Health sector reform and the Health Management Reform Project in Fiji
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1 PNG Med J 2006 Sep-Dec;49(3-4): Health sector reform and the Health Management Reform Project in Fiji LUKE ROKOVADA 1 Ministry of Health, Suva, Fiji Introduction The Fiji Health Management Reform Project is aimed at improving the management of the health system, which should have a direct flow-on in improving service delivery to the community. The Minister of Health initiated the Fiji Health Management Reform Project in 1997 as a strategy to overcome several of the management problems the Ministry had been facing over many years. The project was designed in 1998 through extensive consultation among officers of the Ministry of Health, National Planning Office, Public Service Commission (PSC), Ministry of Finance and AusAID. The reform project is a response to community dissatisfaction with the state of Fiji s health services, expressed through public complaints and outcries, parliamentary committee reviews, Auditor-General reports, and various reviews of Fiji s health system in the late 1970s and the 1980s. Towards the end of the 1980s and early 1990s the Fiji Government, following the events of 1987, embarked on a program of reforms for the public sector. There were various reform programs including trade and financial services reforms, reform of the labour market and so on. The reform in the health system tied in with the government s reform agenda at that time. The Fiji Health Management Reform Project The Fiji Health Management Reform Project is based on two fairly simple and wellunderstood principles: that health services, health care and ultimately health outcomes can be improved with a more effective management of resources, both human and physical; and that decision-making should occur as close to the point of implementation of that decision as is possible. The Fiji Health Management Reform Project was sanctioned as a partnership between the Fiji and Australian governments and commenced in February The project has been driven by senior managers of the Ministry of Health as well as our partners in central agencies in government. The project has been jointly funded by the governments of Fiji and Australia. It started in 1999 with a planned life of five years. The overall objective of the reform project was to improve health service delivery in Fiji through decentralization and management capacity building within the health sector. The end result will be an improved customer-focused service delivery at primary, secondary and tertiary levels. What will be the results of the reforms? We will have decentralized health management to increase human resource and financial delegations. Primary health care will be enhanced, increasing the use of primary facilities, while the main office which we now call the Central Office, previously referred to as head office, has been restructured to focus on: setting the strategic direction, developing policy, coordination, standards, resource allocation, and monetary performance. Hospitals and community health services will become integrated. One of the key components of the project 1 Permanent Secretary, Ministry of Health, Dinem House, 88 Amy Street, Suva, Fiji 87
2 is strengthening the structure of the Ministry of Health through the development of an appropriate decentralized organization restructure, recognized by a devolved management authority. The project focuses on role definition, capacity of senior management, policy development, monitoring, coordinating and promoting appropriate research and equitably allocating resources for the national health services. Where allocation of resources is concerned, we do not have a national health account system in Fiji but are developing a resource allocation formula. I hope that we can all follow Samoa s example where government allocates 11.7% of the government budget to health, or 6.1% of the GDP (gross domestic product) (1). In Fiji, the government allocated 8% of its budget to health over the previous 10 years and in 2004 increased the amount to 9%. It was to remain at 9% from this point on, which is about 3% of GDP. This is minimal compared to the 18% of the government s budget allocated to education, or 5% of GDP. Health should be receiving close to the same amount as education, and over the previous five years education received 16-17% and continues to increase. The health allocation works out at about FJD per capita allocation for health care, or $US70.00 per capita. In terms of health service management training, the objective is to strengthen health service management capacity at all levels within a decentralized health system through the promotion of appropriate health service management training programs. We aim to develop new health information systems and enhance existing systems in order to improve the Ministry of Health s capacity to plan and manage its resources. The key is to empower health service managers at all levels by addressing critical issues including legislation, staffing, finance, supply and maintenance. Decentralization The objective of component one of the reform project is to strengthen the structure of the Ministry of Health through the development of an appropriate decentralized organization structure recognized by a devolved management authority. The restructuring involves three main divisions. There are seven divisions altogether: Public Health, Health Services Development, Nursing and Health System Standards, and Corporate Services, which are Central Office divisions, and the geographical divisional structure of three divisions, namely Western Division, Northern Division and Central Eastern Division. Three operational divisions have been established: Northern Health Service, based in Labbasa; Western Health Service in Lautoka; and Central Eastern Health Service in Suva. Each division is managed by a director. All seven divisions are headed by directors who are all on the same level and salary grade so that they may be interchangeable. All seven are capable of taking over from the Permanent Secretary at any point in time. Also, all seven positions except for the Director of Public Health, who is required to be a medically registered officer, are open to non-medically trained professionals. This ensures that the best person gets the job, be they from within the health service or outside the health service. Ideally, I feel the positions should come from within the health service, but this is only because I have been working in the health system for quite some time and know we have trained people within the health service. There is nothing to stop the system from appointing the best person from outside the system. Previously, most management positions in the Ministry of Health were held by doctors, or by registrable medical officers. We have had to change that: it is the best person for the job but it does not exclude doctors from being appointed to the positions either. I am happy to say that that is already starting to happen. Of the seven director positions, we still have four doctors but there are three non-doctors. In terms of gender, we have two, with a likelihood of three, women holding seven of the director positions. So it is well integrated in that sense. We recognize the gender issue and the professional issue, so it does not preclude or exclude anyone. I think that has been one of the benefits of the restructuring exercise. We have trained the people and they are ready to take on the role of leadership in the Ministry of Health. 88
3 In the divisions, below the directors, we have three general managers. These are all new positions and of those three general managers one is responsible for community health, one for corporate services and one for the hospital. General Manager Hospital handles the main hospital in a division. There is one main hospital in each of the divisions; these are referral, tertiary hospitals, and those three positions are replicated in all three divisions. What it means is that, again, these three positions are open to anyone, the best person for the job, and we see these as breeding grounds for potential directors and even Permanent Secretary or Chief Executive Officer level. I would also like to mention that all Permanent Secretaries in Fiji are becoming Chief Executive Officers. The process is already underway. I think we are following Vanuatu, the Solomon Islands and Papua New Guinea. All Permanent Secretary positions will be abolished and new positions of Chief Executive Officer will be advertised, and will be handled by the Public Service Commission. Again, as far as the Commission is concerned, it is the best person for the job. So the best person for the job will win the appointment as Chief Executive Officer in the Health Ministry. It could be from within the Health Ministry or it could be from outside. I am keeping my fingers crossed that it will be from within the Health Ministry, even though I came from outside the Health Ministry. But I have spent many years, more than seven years now, in the Ministry, and I strongly believe that there are suitable people within the health system. This is as a result of the training and development programs that have happened during the tenure of the Health Management Reform Project. Each director is in overall charge of all health services in their respective division, with all staff in the division reporting to the director. Central Office has four divisions, as I have already mentioned, established to support Central Office s responsibilities of policy development, national health service planning, monitoring and evaluation of health service delivery and legislative and regulatory compliance. These four divisions are Public Health, Nursing and Health System Standards, Health Services Development and Corporate Services. There is now a clear distinction between the roles of Central Office and the divisions. As far as the Public Health Division is concerned, there will be an increased focus on public health activities and I am pleased to say that that is already starting to happen and we are focusing on public health, primary care, health promotion and disease prevention. We are not richly endowed with resources. Prioritization of resource allocation We are a relatively poor country, unlike Samoa and other countries, and we cannot be spending money on expensive hospitalbased care and treatment, so our focus is still largely on primary health, disease prevention and health promotion. This is already happening, and we have increased the funding for public health programs. Even though it is minor funding, it is starting to have an impact and we are trying to build on that as we go along. So the shift is already starting to happen. Previously we used to spend about 65% on hospital-based treatment. That is starting to come down and the public health share is starting to move up from 30%. The actual quantum has not come down but the proportion between public health and hospital-based treatment is starting to shift more towards public health, especially as we get more funds from government. We are not getting it as yet, but we were told that we were likely to get an increase to 10% of the national budget, 11% in the following year and 12% in This has not happened so far mainly because our government has to operate on a very tight budget. They are trying to reduce our GDP debt burden, from what was previously 5%, and even 6%, to 4%. The following year they hope to reduce it to 3.5%, at which point, according to economists, the country should be all right and can manage well; hopefully the country will then grow economically, leading to improved funding for health services. If we do get more funding for health services we will see that public health does get more in relation to hospital-based treatment. So there is an increased focus on public health activities, expanded coordination of public health programs, with high-level professional support to those working in the divisions. We will no longer have the responsibility for the management 89
4 of subdivisional hospitals. That will pass to divisional management. What happened before was that Public Health managed all the divisional hospitals in fact, managed the rest of the health services aside from the main hospitals that were under a central Director of Hospital Services. It was very much a centrally managed system from within the Ministry s Central Office whereas now we have moved away and delegated responsibility to the divisional health services that will actually manage, in an integrated fashion, all the health services in the division. Dr Rabukawaqa (2), Director Western Health Services during the health sector reform, has a paper in this series detailing how things have developed during the decentralization process in the Western Division. Role definition Health services development will be responsible for the development of national health policies, health service planning and workforce planning. National health policies will also include the setting up of national health accounts, a resource allocation formula and health care financing. I believe that health care financing is important, and is covered in these Proceedings (3), as well as costing and financing of a National Health Service and national health information management. As I mentioned before, there is now a clear distinction between the roles of Central Office and the divisions. Component two of the Health Management Reform Project concerns redefinition and institutional strengthening. The objective is to strengthen the capacity of senior management to develop policy, plan and set standards, monitor, coordinate and equitably allocate resources for the National Health Service. A feature of the decentralized model is the change of relationship between the Central Office and the divisions. Divisional managers, be they senior or middle management, will have more direct responsibility and accountability and are required to make decisions. No longer do operational matters get referred to the Central Office. As a consequence, the roles have been redefined. A significant part of the project input has been focused on capacity building of senior and middle management. This has been achieved partly by education, and partly by the role of health management advisers in the Central Office and the divisions. The advisers have been available to assist management in reviewing current policy and procedures, formulating alternative strategies, establishing sound management practices and generally supporting the change process. We have covered the roles of the various divisions and the National Health Service development. I will now turn to the Nursing and Health System Standards Division. Their role is the development and monitoring of standards in relation to patient care, treatment standards and protocols, and those relating to professional conduct, management and service delivery. Again, in the previous structure, when everything was managed centrally, the Nursing Division in the Central Office managed virtually all of the services as far as nurses are concerned, even though nurses also had other bosses in their divisions. Under the new system, management of nurses is handled by the directors in the divisions so that the nursing team in the Central Office can concentrate more on standards, policies and so on. They will provide administrative support for Fiji s professional and para-professional registration boards and councils, and will be a head office professional point of contact for the Fiji School of Nursing Services. The role of Corporate Services Division is coordinating the Ministry of Health input into the national budget, national financial policies and procedures, monitoring of financial delegations, and national human resource and industrial relations policies and procedures. They also cover coordination of organization and staff development activities across the Ministry, and the monitoring of human resource delegations, as well as information services management. This includes support for health information management systems, IT (information technology) policy and procurement responsibility for the Ministry of Health library. The geographical divisional structure includes Northern Health, Western Health and Central Eastern Health. The example we have given is the Director Western 90
5 Services (2), where he has the three general managers also reporting to him. A significant part of the project input has been focused on capacity building of senior and middle management. Health service management training Component three deals with health service management training. The objective is to strengthen health service management capacity at all levels in the decentralized health system, through promotion of appropriate health service management training. Approximately 80 members of staff have undertaken the Frontline Management Program. It is the equivalent of the former program in which credits can be received if further study is undertaken. The present Frontline Management Program has been delivered jointly by Box Hill TAFE (Technical College) and NZPTC (New Zealand Pacific Training Centre). Many of those participants are from a clinical background and deliver a departmental or divisional management responsibility. For most frontline management it was their first exposure to management change. The Frontline Management Program provided a significant number of staff with sound and practical management training to enable them to more effectively carry out their duties. We also had a Senior Executive Leadership Program which was a 12-month program. This program was provided from September 2001 to September We chose our top 24 chief executives to go through the Senior Executive Leadership Program. It was an on-the-job, experiential training program; all 24 were split up into learning groups and were required to undertake workrelated projects. The 12 months of training was interspersed I think there were three weeks of in-classroom lectures interspersed with actual on-the-job projects. The projects were not only undertaken during the 12 months of the training program but were continued after the program ended. These projects are implemented as and when they are ready to be implemented. They do not have to wait until everything is done. One of the learning groups was working on health care financing and they gave a presentation to us on where we are in terms of health care financing. I have already alluded to the 80 middle management managers in terms of the imparting of skills by advisers in the following areas: general management, finance, human resource management and human resource development. We have three health management advisers, one based in each division, and they are working with the directors. Initially there were hospital management advisers but we extended their role to include the whole of health management in a division when we had the integration. They are involved in everything from theatre management systems to admission and discharge, quality improvement, infection control and so on. In terms of capacity building there are also human resource workshops occurring to develop skills in various areas such as finance, information systems and information technology. These are an ongoing part of capacity building throughout all levels in the health system. Selection committees are already in place in the divisions. Again, what happened previously was that all these functions were centralized in the Ministry. Appointment and promotion functions were centralized in the Ministry. We have started to change that. We have selection committees in the divisions and the Public Service Commission has agreed for us to subdelegate some of the functions, delegated by the Permanent Secretary to the divisional directors. Health information systems Component four involves health information systems. The goal is to develop new health information systems and enhance existing systems in order to improve the Ministry s capacity to plan and manage its resources. There are two major information systems that have been implemented as part of the Health Management Reform Project. The first is a patient information system known as PATIS. We have adapted this from the Samoan health information system (HIS) and I think ours has taken all the good things from the Samoan system, and we have developed it further as far as the performance management evaluation is concerned. Where the performance agreement for the 91
6 Permanent Secretary is concerned, we have dealt closely with the four Central Office divisions as well as with the directors of the health services. Progress and next steps Where are we up to now? Cabinet endorsed the health reform program in September We have had four different governments since the reform program was introduced in In 1999 we had the Labor Coalition. In 2000 we had the interim government after the events of We first had the caretaker government and later in 2000 we had the interim government, and then from 2001 we had the new government. So each time there was a change in government we have had to go back and seek their endorsement of the program for them to take ownership of the program, and we are grateful that all four governments have endorsed and strongly supported the project. Public Service Commission approved the new organizational staff changes in December The Ministry of Finance adjusted the budget to cater for the new structure. They started doing that in 2003 and in 2004 it was further enhanced. Acting directors have been appointed in all seven divisions. These directors have been acting for quite some time and we hope that shortly the Public Service Commission will confirm their appointments. If we were delegated the powers I am sure we would have done so within three months of their positions being advertised. Formal requests have been made to the Public Service Commission for approval to subdelegate the Permanent Secretary s powers. I am happy to mention that that has already started to happen and we have received permission from the Commission for some of the Permanent Secretary s powers to be subdelegated to the divisional directors. We are working on those again just to ensure that everything is satisfactory before we formally make the decision to subdelegate. A new financial management information system (FMIS) is now being put in place. The FMIS will allow for the establishment of cost centres, allocation of budgets and the ability to better understand true costs, as well as the ability to benchmark and identify inefficiencies and make improvements in inventory management. PATIS has been rolled out in the Northern Division, in Lautoka and Nadi. After we have trained 80 of our middle and senior level managers this will become an ongoing exercise for us. We feel that human resource development and capacity building is important to support the new structure. There will be further enhancement of the FMIS and PATIS and ongoing training in human resources in the divisions to ensure that the Ministry of Health is prepared when the PSC hands down additional human resource delegations, and to continue capacity building at the Central Office level and divisional level. After the Fiji Health Management Reform Project has concluded the governments of Fiji and Australia have agreed that a new program will commence officially although activities have already started to enable a smooth transition from the Fiji Health Management Reform Project. This new program is to be known as the Fiji Health Sector Improvement Program, which is a sector-wide program somewhat akin to what is happening in Papua New Guinea. Some aspects of the Fiji Health Management Reform Project will remain, particularly where implementation has yet to be completed, but the focus of the Fiji Health Sector Improvement Program will be much wider, including public health and health promotion, rural health and human resource development, including the Fiji School of Nursing. REFERENCES 1 Stowers P. The experience of reform in the Samoa Ministry of Health. PNG Med J 2006;49: Rabukawaqa V. Health sector reform in the Pacific: a Fijian divisional perspective. PNG Med J 2006;49: Pande M. Health financing: the Fijian experience. PNG Med J 2006;49:
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