~;;:,"

.'~Ir; v

Fln6llclng A~n' l

lo '~ K lIons

•

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.. £------" . ._""~"""

..--",-.. . .<... _~

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Ott ... ... o t i · _ f ...........

Fiji NHA Report 2005

Sector Analysis

The Health sector in Fiji depends highly on the public sector and the MOH is the largest in the Fijian public sector. Not only it is the generator of Health in Fiji, but it is also the largest provider of care and collective health prevention services. Fiji has several government public schemes with only two active medical schemes. These include: >- One employment-based social insurance schemes to cover the Armed Forces members and their dependants. >- One non medical compulsory social saving scheme for formal sector employees, which became a major significant player in the Fiji financial system >- The Ministry of Health financing that covers any citizen who is not covered under any other scheme and is not dependent on the income of the beneficiary >- A growing private insurance market that is largely employment based >- Out-of-pocket expenditures The main two social schemes represent the MOH and ,the Military Forces Welfare Group Medical Scheme (MFWGMS). The MFWGMS covers employees and their family members of the Fijian Armed Force. 20 ,000 of the population were covered under MFWGMS and the remaining 830 thousands are eligible for the MOH . As indicated in table 21 , it is estimated that the Ministry of Health provides coverage to more than 95% of the population . . )v ~af/aus Ta ble 21 : P ercen tage 0 fP opuI a fIon C overe db P u bl' Ie A ~~ encles Publi c Financing Agent Nurnl)e( of (.,h lTiber$ He alth (OV &J:lg" Number 6f mefnbQr~ covered Tot'" COltrrib urion (FS) AoSltb Pre:o'i/urtf co ,b.l}101onts (i=$)

Ministry of Health

Army Medical Scheme 20,000

Fiji National Provident Fund s 225000 no medICal scheme

Total Pub lic

Ag ents 24·5.000

Ce"U.,oed Budge:

Sociallnaufance

829361

no 1,336,000

20000 900,000 900,000

849.161

200,000,000

~. 136. 000

Ministry of Health The Ministry of Health is the largest sector in the Fijian national health system . It is a very important sector due to its weight in the national health system . The MOH expenditures account for the bulk of total health expenditures as well as the government health expenditures. The Ministry of Health is the generator of health fund and represents the largest provider of care and collective health prevention services. This chapter will analyze the MOH budget, sources of its funds ,

Fiji NHA Report 2005

economic and functional classification and describing the degree of equity in distributing funds.

Change in the MOH B udget Health is a true priority for the government of Fiji Islands. With the considerable population growth and needs in care and in health prevention , the changes in budget allocated to the Ministry of Health has reflected this priority specially when comparing its share with the government budget and the GOP. The total MOH share of government budget has been raised since 1996. Figure 2 above highlights this increase when comparing the ongoing evolution and indices of the MOH budget and Government and GOP respectively. Over the past 10 years , the curve of the GOP index variable has been always almost at the same level of the Government budget but almost always been below that of the Ministry of Health budge\. However the examination of the changes in the Ministry of Health's budget per capita and in constant value shows that, during the last ten years , the Government has made great efforts in this sector. These efforts have primarily been a benefit to the curative care and administration at the expenses of the rest of the operating budget and the preventive care. This migrates and weakens the benefits of increases in investing on public programs and preventives.

Since 1995, the actual budget allocated to MOH has been increasing with a highest increase occurring in the year 2000. A significant increase in government expenditures occurred with the establishment of an affirmative action program AAP for indigene Fijian and the government back pay of the salary raise but this increase did not affect the share of MOH over the Government budge\. In order to allow for a more meaningful comparison of the MOH expenditures over time it was necessary to compare MOH share over the Government budget indicted in Figure 7 below. FIGURE 7- ACTUAL ANNUAL INCREASE IN GOVERNMENT HEALTH EXPENDITURES

MOH Budget I Government

12.00% , . - - - - - - - - -- - - - - - - - - - - - ,

'''''" 800"t---____("" ~......... 600% 4 .00% 200% 000%

_- ---_..--..._--, ..... 2001 2002 2003 2004

"'996

'997

'998

"999

2000

2005

Fiji NHA Report 2005

Sources of Funding for MOH spending Table 22 indicates that the main source of the MOH funds is easily the Government budget, which amounts to almost 95% of Total Ministry of Health expenditures.

Table 22: Sources of health funds, 2005

Sources of MOH Funds Total (joHnulleut Bu~et T(ltal DOll(1l >( Total HOIL"ehoJd out (If pocket TOTAL MOH 200~

MOH 2006

130,445,500 5,099,300 1,336,000 136,88O,8QO

95% 4% 1%

100%

The share of other ministries for health is still unclear and undefined as no charges are accounted at the MOH or at the other Ministries (user of services ) level. For example the Army medical scheme and the NPF used the MOH facilities to treat its patients at no charge , As indicated in Figure 8 below, other sources of funding (households and insurance companies) provide more or less than 1% of the MOH Spending . Donors contribute to some 4% of Total Ministry of Health expenditures and mainly on Public Health Programs.

FIGURE 8- SOURCES OF THE MOH FUNDS, 2005

Sources of MOH Funds 2005

Total Household out of pocket 1% Total Donors

To tal Government Budge t 95%

--~~~--~~----------------------------------------

Fiji NHA Report 2005

MOH Functions by Subdivision: The Fiji MOH is facing a number of health challenges. The Health sector has been transformed in 2003 from a highly centralized system to one that is decentralized within the MOH . This transition has been taking place at a slower pace than originally con ceived and will continue to need technical support and system development to put it into place. The MOH budget has been segregated by Division and subdivision. This segregation was not compatible with the NHA functional classification . In 2005, The MOH budget has been allocated to four main fun ctional subdivisions with a highest share favor the Central Eastern Health services. A breakdown of MOH spending by division is indicated in Tables 23 below.

E x p~nditur~ $

Table 23: breakdown of MOH funds bv Divisions, 2005 by Div isions HQ Administration and Reserves 40,660,400 Central I Eastern Health Services 49,568 ,380 Western Health Services 28 ,927,422 Northern Health Services 17,724,598 136.880.800

29.7% 36.2% 21.1% 12.9%

100.0%

FIGURE

9 - MOH BREAKDOWN BY DIVISIONS,

2005

MOH Expenditures by Divisions Northern Health SeNices 13% HQ

Administration and Reserves 30%

Western Health

Services 21%

Central / Eastern Health Services 36%

32 Fiji NHA Report 2005

MOH Functions The NHA study resu lt shows the Fiji first ever breakdown of MOH health expenditures by function following the International Classification of Health Accounts (ICHA). Of the entire MOH budget, 42% is used for local curative inpatient care versus 28% for the basic care network. It is true that this percentage is fairly high , but it is mostly spent on Salary and Wages including Doctors and nurses. The Administration of the Central office of the MOH absorbs 10% of the budget. However it should be stated that , in the context of health programs and monitoring, health prevention activities continue to be substantial and not exceeding 4%. Pharmaceutical absorbs a good share of 11 %.

Table 24: Uses of MOH funds, 2005

NHAltems Inpatient curative care Basic Outp atient Medical and Diagnostic Services Pharmaceuticals and other mechcal non durables Prevention and public health services General Government Administration of Health Capital F ormation on H ealth Research and Development

Amounts Allocated 57 ,882.2 11 38.251.857 15.164.000 4 .64 9.608 13.772.244 4.670,000 2.490.880 136,880,800

Share 42.3% 27.9% 11 .1% 3.4% '10.1% 3.4% 1.8% 100%

FIGURE General Gowmment Mministration of Health

10 - MOH BREAKDOWN BY FUNCTIONS, 2005 MOH Function 2005

10% Prewntion and public heal th services 3%

Capital Formation on Health 3%

Research and Development 2%

Inpati ent cu rative ca re 43%

Pharmaceuticals and other medical nOil durables 11 % Basic Outpatient Med ica l and Diagnostic Services 28%

Fiji NHA Report 2005

MOH Expenditures by Providers The N HA 2005 results show that the MOH Providers are the major recipients of national health funds . Table 25 shows the breakdown of the MOH expenditures among the public providers. Table 25: Breakdown of the MOH funds by providers, 2005

NHA Items Public General Hospitals Public District Hospitals Health Centers Provision of Medical and Diagnostic Laboratories Pharmaceutical Adminsitration Provision & Administration of Public Health Programs Institutions providing HRF

Amounts Allocated 27,132,718 30,749,494 33,688,582 808,875 15,164,000 13,772,244 8.404,008 7,160,880

Share 19.8% 22.5% 24.6% 0.6% 11 .1% 10.1% 6.1% 5.2% 100.0%

136,880,800

This breakdown indicates that the major providers of the MOH were the Health Centers with almost 25% of total funds . General Hospitals accounts to 20% and district hospitals to 22 .5%. Provision of Drugs by the MOH absorbs 11 % and salary and wages of the Central accounts to 10% of the budget not including thE: salary and wages of Hospital and Health Centers' staff.

Fiji National Provident Funds The Fiji National Provident Fund is a compulsory social saving scheme for formal sector employees. It has become a major significant player in the Fiji financial system . The fund has a well developed infrastructure, with a head office in Suva and two branches in Lautoka and Labasa and is interested in developing a medical benefits scheme for its member. The Fiji National Provident Fund has a total of 230000 active members (including a small number of voluntary members) out of a total of 335,890 in labor force population as named by the 2004-2005 Employment Unemployment survey conducted by the Fiji Statistic Department. The total revenue of the Fiji National Provident Fund from contributions amounted to almost F$200 million in 2005. Although a medical insurance scheme is not yet in place, it was important to mention this important sector in our National Health Report.

Fiji N HA Report 2005

The Military Forces Welfare Group Medical Scheme The Military Forces Welfare Group Medical Scheme (MFWGMS) is the only health insurance scheme in Fiji that has some feature of social health insurance. The scheme covers about 20 000 military forces personnel members and their dependants. The premium is F$17.00 per month, and F$34.00 for members older than 65 years. The scheme covers health expenditure at the military hospital (which is owned and run by the scheme itself) and treatment overseas (New Zealand and Australia). In 2005, F$200,000 out of the total premium revenue of F$900,000 was spent on treatment overseas. Hospitalization costs at referral public hospitals are covered by the government budget, except for private admission for F$4 per ward day or a private room of F$10 per day at the Colonial War Memorial Hospital in Suva. The NHA study was not able to get data regarding this sector for many reason (refer to limitation Chapter). Therefore we assume the remaining funds, other than the F$200,000 spent on overseas treatments, is spent in the Military Hospital.

Private Providers According to the Private Providers survey, the estimated total income of this sector in 2005 was over F$24 million and was higher than data collected in previous reports. 31 % comes from the private Insurance reimbursement and 35% as a user fees. This number is valid regardless of whether they live in an urban or rural area. It was difficult to study the degree of severity of illness in this round of NHA. More data needed in the next round of NHA to define the percentage of women versus men as well as on the reproductive health issue. I' '." '''''~":,,,:I!r H:::;' I " , ,". iii PrlvatePrQv tI.~II.I.,com. ' , 1,,,, 0"""",

Table 26 : B rea kdown 0 f th e private proVl'ders Income, 2005

,)..'

Year 2006 7,645,000 715,000 8,613,000 1,100,000 1,760,000 220,000 2,365,000

Percentage 31.4% 2.9% 35.3% 4.5% 7.2% 0.9% 9.7% 0.0%

Private Insurance re·imbursment Employer re·imbursement Direct User fees Community Funds Employer Contributions/Premiums Group contributions/premiums Individual contributions/premiums Loans from Commercial banks Government assistance Donors assistance NGOs assistance

1,100,000 440,000

4.5% 1.8%

Others specify "II"

407,000

1.7% 100°'"

TOTAL ' ,;'}':

24,3611,000

------~~--~~---------------------------------------- 35

Fiji NHA Report 2005

According to this survey total household spending at private providers accounted to almost F$11 million and detailed in table 19 below: Table 27: Breakdown of the HH spending at the private providers, 2005

Household Medical spending at Private Providers Paymentto Priv Providers (user fees) Individual contributions/premiums 8,613,000 2,365,000

10.978.000

Table 28 indicates the total provision of ambulatory care visits to private providers and amounted to F$4.8 million in 2005 with 20% of total spending on this sector. Inpatient curative comes to 17% and pharmaceutical charges of 3 million which accounts to 13% of the total. The income and expenditures distribution help the NHA team to estimate the Total and distribution of the household spending on health as well as estimating the private insurance market. Table 28: Breakdown offunctions at the pri;; ... ~& providers, 2005 Private Providers Functions Inp~tient -cur~tive c~re

Year 2005 4,191,000

Percentage 17.2"'/. 20,0% 1.1% 1.8<>/.

B~$ic Outp~ti.nt Medic~1 ~nd Di~gno$tic OU1'p~tient Dent~1

Services

4,862,000 275,000

~re

All Other Speci..,lized He.;..th Clinic~ll"borator'V

C~re

440,000 836,000 550,000

3.4°/. 2.3%

Di;ljgnostic Imaging P.ltienl' Tr.:llnsport ~nd

Emergency Rescue

165,000 55,000 3,168,000 2,365,000 55,000 110,000 165,000 55,000 33,000 825,000 165,000 231,000 55,000

0.7(1'/.00.2°/ .... 13.0°;(. 9.7·/.,.

All Other Miscellaneous ancill.)ry services

Pharm.lc eU'tic .)Is and other medic.)1 non dur abies

r..ledic.:.1

appliances and other medicc?l1 dur.Jibles He~lth

Reproductive Health (roJlCH. FP and counseling) He.;\lth Prohlotion & S.ohool Servic:&s

O.2"'l<)0.5% 0.7<)-/<)0.2'% 0.10)/<)3.4% 0,7<)-/<)0.9"'l<)0.2%

Prevention of cOhlhlunic.;\ble dise~s.s Prevention of non-C:Ohlhlunic.;\ble dise~ses

Environment.;\1 He~lth. S~nit.;\tion & food s~fetv He.olth Adhlinistr~tion & He.;\lth Insur.once C~pit~1 Form.."tion of he.."lth c~re providers Edu(:~t'ion .;\nd tr.."ining of heJilth personnel

ReseJirch .;\nd develophle-nt in heJilth

Income from exerdse

5,764,000

23,7% 100<)-/<)-

24,365.000

Fiji NHA Report 2005

Household Expenditures on health: A National Household Income and Expenditure survey has been conducted by the Statistic Department. The level of desegregation of health and health spending was limited in this survey. The only information on health extract from this survey on health is the percentage of the Fijian on medical expenditures which comes to 3% distributed as per table 29. Table 29: Spending on health as percentaJle of Income Expenditures Items as % of Income

iEi"lnil~resltems" Medical Expenses

' '.:''., ". .'~iJfaris:' 3.10%

'''lnfJol.fijia"s'' . 3.50%

ethel":" . 3%

I": ······1ot~1 . ..

,,,.

." ..':

Source. Table 66. 2002-2003 Household Income and ExpendIture SUlve'/, Flil Islands Bureau of statistics

The current Household expenditures are estimated based on the above mentioned survey and the different surveys conducted by the NHA team. Household out-of-pocket expenditures account for nearly 15% of total health expenditures in Fiji. A more systematic way to estimate household expenditures on health has been used taken into account the private providers survey, the insurance survey and the traditional healers survey conducted by the NHA team as well as the 2004-2005 Employment unemployment survey and the HIES conducted by the Statistic Department. A variety of data sources was used to estimate total household expenditures on health and this includes: • Use data from the providers' survey to estimate OOP functional expenditures for outpatient and inpatient care as well as estimate average premium paid at the private insurance companies. Use the Traditional healer survey to get OOP costs on traditional healers. Data from the Household Income and Expenditure survey (HIES) regarding percentage of medical expenditures out of the household total income. Use the Employment Unemployment survey to estimate total household income. Use WHO reports for 2005 3 spending on public and Private spending

• •

The information based on household sources of funds and uses of expenditures was carefully examined to match all household spending during the considered year. Having done this, it was possible by using the best judgement to estimate the approximate volume of funding received by providers in the form of user fees paid to Private Providers, pharmacists and to insurance comapnies, for which data were not available, plus the market value of expenditures funded from household to traditional healers in both cash and in kind. This estimate was not Beaver Carol, Review of pharmaceutical financing in 2005 Fresbout Consulting WHO, Review of financing and Expenditures on Phannaceuticals

Fiji NHA Report 2005

enough to get total household spending . Additional survey has been carried out on pharmaceuticals to re evaluate the total consumption of drugs at the private and public providers. Table 30 ' Household Distribution in 2005 Descripti on MOH cost recovery at public facilities IndIVidual contributions/premiums to Private Insurance companies Armed Force s Contribution to Military Forces welfare group

Payment to Pr" Providers (Hospital user fees) Payment to Priv Providers (user fees)

Outpatient Dental Care Clinical laboratory Diagnostic Imaging

Pharmaceutical spending at Pri'v'ate ProViders Reimbursement of Pharmaceutical by Insurance Companies and Large Firms In kind contnbution at Traditional Healers Hou sehold Medical sp ending

2.005 Percentages 4.9*/. 1.336.000 4.864.41 6 17.7% 900.000 3.3*/. 13.S·A 3.696.000 17.7+/. 4.862.000 1.0·/. 275.000 3.0·/. 836.000 2.0*/. 550.000 7.351.580 26.8% 2.4+/. 653.420 2.122.800 1.7·/. 27.447 .216 100%

Total household expenditure on health in 2005 accounted to F$25 million or 15% of total health expenditure in Fiji for that year. Almost 90% of household expenditure was spent on private providers and 10% on MOH facilities and Armed Forces contribution .

FIGURE 11 - OUT OF POCKET EXPENOITURES ON HEAL TH, 2005 ReirrtJurserrent of Fharrreceutical by hsurance Coflllanies and large FirrTS 2% Alarrraceutical spending at Private A"oviders 27%

- - - - - - - - ---I

OOP Expenditures on Health MJH cost recovery al public f ac i~ies ndividual contributions/prerriurTS to Private Insurance corrpanies 18% Arrred Forces Contribution to Mlitary Forces w eltare group

n kind contribution at Traditional Healers

3% IAagnostic hBging 2% Clinical laboratory

3% Outpatient Denial Care

Payrrent to Priv Payrrent to A'iv A'oviders (l-bspital Providers (user fees) user fees)

18%

13%

38 Fiji NHA Report 2005

Private Insurance Market: The Insurance in Fiji has become essential, especially for the employees working in the private sector as well as to the public, together with their families, who support themselves, Compared to other countries in the region, Fiji has a fairly well developed private insurance sector, As per the Employers surveys result, the list of most frequently used insurance companies by employers are: Fiji Care, QBE, Aon Risk, Health Plus and Colonial. Insurance companies refuse, to some extent, to provide data to the NHA team and we have to extrapolate data from other surveys, There were about 330,699 employees in the formal sector in 2005, with about 24 000 public servants, The Employers survey result estimated that almost all big firms used the private insurance companies to cover their employees and dependants, Table 31 of the EUS survey shows that almost one third of the population was in labor force and more than 40% of this segment earns more than F$10,000 per year, Assuming that most of this segment, benefits from an insurance scheme, it is estimated that 135,500 employees or more than 16% of the population has a private insurance coverage,

Ta ble 3 1: Income ranges of in labor orce In 2005 Income Range 0;:$) Oto 2,999 3,000 to 4,999 ,. ....

.:~

FiJlln 86,883 26,976 20,203 20,107 20,665 1,513

Person and Income by Ethnicity Indo..f'ijian others ~dtumln 39,815 32,108 22,948 20,024 21}32 1,345 4,124 1,825 1,020 1,393 3,204 790 1,478 250 373 686 1,062 175 .

All 132,300

% 40.0% 18.5% 88.5% 12.8".4 14.1%

5,ClOOto6,999 7,000 td 9,999

61159 193,459 4:1,210

10,OOO.,to4!),0Q0: ,r:

mOrt U1an40,odGi

'rotll:'·

. ·:t:·· .•

: :. ': i: : 178.U7.· :1'

137,972

12,356

: .~ 4.0241

46.663 ...:. .88,873 33Q~699

., 26.9"'" 100.0"1.

Source. 2004 2005 EUS, FJj! 1618006 Bureau or Stati.stic.s

There is no evidence that private insurance companies transfer the burden of medical cost cases to the Ministry of Health even though the latter does not have the ability to verify whether patients have insurance or not.

Donors: Out of the Total Foreign aid, AUSAID was the biggest donor comprising more than half of the total aid given to Fiji. On average, Japan and New Zealand provided 16% and 12% respectively, whilst donors such as the World Health Organization, UNICEF and UNDP and others were responsible for the remaining funding. ~ ~ ~

Provision of adequate primary and preventative health services Provision of efficient curative health care services Maintain appropriate level of human resources in health

Fiji NHA Report 2005

~ ~

Generate funds for the health system through the introduction of user pay system Build management of culture that promotes and supports continuous quality improvement in the health sector

Aus Aid Assistance: Total Multilateral and bilateral programs on Health accounted to 3.5 F$ million in the year 2000 4 • Main agencies were AusAid, JICA and Korea. In year 2005 a Health sector improvement program funded by AusAid has granted to Fiji an amount of 5.9 million F$ (4.5 million Australian Dollars). This fund is part of a long-term capacity building initiative to improve the quality of health services in Fiji MOH (4 million A$) and an amount of 500,000 A$ for the School of Medicine. It is supporting the Ministry of Health, via a program approach, across the priority areas of health information management, rural health, clinical services, and management training and development. In addition, the program has supported an expanded program of immunization against measles, the scaling up of health promotion and communication campaigns, leading to a documented increase in the public focus on food and water safety. Aus Aid Grant has been distributed as follow:

Ministry of Health: );> Health Service Development: );> Health Information Management: );> Training & Strengthening Health Worker: Schoal af Medicine: Assistance to school of Medicine

F$ 3.5 million F$ 1,5 million F$ 0.2 million

F$ 649,000

Japan Grants: JICA, the Japanese Government Agency has been present in Fiji for many years. Among the support recently provided are support for the proviSion of a senior volunteer for the EPI program (plus equipment) and a Research specialist with an estimated cost F$ 2.9 million. There is also grass root program managed by the embassy providing small grants and among them some with health impact, like the rehabilitation of a dispensary.

Country Concept Paper and National Indicative Programme 2003-2007, European Commission

Fiji NHA Report 2005

Table 32: JICA Health Sector

in 2005

JICA Health Sector Expenditure JFY 2005

Training Dispatch of Experts Dispatch of Research Tea JOCV Volunteers Provision of E<tuipment Other Volunteers Other

Trying to avoid double counting but also trying to avoid leaving out any fund spent in the health sector in 2005, Table 32 was assembled with the information from the Japanese Embassy, opting for the most reliable ones when there were information from two or more sources for the same donor.

New Zealand Aids New Zealand AID has been in Fiji for some years and has a defined strategic program for development of Fiji including the year 2005. NZAID acknowledges AusAID commitments to the health sector and has defined its role as complementary and limited to supporting regional programs. A number of supports have been provided. NZAID has supported regional initiatives (PIAF) and the medical school in Fiji, UNICEF regional programs and many other regional initiatives that should generate direct and indirect benefits for Fiji. Besides that, NZAID has kept a Medical Treatment Scheme which provides medical evacuation and treatment in New Zealand in certain circumstances, and a Small Project Scheme which provides funds for specific areas, including primary health, upon request. In 2005 this program spent NZ$ 115,889 (185,000 F$) in health related activities. According to the information provided by the MOH, the external funds received from New Zealand, this part of the NZAID funding did not go through the MOH. There was no estimation available on other than the costs of the Medical Treatment Scheme in 2005.

Fiji NHA Report 2005

Global Funds The Global Fund to fight AIDS and Tuberculosis provides support to Fiji for the two component diseases. The funds are administered by the MOH, SPC, some donors and NGOs, the principal recipient of the Global Fund grants, for procurement of drugs and other medical goods. It was requested by the NHA team from SPC the exact amounts of goods purchased on behalf of Fiji. The information was not received until the end of the preparation of this report. According to the information provided by the SPC, the external funds received from Global funds amounted to US$ 115,069 (F$184,595). This figure need to be revised as it is different of the figure provided by the Ministry of Health.

WHO Funds The World Health Organization funds a number of programs on an on-going basis. These include: • Human resource development • Health System Development • Non-communicable diseases program and support for TB and mental health training. • Child and Adolescent Health - support for nutrition programs and dietetics training • Health sector reform • Reproductive health • STIIHIVIAIDS Other WHO programs include Environmental health and communicable disease control initiatives. Total spending on health in Fiji for the year 2006 amounted to F$ 460,000.

Other Donors Other donors provided some form of assistance (e.g. equipment, training, project salaries, etc) to MOH. These donors include UNICEF, World Heart Foundation, Global Trust Fund (HIV/AIDS), University of Melbourne (for Pneumo Project).

Non Government Organizations NGOs provide a bulk of welfare assistance in Fiji, generally through non-cash donations, which is a very cost-effective manner. Some NGOs provide primary health care and first aid kits to villages organizations such as Red Cross and Reproductive Health Centers and a good number is funded by the Ministry of Health. Those NGOs received grants from the MOH and are counted under the MOH budget, namely: Ra Catholic Hospital, Responsible Parenthood council, St John Ambulance Brigade, Fiji Red Cross, Channel Home of Compassion, FatherLaw Home, Reproductive and Family Health Association, Family Support Association Group and National Food and Nutrition Committee. Total 2005 transfer to NGOs are detailed in Table 33 and accounted to F$ 502,900.

Fiji NHA Report 2005

Table 33 - 2005 summary NGOs throuah MOH SEC - 6 :OVualing Gt.t.w.A:u:a Tt' J lutU' C,anl. RunJ lDe.t Aulhorttlu Gr.nt to Nation.! Food & Nubition Comminu

aoJl<)OOO

248..000.00

T: Kl Seg6

QIW61 5Jl<)O.00 2!SJl<)O,OO 3Jl<)OOO 40,400.00

![JNFP.... Gl'artt \0 Ra Catholic HoI pita! Grant to

Resp Parenthood Council

.subsIdy to St,Johrl. Ambu~

Gtarlt to Fiji Red erau Channel Home of Compassion Grant to iafue:r Law Home Grant to R~prod uctlw and FIlMUy Health AssQCtahon

26,500.00 2O'/XXJ.OO 30/)00.00 15.000.00

,t ."lSu.'

Gra~ t~F~ ~~,~ ppOrt AnocliltiOO (;roup

10..000.00

\D:o\i\.

174;oJ

Ioa!.NGQ. ,

Other Donors and NGOs contributed to different small projects focusing on health related fun ctions like provision of safe drinking water, which has considerable impact on health , and nevertheless cannot be properly measured and incorporated into the health sector account. These numerous projects accounted to 3.5 million in 2005 and are managed by the NGOs themselves and therefore the MOH does not have a complete figure of the resources involved. Table 34 indicates the NGOs Health expenditures distribution in 2005.

Table 34 - 2005 summary NGOs expenditures distribution NGO s Expenditure s distribution in 2005 Health Centers Repr oducti v e Hea lth (Maternal and Child health . FP ,nd counseling) Health Promotion & Blood Safety Prog ram Pre vention of communicabl e dj ~ e a~ e s

17.9% 53.9% 5.9% 9.9% 10.7 ~%

Pre vention of non-communicable d i ~ease $ Education and training of health personnel

1.7(}A

Traditional Healers The informal private health sector consists of traditional healers and Traditional Birth Attendants mainly funded by out of pocket expenditure through in kind or cash. There are no set of fees for services in this sector. Traditional healers

---=F~iji7N~H~A~R ~e -po~rt~2~ O~05 ~-------------------------------------------------

make up an integral part of the informal health care in the pacific islands. It is estimated that more than 500 hundred traditional healers existed in Fiji and absorb a big part of the outpatient consultation at the rural level as well as the urban. The 2005 NHA estimates a total of F$ 2.1 million spend on traditional healers through in kind and Cash. Traditional healers' expenditures are estimated based on data collected from surveys conducted in Fiji and using some assumptions. The survey data was preservative in estimated both numbers of admissions and amount paid by Household. NHA team uses a special methodology for estimating Out-Of-Pocket Expenditures at this sector considering the following assumptions:

> >

We assume that the number of traditional healers in Fiji is correct We use the data on number of traditional healers per village surveyed and estimate total number of traditional healers in other villages. We use data on number of visits per Traditional healer per year from the survey. We estimate the traditional healers' fees and use an average of Traditional healer cost per visit. We use data from step 2, 3 and 4 to estimate total OOP expenditures on Traditional practices at the national level. Table 35 - Summary Traditional Healers Survey results

> > >

Fiji National Health Account 2005 Traditional Healer Survey - 2005

Sll,.,~y~d:

• Illst 4 w@~.ts

p~op/~ t"~lIt~d &ti",at~d

100 1220 500 3 3 14,640 73,200

/IIII",b",. of Traditional Hl>al"rs

/IIIImb~r of villagM .

Av",.ag" /IIIImb"r of TH p~r Villllg~ av~rag"

H"n p"r w@~.t p"" traditionalll"lI/~r Total Visits p~" y"ar ('100 Til) Totlll visits p"r y~a,. (500 Til) tt>olll ,.lIrlll HH E'xpPlldirllrM Oil TH AnnlJa! rlrlEx.pendltlJres on Trl SeNlc ,Average Cost per visit (top 5 Iffn) Per Capita spending on Tradltlona! fie,

$2, ~22,I'OO $29.00 $2.50

44 Fiji NHA Report 2005

Cross Country Comparative Analysis As indicated in Table 36 total expenditure on health in Fiji is almost 4% of the GOP. The proportion of government share is high and come up to 3% of GOP and private sources for around 1% of GOP. As we can observe, Fiji lies in the middle of the spectrum of East Asia and Pacific Region (EAP) countries in terms of GOP and in the highest of the spectrum in term of GOP per capita. However, in terms of expenditure on health care, Fiji Public expenditure as a percentage of total health spending is one of the highest amongst countries in the region.

Table 36 - Summary Traditional Healers Survey results

'i t 1/ . ! '

;tastNHA yeal' 2005

"./

.. ..

:E!l!r C/;ipita GDl' (USS) 3,~13

H~aIth

CoUIUtY orRel!iDn Fiji KiIibati

Expenditure Health E>.~enditm·es As Percentage GDP .. /' ." (pel' capita /' Total Public Private USS) $154 14 ~8 9~

3.80·. 2. ~O~O

1.90·0

0.90·. NA WA 2.40°0

8'11

NA N·A 3,~0·.

!\I"rsb.,U IsL'mds Samoa

1.860 1001-1003 L6S6

3,11·'. ~.60o!o

Solomon Isklllds Tonga \·..nu" .....ht

960 2001-2002 100~

54 93 tiD ~-I

5.60 00 0

....80··0

0.80·, 3.40°. 1.60 6 •

1.4'1 1.6-10 1,0':'0 9"0 14,930

6.20°0 -'.10·-0

1.80°0 ~>~O()o

MENA F,,' East OECD Source:

4.80·. 3_50~'o

1.60°'0

2.20°0 1,00·'. 3.90·0

18 1.-1 '0

150·,0 6.00·0

9.90~'o

World Health Organization indicators http://wwwwho.int World Development Indicators. http://www.worldbank.org Samoa National Health Accounts 2002-2003 findings Tonga National Health Accounts 2001-2002 findings Vanuatu National Health Accounts 2005 findings Fiji National Health Accounts 2005 findings

Fiji NHA Report 2005

Key Health System Performance: The health system has been developing even with the lack of expertise and resources, initially driven by the needs of the population. During the past decade, the health system continued to develop and expand in an unregulated unplanned manner. Currently, the health system performance seems to be suboptimal, as evident by the large budget allocation for health (10% of the government budget) with unmatched improvements in health outcomes at population level. In fact, three main policy issues are of great concern for the Fiji health system:

> > >

Equity Sustainabi/ity Monitoring quality.

Equity: At the national level, the current health system is largely developed by the public sector. This development is driving the health sector towards favoring urban areas at the expense of rural areas in peripheral islands, and the poorer population groups. Equity in Health is described according to the following: Discrepancies in physical access to health care

The physical resources for health are apparently not readily available in Fiji, with low High Medical Technology and low standard. There is a total of 1,768 hospital beds available distributed over 16 sub divisional Hospitals, 3 referral hospitals and 3 specialized hospitals; around 101 Government subsidized Nursing stations and 76 health centers and dispensaries, around 373 private clinics, 56 dentists and some 87 private pharmacists. However, the coverage remains unequal, favoring more large cities like Suva and Lautoka, despite the efforts over the past few years of the government to fill the gaps especially in terms of primary health care. On the other hand, imbalances in terms of human resources for health are also observed. There are 375 medical doctors, 1,648 Nurses, and a shortage of Specialists and other paramedical staff. The human resources in health are also unevenly distributed, favoring the large cities at the expense of the peripheral areas of the country.

Fiji NHA Report 2005

Discrepan cies in financial access/ affordability:

Health care cost in the country is inflated , and mainly driven by Government support of its own facilities and low private market that provides around 20% of the health services. It is estimated that less than 10% of the Fiji population benefits from any type of Health Insurance (private or group) while the remaining 90% of the population has no insurance coverage whatsoever and subsequently rely on the MOH as an insurer of last resort. Taking into consideration that, the public health care system , being funded only from the government budget, has been chronically under funded and the approved government budget for health care is always less than the requested budget, and taking into account that the ambulatory care, medications and dental care in the private sector is mostly paid out-of pocket by the population. Thus the poorer population groups will not be able to have prompt and timely access to health care except at the public facilities. Ta bl e 38 - D'IS t rI'bUt'Ion 0 fP ubl'IC Coverage . In F'" IJ I Ministry of AI my Medical

Public Financing Agent Numb .r of Me mbers He olJth c. ov.r:tge

He-alth

Scheme

FIJi National Provident Funds

Total Publi c .Agents

Centl~hIid &dget

Numb . r of me mbe rs c.ove re d Tot" / contrlct/tien (FS) He.tltb Premium eo p.2Yments (F$)

20000 225000 Soc;"lIMWattCe no medical scheme 829361 20000 771538 193200000

245,000

849.36'1 2,1.D7,538

1,336,00(}

Table 39- Distribution of Private Coverage In FIJI

...

771.538

Sustainability Over the past decade, around 2.6% to 2.8% of the GOP equivalent to around 100 to 140 million Fiji Dollars goes to the Ministry of Health every year while the total health expenditure is close to 182 million F$, that is around 4% of the GOP. This means that there is a deficit in the health budget that is somehow compensated for by the population . Three main observations seem to affect negatively the financial sustainability of the health system : The health system is providing a large offer that is not paralleled by a matching demand. For example, the average annual occupancy rate of the 1,768 hospital . beds available does not exceed 40%s A significant number of health centers In the public and NGOs sectors are utilized for ambulatory care. An increasing number of nurses (1648 or 19.8 per 1000 population) and a good number of phYSICians , MO H Annual Report 2005 --~~~~~---------------------------------47 Fiji NH A Report 2005

(375 or 4.5 per 1000 population) is in need to make up for the reduced income generated from the medical practice. The number of beds is larger than in any other pacific islands (more than 26 beds per 1000 population). Most of the Ministry of Health budget is spent on the curative aspects of health care at the expense of the preventive aspects of health care. In fact, less than 6% of the MOH budget goes to public health programs, while 65% of the budget is spent on hospital care (mainly divisional and sub divisional hospitals), and less than 11% on the drugs and medication program . ~ High out of pocket expenditures It is estimated that around 15% of the total expenditures on health come from private sources namely out-of-pocket and private health insurances while the rest is paid by the public funds (MOH, Military Forces Welfare Group Medical Scheme). Recently there is evidence that some families are getting impoverished by emerging health costs.

Quality Quality issues in the health sector have been relatively neglected , mainly because of the weak regulatory and auditing capacity of the MOH, and the absence of data in terms of quality perception among the beneficiaries. The government initiated recent efforts towards establishing a clinical governance framework which was developed in 2004 and it is the basis for all the different quality projects and initiatives that have occurred in isolation over the years. These include infection control, quality improvement, customer service and risk management. This development procedure has been shy, mainly restricted to a few areas like the poor compliance of the health professionals coupled with the weak reinforcing capacity of the MOH. On the other hand , in the absence of a gate-keeping system, a social insurance scheme or a clear referral system limiting the abuse of the tertiary care like overs~as treatment and ensuring the continuity of the health care respectively, there IS no doubt quality of care will be affected .

Fiji NHA Report 2005

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Publications

Date d'adoption 31 décembre 2007

Source Organisation mondiale de la santé