Culture and healthcare in Fiji: A WPR analysis of Health Policy in Fiji

A thesis submitted in partial fulfilment of the requirements for the degree of

Master of International Development

Andrew Gordon Boyle,

Bachelor of Arts in Music, Victorian College of the Arts; Diploma of Education, University of
Melbourne

December 2020

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Candidates’ Declaration

2
Acknowledgements

The following staff at RMIT, Dr Roberto Guevara, Dr Vandra Harris, Associate Professor, Dr

Yaso Nadarajah, Dr Panayiota Romios and Dr Cirila Limangog have all played invaluable

roles in leading me to what has become my overriding passion, the nexus of health and

culture in the South Pacific, and I thank them for their guidance and support.

You hope to encounter inspirational people in your studies, and Dr Debbi Long, Health

Anthropologist, academic, mentor, and friend has been that person for me. The germinal

ideas contained in this thesis all come from a lecture she gave on competing health

epistemologies. I had just lost my friend to type 2 Diabetes, to whom I refer in the

introduction, and what Dr Long said in her lecture, resonated strongly with my impressions of

how my friends in Fiji thought about health and wellbeing and suggested a way forward.

Debbi, I can’t thank you enough.

My supervisor, Dr Paul Scriven, has been a tower of support. His belief in this project, has

helped sustain me throughout this journey and has helped me take a welter of half-conceived

ideas and turn them into a cogent argument. He is everything you could ask for from a

supervisor: punctual, supportive, encouraging, and above all, able to see the bigger picture

even when that was unclear to me.

I send a big vina’a sara va’a levu to all of my friends on the island of Vanua Levu, Fiji.

COVID19 has made this a very different study to what I had planned. Instead of the

ethnographic study of medical pluralism in an iTaukei village, policy analysis has been the

focus. As should be apparent, I am passionate about iTaukei health in Fiji and my friends in

Fiji have never been far from my thoughts. I am looking forward to being able to visit once

travel restrictions ease.

Finally, my partner, Randeep Dhillon as always has given unwavering support throughout

this project and I can’t thank him enough for everything.

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Contents

Candidates’ Declaration.................................................................................................................2

Acknowledgements........................................................................................................................3

Contents........................................................................................................................................4

Abstract.........................................................................................................................................7

INTRODUCTION............................................................................................................................11

Trouble in paradise......................................................................................................................11

Background..................................................................................................................................11

Causation of disease in Fiji...........................................................................................................12

The problem of Mere’s foot.........................................................................................................13

The problem................................................................................................................................14

Methodological choices...............................................................................................................16

What’s the Problem Represented to be?....................................................................................16

Testing the method.....................................................................................................................17

Thesis structure...........................................................................................................................17

CHAPTER ONE: LITERATURE REVIEW.............................................................................................19

Introduction.............................................................................................................................19

Part one. Setting the scene.......................................................................................................19

Fiji................................................................................................................................................19

Fiji’s health situation....................................................................................................................22

Healthcare Paradigms..................................................................................................................23

Health Policy Research in Fiji.......................................................................................................24

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 Traditional Medicine Policy.........................................................................................................25

Key regional organisations...........................................................................................................26

Cultural policy in Fiji.....................................................................................................................27

Part Two: the relationship between culture and health.............................................................28

Determinants of health................................................................................................................28

Cultural Determinants of health..................................................................................................29

Indigenous world views...............................................................................................................31

Cultural determinants in action: The He Pikinga Wairoa Implementation Framework...............32

Conclusion...................................................................................................................................35

CHAPTER TWO: METHODOLOGY...................................................................................................36

Introduction.............................................................................................................................36

Research design...........................................................................................................................37

Research Method........................................................................................................................38

Not just iTaukei culture...............................................................................................................39

Limitations...................................................................................................................................40

CHAPTER THREE: WPR ANALYSIS OF STRATEGIC PLAN..................................................................41

Analysis references and supporting documents..........................................................................41

Problematization: Access to healthcare....................................................................................41

Suggested genealogy of ideas...................................................................................................42

Underlying assumption one: expertise sits solely with medical authorities................................45

Underlying assumption two: Culture plays no part in understanding health outcomes..............48

Analysis summary.....................................................................................................................52

CHAPTER FOUR: CONCLUSION......................................................................................................53

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REFERENCE LIST............................................................................................................................56

ANNEX 1.......................................................................................................................................68

ANNEX 2: WPR CHART: WHAT’S THE PROBLEM REPRESENTED TO BE? (WPR APPROACH TO POLICY

ANALYSIS)....................................................................................................................................75

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Abstract

Introduction

Non-Communicable Diseases (NCDs) are increasing in Fiji. Late presentations amongst

many iTaukei people with NCDs often result in poor health outcomes. Little research has

been conducted on the nexus between culture and health seeking behaviours in Fiji which

might shed light into this situation.

Therefore, a policy analysis of the 2020-25 Ministry of Health and Medical Services

(MHMS) Strategic Plan, focusing on determinants of health was conducted. The aim was to

investigate the underlying assumptions which inform health policy in Fiji.

Method

The analysis used Carol Bacchi’s ‘What’s the Problem Represented to Be’ (WPR) method

(Bacchi, 2012) as a means of investigating what the policy has problematized, and the

unexamined assumptions that underpin the strategic policy. It also draws attention to silences

and alternative ways of conceiving of the problematization while proposing a genealogy of

ideas that explain the problematization and its underlying assumptions.

Results: The study uncovered that the strategic policy problematises access to care and is

informed by two underlying assumptions, the primacy of biomedicine, and iTaukei or other

cultural epistemologies have no part in healthcare delivery or policy formation, in spite of the

Fijian government’s obligations to national and regional cultural policies, and the United

Nations Declaration of the Rights of Indigenous People (UNDRIP). It is suggested that

employing a strength-based cultural determinants of health model to inform health policy can

result in improved NCD rates.

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Abbreviations and Glossary of Terms

iTaukei conventions of spelling are used throughout. The letter ‘b’ is pronounced ‘mb’ as in

member, ‘d’ is pronounced ‘nd’ as in hand, ‘g’ is pronounced ‘ng’ as in sing, and ‘q’ is

pronounced ‘ng’ as in finger. Translations are based on the Fijian-English Dictionary

(Gatty, 2009)

Abbreviations:

CCA Culture Centred Approach

CDA Critical Discourse Analysis

CHW Community Health Worker

CMNH College of Medicine, Nursing and Health Sciences, Fiji National

University

C-POND Centre for the Prevention of Obesity and Non-Communicable Diseases

DESA United Nations, Department of Economic and Social Affairs

DOHA Department of Heritage and the Arts, Government of Fiji

FNU Fiji National University

GHO Global Health Observatory

HPW He Pikinga Waiora Implementation Framework

ICH Convention of the Intangible Cultural Heritage

IDA International Diabetes Association

KPI Key Performance Indicator

MANA Pacific Monitoring for NCD Action, South Pacific Commission

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MHMS Ministry of Health and Medical Services, Government of Fiji

NCD Non-Communicable Disease

NGO Non-Government Organisation

PICTS Pacific Islands Countries, Territories and States

RCS Regional Cultural Strategy, South Pacific Community

SDG United Nations, Sustainable Development Goals

SOWIP State of the World's Indigenous People's Health

SPC South Pacific Community

T&CM Traditional and Complimentary Medicine

T2DM Type 2 Diabetes Mellitus

UNDIRP United Nations Declaration on the Rights of Indigenous Peoples

UoF University of Fiji

UPSM Umanand Prasad School of Medicine

USP University of the South Pacific

WHO World Health Organisation

WPR Carol Bacchi's What's the Problem Represented to Be analysis method

Terms

communualect A variety of speech with little or no apparent regional variation.

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iTaukei iTaukei word: owner, in this thesis understood as the indigenous

people of Fiji.

Mana iTaukei word: personal power, prestige as recognised by others.

Nasi ni koro iTaukei word: Literally village nurse: voluntary community health

worker, today a community leadership position.

Tabua iTaukei word: a traditional item of exchange.

Talanoa iTaukei word: tell stories

Tikina iTaukei word: administrative district that encompass traditional

territories.

Turaga ni koro iTaukei word: Village headman (or woman), an elected position.

Turaga ni vanua iTaukei word: hereditary Fijian leader: chief.

Vanua iTaukei word: territory, land, country, nation, place. Can also be used

to indicate the traditions and culture of a place or people.

Yaqona iTaukei word: Kava, Piper Methysticum, Piperaceae, used as a

ceremonial and social beverage.

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INTRODUCTION

This thesis is an analysis of culture and healthcare in Fiji with a particular focus on Non-

Communicable Diseases (NCDs). The Ministry of Health and Medical Services 2020-2025

Strategic Plan (MHMS, 2020) has been analysed using Carol Bacchi’s ‘What’s the Problem

Represented to Be’ approach to examine the extent to which culture plays a role in

formulating health policy and what underlying assumptions inform government policy. It is

contended that ignoring indigenous concepts of health and wellbeing in favour of a

biomedical approach in the delivery of healthcare is a contributing factor to the poor

health outcomes experienced by Fiji’s indigenous iTaukei1 people.

Trouble in paradise

Fiji is in trouble. Non-Communicable Disease (NCD) rates are high. According to Fiji’s

Ministry of Health and Medical Services, one in three people tested have Type- 2 Diabetes

Mellitus (T2DM) rates, (MHMS, 2020) while the IDF Diabetes World Atlas states that over

half the population are likely to be prediabetic 2 (IDF 2019). The impact of this on both

indigenous and non-indigenous people in Fiji is immense. Foot amputations due to TD2M

complications, are commonplace amongst the indigenous iTaukei people (Hjorth, 2012;

Kumar, 2014). Early deaths due to NCDs are common, and the life changing impacts of

T2DM, hypertension and obesity, impinge on many people’s ability to lead active lives.

Background

I have been an annual visitor to several rural iTaukei communities on the island of Vanua

Levu, Fiji for over 30 years. I speak the local dialect and have lived, farmed and fished with

iTaukei people. I have stayed in their homes, celebrated with them, and mourned with them. I

have taken part in traditional ceremonies and have been honoured with their continued

1
A term used to signify the indigenous people of Fiji, as opposed to Fijian, which is taken to mean a citizen of
Fiji who is not necessarily indigenous. iTaukei literally means owner. Both these terms remain problematic to
some indigenous people who see the term Fijian as exclusively applying to the indigenous people of Fiji
2
Defined by the IDF as being people with impaired glucose tolerance
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friendship. I respect their unique way of life, their humour, stoicism, their skills, and their

vast knowledge. Sadly, I have also seen friends of mine, who lived active and full lives,

suffer because of NCDs. I have lost friends and I have seen others maimed.

I find this puzzling as Fiji seems to have a functioning healthcare system. I know from my

iTaukei friends in Fiji, that most births take place in the regional hospital in Labasa and I had

often travelled on local buses together with women going to the subdivisional medical centre

for follow-up postnatal care. When I have become ill, I was able to access a good level of

healthcare, delivered by well-trained healthcare professionals, both in the nursing station at

the village in which I stayed or at the hospital in Labasa, all of whom seemed passionate

about the health and wellbeing of those they were charged to care for.

Causation of disease in Fiji

As an academic, I noticed something else at play. Sometimes, during conversations with my

iTaukei friends, health would be discussed. While I understand many aspects of their lives,

and those things that I don’t understand, I accept, when it comes to health and wellbeing, I

have often been at a loss to understand their viewpoint. I am not referring to the many herbal

remedies most turn to, including myself, but the question of causation. People with great

sincerity have explained to me that a mutual friend’s illness was caused because a tabua3

hadn’t been given to a chief, not the cancer that I knew was wracking their body; most

distressingly, a close friend’s mental illness, due I knew to tertiary syphilis, was apparently

because the family was cursed. Too often, I encountered people stoically enduring pain

because they hadn’t sought help. I too have been told that some people possess healing

powers: if you have a broken limb, then you should go to the people who lived down the

coast who were adept at setting bones without the use of a cast; that person could treat burns;

that family were known to have the power to cure what were called “Fijian illnesses”, ones
3
A tabua is a traditional item of exchange of great cultural value, usually made from the tooth of a Sperm
Whale. In this case the tabua was meant to have been given to the chief to acknowledge the first visit to the
village of my friend’s sister’s children, normally a large ceremony, which in this case hadn’t occurred. My
friend hadn’t given the tabua to the chief because he was ashamed the ceremony hadn’t been performed.
12
that in my albeit limited understanding of medicine, seemed to have no outside equivalency.

Clearly, a fully functioning indigenous system of disease, illness and attendant behaviours

was at play here. Indeed, it was one of the things that I continued to find fascinating during

my many visits.

The problem of Mere’s foot

I’d like now to share the story of a friend I will call Mere Viti (Fijian Mary) 4. Mere Viti lived

in one of the communities I visit. She was an iTaukei woman in her middle 50s, an outspoken

yet kind woman. She was curious about the outside world yet remained a woman of deep

Christian faith. Mere was hardworking and funny. She was a respected community leader, a

mother, and a wife. I liked to drink tea and talanoa (tell stories) with her at the small roadside

canteen she ran. Unbeknownst to me, she also had T2DM.

In late 2017, I was shocked to learn Mere Viti had died in great pain, of severe blood

poisoning from an untreated foot ulcer, the result of T2DM. What was particularly distressing

was that Mere Viti had refused care, going to the extent of signing a document to that effect,

in spite of the district nurse, her many children, her husband, and many in her community

advising her to the contrary. I asked myself, why had this occurred? Why would someone act

in a way so completely at odds with their own self-interest, indeed against the wishes and

advice of those closest to them?

It clearly wasn’t because there was no healthcare available. Mere Viti lived in a roadside

village with a regular bus service to the divisional hospital, located only a few hours away.

Also, she had received home visits from the district nurse during the early stages of her

illness, and the subdivisional medical centre was less than an hour away. Several members of

her own community were themselves qualified doctors, nurses and health inspectors, so it

wasn’t lack of familiarity with biomedicine and it certainly wasn’t financial; Mere Viti was a

successful businesswoman who ran a popular roadside canteen and was one of the most well-
4
Not her real name. I have obscured locations and changed the names of people to protect their privacy.
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off members of the community; even if she had had no money, healthcare is largely free in

Fiji and relatives or her church minister could easily have given her the fare to travel to

hospital should she need.5

While I can never know why Mere Viti made the choices she did, it was a story familiar to

me; I knew of other iTaukei people who had refused care, often with disastrous results;

conversations with a district nurse in rural Fiji had led me to understand getting people to

present for care at all was often a challenge and too often their case was beyond the capacity

of a rural health centre to treat by the time they did attend, often with compound health

problems requiring hospitalisation and more.

The problem

What has emerged from this and from other anecdotal observations, is that it appears many

iTaukei people with NCDs, are often electing to not present for care (or only do so when their

symptoms are advanced) even though care is available free of charge; there are many people

who have a different understanding of health and wellbeing to a biomedical explanation, and

a government committed to addressing these high NCD (Non-Communicable Disease) rates,

yet no evidence this situation was changing.

Therefore, I wanted to understand why the health system in Fiji was having little success in

mitigating increasing rates of NCDs. It was necessary to understand the framework that

informed healthcare delivery in Fiji, in particular because many healthcare workers in Fiji are

themselves iTaukei, far more familiar with this indigenous understanding of health and

wellbeing than myself. A conventional understanding by which medical professionals from a

different culture simply do not understand iTaukei culture, did not apply here. This was a

case of indigenous healthcare workers delivering biomedicine, a system at odds with how

5
While it is acknowledged women may be less likely to be given money to attend medical care and that there
are many other barriers to women accessing the care they need, the point here is that in Mere’s case, to my
knowledge, these barriers weren’t present.
14
they would have known some of the people whom it was their responsibility to treat,

understand health and wellbeing. And it wasn’t working.

Thus, I began to develop an interest in the nexus between health and culture as it applied to

iTaukei people in Fiji. I wanted to understand the extent to which culture informed medical

practice. I was unable to go to Fiji due to COVID-19, so had to look elsewhere for evidence.

The government of Fiji’s Ministry of Health and Medical Services (MHMS) released a five-

year strategic plan in early 2020; this would be an ideal place to examine the extent to which

culture informed health policy. A preliminary reading of this revealed no reference to culture

at all in the strategic plan. In fact, there were conspicuous efforts to discuss anything but

indigenous culture when it came to describing the influencing factors on iTaukei people’s

health-seeking behaviours.

This initial reading highlighted a conspicuous gap: why was culture being ignored? Why

would a health policy written under the direction of an iTaukei Minister of Health and

Medical Services, a widely respected doctor himself, who had practiced medicine throughout

Fiji, so blatantly ignore culture as a contributing factor to addressing Fiji’s enormous health

challenges?

As part of my background research, I undertook a scoping review of academic literature,

NGO reports, regional organisation publications and other Fijian government documents and

reports focusing on culture and health, in both Fiji and the region. This revealed that although

there was a great deal of evidence of culture being integral to people’s health and wellbeing,

and the necessity of policies at least making tacit recognition of this, there was a no evidence

of these ideas being present in the delivery of healthcare itself in Fiji.

Methodological choices

It was then necessary to find a way of understanding why this was the case. Critical

Discourse Analysis (CDA) offered potential, but several methodologies I surveyed, called

15
upon complex linguistic analytical skills. While the choice and use of language tells us much,

I didn’t consider linguistic analysis alone was sufficient to understand the exercise of power,

who got to talk and contribute and who not, that I reasoned were at the heart of this

phenomenon. Such methodologies might be useful to analyse say interactions between a

doctor and a patient, but far less so with strategic policy documents couched in neutral

language. The notable absence of culture recognition and acknowledgement in the policy at

all was what is of interest, not how that is being described and that is where I wanted the

focus of the analysis to sit.

What’s the Problem Represented to be?

Carol Bacchi’s “What the Problem Represented to be” WPR (Bacchi, 2012) is a form of

CDA which takes its departure point from the concept that governments don’t just solve

problems, they create problems which they in turn try to solve, a process Bacchi calls

problematization. Bacchi’s methodology is centred around a set of seven questions focusing

on unexamined assumptions which sit behind such problematizations, the logic necessary for

the problematization to make sense, what silences are there, who is and isn’t being heard, and

what alternative ways of describing the problem might exist. It contains flexibility that allows

it to be adapted to different situations, and as this policy has only just being released, it's too

early to know what the impact of the policy will be on people’s lives, meaning that the

flexibility of the methodology was ideal to ask the questions I wanted to address without

getting bogged down in surmising results, a process that would at best be speculative.

Testing the method

A preliminary application of this method to the policy document revealed a seemingly

irreconcilable fact; the policy continually referred to the increase of the availability of

healthcare as being the best way of improving health outcomes. This seemed contrary to what

I had seen in the case of Mere Viti and others like her; it wasn’t lack of access that was the

problem, but something else. This was a key piece of information. The policy was focused on
16
problematizing something unrelated to how healthcare was delivered and was doing so

without addressing the underlying assumptions. According to WHO’s Global Action Plan

for the Prevention and Control of NCDs 2013-2020 (WHO, 2013a p 13), ‘evidence-based

strategies taking cultural considerations into account, together with the empowerment of

peoples and communities, are essential to tackling the multifactorial contributing factors at

the heart of the current world NCD epidemic’. There was little evidence of this occurring in

Fiji. This was both troubling and surprising.

This suggested Bacchi’s WPR would be an appropriate methodology to understand why the

policy looks the way it does, and how the design of the policy may help explain why rates of

T2DM and other NCDs are not improving and most importantly, to formulate suggestions for

change. Further, it provides a means of formulating a genealogy of ideas that might lie behind

what at face value made little sense, and in doing so, might shed light onto not only the blind

spots within the policy, but alternative ways of addressing the health challenges facing Fiji.

Thesis structure

Chapter one describes the current health situation in Fiji. It then examines international,

regional, and local conventions which place culture at the centre of indigenous rights and

presents evidence of successful programs deliberately placing health within a cultural

paradigm that have been successfully applied elsewhere. The glaring gap between words and

actions, the conventions and agreements to which Fiji is a signatory and what is current

practice, provides compelling evidence that there is the need to delve deeper.

Chapter two explains the ontological framework underlying a case study and then the

application of Bacchi’s WPR approach in detail, focusing on how the WPR analytical

approach is to be applied in the context of Fijian public health policy.

Chapter three sees applied WPR in detail. The analysis identifies one main problematization,

and two unexamined assumptions necessary for the problematization to make sense. In doing

17
so, it identifies silences, both in terms of who gets to meaningfully contribute, and concepts

which are absent.

A concluding chapter contains a discussion of the findings of chapter three and a suggested

way forward in terms of further research. Recommendations focus on basing future policy on

agreements to which Fiji is in fact a signatory and explicitly taking advantage of Fiji’s unique

two-stage cultural and administrative leadership structure to integrate cultural understandings

into healthcare delivery.

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CHAPTER ONE: LITERATURE REVIEW

Introduction

In developing the research question, it is necessary to understand what is known about the

health situation in Fiji. This includes any evidence Fiji includes cultural concepts in the

delivery of healthcare. If we are to examine the nexus between culture and health, we then

need to examine international and regional agreements relating to indigenous and cultural

rights to appropriate healthcare and policies on traditional medicine to which Fiji is a

signatory, to understand the obligations to which Fiji is subject.

Once this is established, we need to find evidence of examples of where culture and

healthcare have been explicitly combined, backed up by a theoretical discussion to

demonstrate the ideas underpinning such a concept, and that such programs have worked

elsewhere. All of these elements point to a gap between the current practices in Fiji, its

international and regional obligations, and both theoretical frameworks and case study

evidence.

Part one. Setting the scene

Fiji

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Figure 1 Map of Fiji, Googlemaps.com

Fiji is a pacific island nation of approximately 884887 people (FBoS, 2018, p.1) of whom

approximately 56% are indigenous iTaukei people. It is a former British colony (1874-1970).

Fiji also has a large (37.5%) Indo-Fijian population, descendants of indentured immigrants

bought by the British to work the sugar cane farms from 1870 to 1919, and small populations

of immigrant Pacific islanders, part European, and Chinese (CIA, 2019)6. Its original

inhabitants have continuously occupied the islands for approximately 3500 years and are a

mixture of descendants of Melanesian migrations from the north west with a later migration

from Tonga arriving from approximately 300 years ago, who are chiefly found in the eastern

part of the country (Clark & Anderson, 2009).

The iTaukei speak many communualects of Fijian7 which divides into two language groups

which are mutually unintelligible (Pawley & Sayaba, 1971). One dialect from the east of the
6
The Fijian Bureau of Statistics hasn’t included racial statistics since its last census in 2007
7
Renowned Fijian Language scholar, Paul Geraghty in his History of The Fijian Languages counts 37
communualects, a variety of speech with little or no apparent regional variation. (Geraghty, 1983) within the
Fiji group. Some of these communalects are spoken in just one village, others have much wider use; all signify
to the speakers and their audience alike information about status, inter-communal relationships and the speaker’s
origin which is likely to be hidden to all but a few.
20
country, the language of Bau island, was adopted in the 19th century as a lingua franca

(Capell, 1991, p. iii) and today is the most commonly heard Fijian communualect. English

and Hindi are widely spoken and all three have the status of official languages.

Fiji is in the South Pacific Ocean and has a total land area of 18274 sq km, made up of

approximately 320 Islands, about 100 of which are inhabited. The capital is Suva, with a

population of 93000 which is located on the main island of Viti Levu, home to around 70% of

the population.

Approximately half of the total population live in urban areas; the Suva-Nausori corridor

alone contains over a third of the country’s population. Outside of the two main islands, the

remaining outer islands are mostly populated by iTaukei people with the Indo-Fijian

population mostly found in urban areas and in the dryer, sugar-growing areas of western Viti

Levu and northern Vanua Levu. Rabi, off the coast of Vanua Levu, is the home of the

Micronesian Banaban people and a smaller population of Tuvaluan migrants are found on

nearby Kioa (Teaiwa, 1997; Teiwa, 2012) and finally, descendants of Solomon islanders

brought to Fiji as slaves in the blackbirding era (Summy, 2009), make up a small but distinct

community, today found on the outskirts of Suva.

Population is growing at around 0.6% PA (FBoS, 2018, p.1) which is accompanied by a rural

to urban migration rate of 1.65% PA. This is putting pressure on current housing stocks, with

an estimated 100,000 people living in 200 squatter settlements on the outskirts of the major

cities and towns (Matadradra & Naidu, 2014 p.9). Poverty rates are at 28%, with rural

populations much worse off than urban dwellers.

Fiji’s health situation.

In Fiji, life expectancy has remained steady at around 67 years for men and 72 for women

(FBoS, 2016)8. Mortality figures show an ever-increasing burden caused by NCDs, with over

8
These statistics cover the whole population. It is not clear what the life expectancy is amongst different
communities or if there is a variation between rural, peri-urban or urban dwellers.
21
half of all deaths the result of these conditions which is a comparatively recent phenomenon.

Historically, Communicable Diseases were more prevalent, with measles, yaws, and

hookworm being reported at far higher rates than is the case today (Asante, Roberts, & Hall,

2011; Brewster, 2013). With 803 deaths per 100000 due to NCDs in 2016 (WHO, 2018), Fiji

finds itself in the unenviable position of having the second highest rate of NCD deaths in the

Western Pacific region and one of the highest in the world.

In spite of these figures, Fiji has one of the most well-developed medical systems amongst

PICTS (Pacific Islands Countries and Territories) (WHO, 2011). A workforce of

approximately 690 doctors and 2860 nurses, work in 3 divisional hospitals, 16 subdivisional

hospitals, 77 Health Centres and 101 nursing stations. They are supported by an estimated

820 voluntary community health workers (CHWs) located in villages and other smaller

communities9. According to WHO, as of 2015 there were 8.6 physicians per 10000 people,

(GHO, 2020) and the World Bank records in 2018 there were 3.375 nurses per 1000 people.

This equals a total of over 4.6 health workers per 1000 people, well above the WHO

suggested level of 2.5 health workers per 1000 people. These figures paint a picture of a

health system in overall good shape which is perhaps surprising given Fiji in 2015 spent only

3.5% of GDP on health (World Bank, 2020), one of the lowest in the region, where the

average is 5.1% of GDP (World Bank, 2020).

Healthcare Paradigms

Fiji has a long and proud history of health training with today two schools of medicine and

two schools of nursing providing a high level of health education for both Fijians and other

9
Fiji has a ong history of community-based voluntary community health workers (CHWs) (Jerety, 2008) or
nasi ni koro (village nurse) (Morse, 1989). This system, introduced in the 1970s, had been allowed to lapse in
the face of other strategic priorities in the past. While there has been a recent move to integrate CHWs within
the community leadership structure and further strengthen the program itself (Hassan, 2015), training resources
haven’t been updated for five years and as they are in English not iTaukei, are likely to be of limited value. A
notable change has been the drastic reduction in the length of time for training CHWs, reducing from a six-week
course with annual two-day refresher courses as reported in the Fiji Islands Health System Review published by
WHO in 2011, to a three-day course articulated in the new CHW policy and training package.
22
Pacific islanders10. To gain an understanding of how health professionals are trained, an

internet search was conducted of the three tertiary institutions in Fiji which teach healthcare

to see what could be identified about their teaching frameworks. Such information might

point to factors that influence health policy at the national level. The only framework that

could be found is in the overview of the Certificate IV nursing course at CMNH. According

to the website (CMNH, 2020), nursing training is based on Dorothea Orem’s Self-Care

Deficit Theory (Hartwig, 1989; Orem, 1989). Based on the concept that patients wish to care

for themselves, and people are best able to recover if they can perform their self-care, in this

theory there is no mention of the concept that within some other pacific island cultures, health

issues are ‘constructed within a collective concept’ (Wilson, 2008 p 181). Others such as

Mellissa Faulkner, recognise the importance of self-care within a family context (Faulkner,

1996) yet these ignore the impact of culture in healthcare which is in contrast to frameworks

such as culture care theory (McFarland & Eipperle, 2014) cultural safety (Papp’s &

Ramsden, 1996) or cultural competence (Duke, Connor, & McEldowney, 2009). It is

suggested these or other frameworks are more appropriate teaching models, better able to

engage with people’s cultural understandings. A parallel can perhaps be drawn between a

nursing theory at odds with a section of the population’s lived lives, and a healthcare system

likewise at odds with iTaukei ways of knowing.

Health Policy Research in Fiji

A search of the state of research into public health policy was conducted to ascertain what

research has been conducted in this area. A search of Google Scholar and PubMed using the

10
Fiji was a pioneer in training indigenous men and women starting with the establishment of the Suva Medical
School in 1885. The establishment of the Central Medical School in 1928 allowed men and women from several
other pacific island nations to join their Fijian counterparts in undertaking three years’ medical training as
Native Medical Practitioners. Intended to assist fully qualified doctors, these NMPs were often the only medical
professionals on hand. Today students from the College of Medicine, Nursing and Health Sciences, a faculty of
the Fiji National University, can undertake studies in Dentistry, Medicine, Nursing, Pharmacy, Environmental
health, and allied health. Two more recent players in the sector are the University of Fiji’s Umanand Prasad
School of Medicine (UPSM) serving in the Western Division and in the northern division is found the Sangam
Nursing School in Labasa. I was unable to find out how many graduates these three schools are producing per
annum, but the evidence points to health education in Fiji being in good shape.
23
search ((Fiji) AND ("health policy" OR "public health") AND (NCD OR Diabetes OR T2DM

OR "non-communicable disease))” produced a limited number of results.

The CMNH has been involved with several research projects with C-POND (Centre for the

Prevention of Obesity and Non-Communicable Diseases), being the most relevant to this

study. There has been some focus on public health policy related to diet and food importation

policy (Bell et al., 2020; Coriakula et al., 2018; Latu et al., 2018), but nothing aimed at

critiquing the assumptions that inform health policy itself. There are other studies aimed at

providing greater understanding of T2DM statistics (Pablo, Mohammadnezhad, Wilson, &

Khan, 2018; Romakin & Mohammadnezhad, 2019) but little research examining reasons why

people are not presenting for care in a timely fashion.

Turning to Fijian health policy research from outside the country, Phillips seeks to critique

health in Fiji using a neoliberal health discourse. This is useful as it focuses attention on the

inequities caused by a ‘neoliberal governmentality” (Phillips, McMichael, & O’Keefe, 2018,

p. 561), but says little about policy itself. Dearie examines iTaukei people residing in

Australia in terms of their knowledge and attitudes toward diabetes (Dearie, Dubois,

Simmons, MacMillan, & McBride, 2019). Both draw attention to iTaukei attitudes towards

causation, with Dearie focusing on the importance of existing social structures as being vital

to tackling T2DM. Phillips does draw attention to perceptions amongst iTaukei people of

spiritual determinants (Phillips, McMichael, & O’Keefe, 2018, p. 569), but sees those as

being secondary to structural factors affecting people’s health. There has been a single

published analysis of primary healthcare policy in Fiji (Negin, Roberts, & Lingam, 2010), but

it doesn’t focus on the underlying problematization and assumptions which inform the policy.

In summation, a small number of researchers in Fiji have looked at public policy, but only in

regard to food policy and the NCD strategic policy, while Phillips and Dearie have looked at

iTaukei attitudes to disease, but there appears to be no evidence of any research that seeks to

critique the assumptions of public health policy in Fiji, particularly with a focus on culture.
24
Traditional Medicine Policy

There has been a growing amount of interest in traditional and complimentary medicine

policy (TCM) world-wide with two key policies at the international and regional level, the

2014-23 Traditional Medicine Strategy (WHO, 2013b) which updated the initial 2002 policy

(WHO, 2002), and the Regional Strategy for Traditional Medicines in The Western Pacific

(WHO, 2012) relevant to this study.

Fiji’s response to these strategies has been sporadic. In 2001, a number of working groups

were set up following a national workshop on traditional medicines. After a gap of over ten

years, the Fijian government released its updated National Medicinal Products Policy

(MHMS, 2013, p. 49), which includes a section on traditional medicines, though so far there

is little evidence its recommendations have been into practice, while in 2018, a draft

traditional and complementary medicine policy was reported in the media as being presented

to cabinet (Katonivualiku, 2018), but a search of the MHMS website revealed no evidence

this policy has been implemented. In June 2019, the current Minister of Health, the

Honourable Dr Waqanibete in answer to a question in parliament regarding traditional

medicine being used to treat NCDs, answered that some work had been done on traditional

medicine policy two years ago “but at this moment of time our focus is on conventional

medicine” (Hansard, 2019, p. 2190) suggesting no further work has been done to develop or

implement this policy, nor would it appear from the Minister’s comments, there is much

enthusiasm in doing so11. These discussions solely are only addressing the issue of traditional

herbal medicines; at no point has the Fijian government discussed indigenous attitudes to

health and wellbeing.

11
The Minister’s lack of enthusiasm for traditional medicine could be informed by the large number of people
who present with symptoms exacerbated by misremembered herbal cures foisted on people with NCDs by
traditional healers.
25
Key regional organisations

While healthcare in Fiji is the responsibility of the Ministry of Health and Medical Services

(MHMS), health policy is informed by regional frameworks and agreements to which Fiji is a

signatory. The following section surveys these to provide context for the analysis. What

emerges is that just as was the case with traditional medicine policies in Fiji, while there is a

broad-based attempt to include cultural concepts in a number of regional policies,

implementation has tended to lag behind. Further, there is evidence the Pacific NCD

Roadmap report (World Bank, 2014) is at variance with the Regional Culture Strategy (SPC,

2012) in so much the roadmap while speaking to pacific concepts, is reluctant to integrate

indigenous ways of knowing, called for in the Regional Cultural Strategy.

The SPC Public Health Division (SPC, 2020a), is charged with improving health for all

pacific islanders. One of main its activities in addressing the NCD epidemic is the Pacific

Monitoring Alliance for NCD Action (MANA), which was established in 2014 to assist

PICTs monitor their implementation of the Pacific NCD Roadmap (World Bank, 2014). The

roadmap provides specific policy, regulatory and tax measures to address NCDs. MANA

developed a dashboard using a ‘traffic light’ rating to track progress. The MANA Dashboard

comprises of 31 indicators across the areas of leadership and governance, prevention policies

(tobacco, alcohol, food and physical activity), health system response and monitoring

processes. While this is something to be applauded, as will be discussed later, it is what

hasn’t been included as factors effecting NCD rates that should be examined. It should be

noted that this report, commissioned by the World Bank, places emphasis on economic

impacts of NCDs, and looks to structural solutions, with less emphasis on understanding why

people act as they do, and policies and programs which seek to integrate those attitudes.

Cultural policy in Fiji

The Fijian government’s Department of Heritage and the Arts has carriage of Fiji’s cultural

policy, articulated in the department’s Guiding Principles and Values (DOHA, 2020).
26
Interestingly, while principle 3 articulates the need to maintain traditional knowledge and

cultural expression of the iTaukei people, there is no specific reference to health practices,

nor is this the case in principle 10, which directs the government to promote cultural

inclusivity and focus attention on the continuance of cultural knowledge, art, and heritage

traits.

This section has established that Fiji has a health system well-positioned to address it’s NCD

challenges, with numbers of locally trained healthcare professionals well in excess of WHO

recommendations. These professionals are distributed throughout the country in both rural

and urban locations in hospitals, clinics and nursing stations. A national cultural policy is in

place but while mention is made of the intangible cultural heritage, no mention is made of

this in relation to indigenous health practice and knowing. The Fijian government also has

shown a reluctance to implement its own traditional medicine policy and while key regional

organisations are focused on the NCD epidemic facing the region, there is likewise a

reluctance to integrate cultural concepts, seen as being critical to the islander identity, into

other government activities. It is noted that such attempts to engage with indigenous health

knowledge and practice has so far only focused on herbal medicines with no attempt to

understand or integrate indigenous ways of knowing into healthcare delivery. Finally, it has

been shown that there has been limited research into the nexus between culture and health

policy in Fiji.

The next section sets out to look at how culture and health have and can be integrated. It

examines theoretical frameworks that underpin determinants of health and appropriateness of

the inclusion of culture in the delivery of health. This sets out to challenge the assumptions

that inform heath delivery in Fiji. The focus then turns to international and regional

agreements regarding cultural and indigenous rights to appropriate healthcare to which Fiji is

subject. This sets out what Fiji ought to be doing. This is followed by a section which says

what Fiji could be doing: indigenous ways of understanding health are briefly surveyed as a
27
means to provide a theoretical framework for understanding them, followed by a case study

from New Zealand is presented as an example of indigenous ways of knowing being

integrated into a community health program, necessary to providing a practical example of

what can be achieved.

Part Two: the relationship between culture and health

Determinants of health

Social determinants of health, the idea that the health and wellbeing of people is influenced

by their broader social context, has had currency since at least 2008, with the publication of

the Closing the Gap in a Generation report of the WHO Council on the Social Determinants

of Health (CSDH) and Marmot’s article in the Lancet, Social Determinants of Health

Inequities (Marmot, 2005). Today, Social determinants of health continue to inform

Sustainable Development Goals and forms the basis of the WHO and UN approach to global

health (CSDH, 2008; Marmot, 2015). The CSDH report takes as a given, health and

wellbeing are influenced by economic and social factors, listing ten categories (stress, early

life, social exclusion, work, unemployment, addictions, social support, food, and transport)

that effect health outcomes and addressing these is likely to increase life expectancy and

reduce the disease burden. A strength of this is the implied call on government to engage all

programs aimed at addressing underlying social and economic barriers to the goal of

improved public health.

While it does see cultural and social norms as providing context to understand social

determinants (CSDH, 2008, p. 43), and there is a call for a bottom-up approach to health

equity (CSDH, 2008) 160, and the report recognises the poor conditions faced by many

indigenous people (CSDH, 2008) pp4, 36, the recommended actions are those that seek to

ameliorate those social barriers to good health. Long, Komesaroff and Kath, point to the fact

that initial research which sits behind the CSDH report was based on health inequities

between and within European countries (Long, Komesaroff, & Kath, 2017) and ‘have been
28
applied to global health with very little adaptation to non-European societal realities’ (Long

et al., 2017, p. 267). This is not surprising given Marmot, one of the principal authors of the

CSDH, points to his famous studies of health inequities amongst employees at Whitehall

(Marmot, 2015, p. 2443) as partially informing his ideas.

A close reading of the initial CSDH report gives pause to question this scepticism. The report

gives considerable thought to indigenous aspects of health (the term ‘indigenous’ appearing

53 times in the document), stating: ‘Indigenous Peoples have distinct status and specific

needs relative to others, and Indigenous Peoples’ unique status must therefore be considered

separately from generalized or more universal social exclusion discussions’ (CSDH, 2008, p.

36). What it doesn’t do is acknowledge the connectedness of health and spirituality. While

the report may call for national governments to acknowledge, legitimize and support

marginalised groups, in particular Indigenous Peoples, in policy and legislation (CSDH,

2008, p. 205), it does so in a manner which doesn’t challenge the dominant biomedical

model. This points to the necessity to place culture firmly within a framework explaining

health outcomes, in particular for indigenous people.

Cultural Determinants of health

Several medical anthropologists and indigenous health scholars have conceived of a model to

incorporate cultural factors which influence health and wellbeing, The ‘Cultural

Determinants of Health’ model. What cultural determinants are, is contested and several

models that seek to acknowledge and address cultural factors that influence health and

wellbeing are surveyed here.

First Australian scholar, Ngarie Brown sets out to distinguish social from cultural

determinants (Brown, 2014). She recognises that social determinants, such as the

environment we live in, distribution of money, education and other resources are indeed

responsible for inequalities. However, she sees social determinants of health as being a deficit

29
model. In her description, social determinants indicate something that needs to be fixed;

increase access to education, jobs, healthcare, in other words, fix the problem underlying

poor health outcomes, and results will improve. This tends to problematise a population,

often one that has already experienced invasion, colonisation, and disempowerment. It is her

claim that ‘a strengths-based perspective, acknowledging that stronger connections to culture

and country build stronger individual and collective identities, a sense of self-esteem,

resilience, and improved outcomes across the other determinants of health including

education, economic stability and community safety’ (Brown, 2014). For Dixon, culture

‘forms part of the multifactorial etiology of disease operating in concert with social,

economic, and political factors’ (Dixon, Banwell, & Ulijaszek, 2013, p. 2), whilst for

Kaholokula, the practice of having health interventions that do not acknowledging culture,

makes little sense and he presents evidence they are less effective (Kaholokula, Ing, Look,

Delafield, & Sinclair, 2018) and favours a sociocultural context for understanding health.

A common theme among Kaholokula, Brown and Dixon is that they all discuss power. This

can refer to both the power or lack of it that many indigenous people have, and the more

specific patient/healthcare provider relationship. Dixon, is interested in how public health can

influence culture (Dixon, Banwell, & Ulijaszek, 2013, p. 5), whilst for Kaholokula it is

integral with indigeneity with a focus on altering the top-down approach of many health

interventions to a ground up approach emerging from the cultural group’s own worldviews

(Kaholokula, Ing, Look, Delafield, & Sinclair, 2018, p. 250). On the other hand, Anderson

discusses how indigenous people often see biomedicine as a form of ‘forced acculturation’

(Anderson, 2013, p.14).

Other aspects of biomedicine appear incompatible with indigenous ways of life, such as

Kleinman’s concept of the disease/illness dichotomy which claims that biomedicine treats

diseases but is less adept at treating the subjective and personal experience of being sick,

which Kleinman calls illness (Kleinman, 1978). He contends that illness is culturally shaped,
30
thus experience of illness is likely to differ between diverse cultural groups. Returning briefly

to Koholukula, the sociocultural context is therefore relevant as being the space in which

illness is experienced, supporting his argument of the logic of culturally designed

interventions. Knib-Lamouche proposes another dichotomy, one that distinguishes between

determinants that impact the individual, such as income education, employment, support

networks and the individual’s social capital, and determinants that impact not only the

individual but the community and whole populations, such as colonisation, culture,

migration, poverty, and access to resources (Knibb-Lamouche, 2013). Phillips takes a slightly

different view, seeing a dichotomy between spiritual and structural determinants (Phillips et

al., 2018) as a way to explain health seeking behaviours. What these all have in common is

they all see culture as central to people’s experience of health and wellbeing and the

desirability of health responses acknowledging this aspect.

Indigenous world views

Macpherson, writing about indigenous Samoans, indicates they hold a far more holistic view

of the nature and cause of their illness’ (Macpherson & Macpherson, 2003). According to

Macpherson, supernatural, natural, and social factors are likely to play a role in illness in the

minds of many Samoan people and with the attendant complexity of diagnosis in the minds

of many Samoans, it is little wonder they would see short consultations of overworked

healthcare workers in the public health system as being ineffective.

This brings into focus three concepts that are likely to be present in the minds of at least some

indigenous people in Fiji: folk medicine systems, which places a strong emphasis on magi-

religious rituals (Vivanco, 2018); personalistic healing systems which are rooted in the idea

that illness is linked to moral and spiritual transgressions; and naturalistic healing systems in

which health is viewed as a state of harmony between an individual and their environment

(Singer, Baer, Long, & Pavlotski, 2019, p. 163).

31
Cultural determinants in action: The He Pikinga Wairoa Implementation Framework

The He Pikinga Waiora Implementation (HPW) Framework (Oetzel, 2017) is an example

from New Zealand of cultural determinants forming the core of a health response. With four

focus areas of cultural centredness, community engagement, systems thinking, and integrated

knowledge translation, HPW aims to improve the uptake and implementation of prevention

and treatment programmes. With indigenous knowledge and self-determination at its core,

and co-design principals employed throughout, HPW has been successfully implemented by

several Maori health providers such as Te Hohao Health, a Marae based comprehensive

health program (Te-Kohao-Health, 2020). Culture-centred approach (CCA) is the theoretical

basis for the program. Developed by Mohan Dutta it ‘centres culture by ensuring that the

community has voice’ (Dutta, 2007). As an evaluation tool, HPW allows community partners

and end users to participate in program design and evaluation, voices that are commonly

missing from designing mainstream health program evaluations.

International, regional and national agreements on indigenous culture.

Fiji is a signatory of several international agreements which spell out its obligations regarding

its indigenous people and their right to appropriate healthcare delivery. These include The

2007 United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP). Two

articles, 11 and 24 of this declaration, are relevant to this discussion; Article 11 states:

‘indigenous people have the right to practice and revitalize their cultural traditions and

customs’ and article 24 states: ‘indigenous people have the right to their traditional medicines

and to maintain their health practices’. Similarly, The convention for the Safeguarding of the

Intangible Cultural Heritage (UNESCO, 2003). Section VI.1.2 states: ‘State Parties shall

endeavour to ensure the recognition of, respect for and enhancement of those health practices

that are recognized by communities, groups and, in some cases, individuals as part of their

intangible cultural heritage and that contribute to their wellbeing, including their related

32
knowledge, genetic resources, practices, expressions, rituals and beliefs, and to harness their

potential to contribute to achieving quality health care for all’.

The first of these, the UNDRIP, was over 20 years in the making. Taking a departure point

from the Universal Declaration of Human Rights of 1948 (UN, 1948), recognition for

indigenous rights grew. Indigenous rights were specifically mentioned for the first time in the

International Labour organisation’s 1957 Indigenous and Tribal Populations Convention 107,

(ILO 1957, Mazel 2018). With the creation of this convention, indigenous rights were for the

first time acknowledged. Mazel and others make the point that while UNDRIP is aspirational

and is not legally binding, countries are nonetheless monitored for their compliance.

Implementation has been patchy in many countries and ‘the effective degree of practical

implementation and effective realisation of the rights of indigenous people is still rather

unsatisfactory’ (Lenzerini, 2019). While some may be sceptical of conventions that are as yet

to be fully implemented, Coates reminding us that aspirational documents can serve to

‘convince people that (their) aspirations and dreams are real, appropriate, and above all else,

achievable’ (Coates, 2013).

The second of these, the 2003 Convention for The Safeguarding of The Intangible Cultural

Heritage (ICH), recognises that indigenous culture is made up of far more than physical

objects. As with UNDRIP, this convention is not enforceable but is likewise aspirational.

That it mentions indigenous health is noteworthy; that is specifically mentions state party’s

responsibilities, unambiguously places indigenous world views concerning their health, front

and centre of government responsibility, and most PICTs have ratified this declaration. At the

regional level, in 2010 SPC launched its Regional Cultural Strategy (RCS) (SPC, 2012) in

response to the ICH convention. The RCS places culture as being essential to progress, and

sustainable development, and ‘has great potential to both drive and support sustainable

development (SPC, 2012, p. 5) The seventh of the Regional Cultural Strategy’s 10 goals,

‘maintain culture in other social and economic sectors’ has particular relevance. In this,
33
culture is claimed to be an integral part of development, and cultural expectations, norms and

practices are important in development areas, including health.

There have been challenges implementing this policy. A report on the implementation of the

Regional Cultural Strategy (SPC, 2012) is critical of the efforts of regional governments. Of

particular note is the following: ‘we recognise that governments in the pacific islands still

treat culture in isolation from other national policies such as trade, development, education,

health, or environment’ (Goro, 2016, p, 15). While 13 PICTs are developing and

implementing national cultural policies, 6 PICTs are using cultural impact statements and 11

PICTs are using culture statistics and indicators to focus their efforts, in line it would appear

with the ICH convention of 2003, a key recommendation of the review is to integrate this

policy with the other SPC divisions. That there is some reluctance for this to occur is perhaps

suggested by the manner in which SPC describes culture. It claims culture is at the heart of

the pacific community but only understands it as a commodity such as dance, music or

handicrafts, things that can be included in a cultural festival. No mention is made of culture

as something intangible (SPC, 2020).

Conclusion

The fact that Fiji experiences elevated levels of NCD reflects a situation found in indigenous

populations throughout the region and the rest of the world. Health efforts in Fiji have

focused on social determinants, and while these are consistent with the SDGs, they aren’t

reducing the NCD burden. International conventions confirm the rights of indigenous people

to their traditional culture including health practices, yet a lack of clarity is observable within

the Fijian government in regards to these very rights. While the government has a cultural

policy in line with regional strategies, it is so far failing to meet its own goals: the integration

of culture into Fijian government ministries. The literature strongly suggests that cultural

determinants do have an important role to play in effective health policy, with an example

from New Zealand suggesting practical ways this could be implemented.

34
With international conventions and a strong body of evidence all suggesting the

appropriateness of basing healthcare delivery on cultural and social determinants, a key

question emerges:

Why does health policy in Fiji either neglect or fail to include indigenous culture as an

influencing factor in people’s health and wellbeing?

To do so, we need to examine the assumptions that inform health policy, which will be the

focus of the remainder of this thesis.

35
CHAPTER TWO: METHODOLOGY

Introduction

In the literature review, we uncovered evidence of a disconnect at the international, regional,

and national level in Fiji between biomedicine and culture. High figures of NCD rates were

revealed and governments and regional bodies have mobilised considerable efforts and large

sums to tackle this to little tangible effect. The numbers are increasing and showing no signs

of slowing. Evidence has been presented which suggests a model of health delivery which

places the individual’s culture in the forefront, can be successful in improving outcomes yet

there is no evidence that is occurring in Fiji. With the lack of success of government and

regional organisations to tackle their NCD burden, the author believes this is a timely

examination of what assumptions underlie policy and in so doing provide an opportunity to

suggest changes to government health policy based on what is revealed as well as uncover

areas deserving of more research.

The document to be examined, the government of Fiji’s 2020-2025 Department of Health

and Medical Services Strategic Plan (MHMS, 2020), was selected as preliminary

examination revealed some surprising themes. As NCDs are a principal focus of many

governments in the South Pacific, an area in which both Australia and New Zealand are

influential, it would be expected that at least some of the strategies employed in both those

countries in dealing with their respective indigenous population, albeit patchily, would be

present in this policy. As indicated in the literature review, some primary health organisations

in Australia and New Zealand have made a conscious effort to engage with indigenous people

in a manner which acknowledges their vastly different understanding of healthcare to the

established biomedical model, yet such views appear to be absent in the policy.

The main contention is that a pre-existing set of assumptions inform government and regional

health policy. Voices that one would expect to be heard remain silent, an 'imported’ health

36
framework is imposed on a population with a well-established and well understood

indigenous health epistemology quite different to that of the biomedical model. When failures

occur, the population is often blamed; it’s the people who are at fault, not the system that is

supposed to be delivering healthcare in the region. To unpack this requires us to understand

how power is coming in to play. That implies that we need to understand not only what is

said by whom, but how. By employing the methods below, it is intended to offer evidence of

the existence of these biases.

Research design

The research constitutes a single case study. At this stage, little is known about the nature of

the problematizations that sit at the heart of strategic health policy in Fiji. With its emphasis

on detailed contextual analysis (Dooley, 2016), case study methodology allows us to explore

health policy in detail. We are not at a point where other forms of investigation could be

undertaken; there is too little that is at this stage unknown.

There are several definitions of a case study that differ quite significantly. Robson

emphasises the case study’s focus on the here and now (Veltri et al., 2013) while Thomas and

Mayer’s definition: ‘the study of the particularity and complexity of a single case, coming to

understand its activity within important circumstances’ (Thomas & Meyers, 2015)

emphasises the singularity of the phenomenon being studied; Simons focuses on multiple

perspectives, while the important distinction between a case study and ‘variable led’ research

is emphasised by (Thomas & Meyers, 2015, p. 2), with the focus on a single phenomenon

exploring as much as possible, its uniqueness. They also quote Flyvbjerg, saying that the aim

of the research generated by a case study is getting close to reality, which requires us to take

a multi-dimensional approach to the subject (Flyvbjerg, 2006).

37
Research Method

Carol Bacchi’s What’s the Problem Represented to be (WPR) (Bacchi, 2012) is a method by

which a policy can be analysed by asking not what the policy is attempting to solve, but to

delve into the underlying assumptions that are necessary for the policy to make sense. Unlike

some other critical discourse analysis methodologies, (Bacchi, 2016a), it takes a radical

departure point, by not saying that the problems that policies seek to address sit outside them,

waiting to be dealt with, but that ‘government practices, understood broadly, produce

problems as particular kinds of problems’ (Bacchi & Goodwin, 2016, p. 14). A one-page

outline of the WPR approach is found at Annex 2.

Another way to explain this is to say that governments, through policies they create, engage

in problematization, in the sense that it refers to ‘the products of government practices, that

is, how issues are problematized’ (Bacchi, 2012). A simple example might be a policy that

focuses on physical activity for young people who are overweight. It is problematizing lack

of exercise as a cause of childhood obesity and is seeking to ameliorate this phenomenon

through policies that address physical inactivity (Bacchi, 2012). In other words, it has

problematized lack of physical activity. To have done so, certain assumptions must exist for

the government to act in such a way and not target other potential causes of obesity such as

food advertising, diet, or social factors unrelated to exercise. This has particular relevance to

understanding healthcare in Fiji. To make sense of the rationale which informs current policy,

it is necessary to understand the assumptions upon which such policies exist, and critically, to

understand what unexamined ways of thinking upon which the accepted practices are

(presumably) based.

This form of critical discourse analysis, while examining the language used, disregards many

of the more complex linguistic techniques that other analysis methods call upon. Critical

discourse analysists such as Fairclough (Fairclough, 2003) while focusing on power, tend to

38
look with far greater attention to how things are said without explicitly attempting to

understand underlying assumptions of the policy itself and the effect on people that it has.

While the WPR approach to policy analysis has seven distinct steps, the decision has been

taken to only employ the first four steps. Step five, which looks at the effects of the policy on

people’s lives would only be speculative. As the health policy was only released in early

2020, it is far too early to see the effect of the policy. In many respects, that part of the

analysis technique is less relevant to the overall focus of this thesis, to whit the employment

of social rather than cultural determinants of health in the formulation of health policy in Fiji.

We can conjecture the impacts of such policies, but it is beyond the scope of this study to

draw specific connections between the policy and the outcomes mentioned above. What this

method does allow us to do, is to shed light not just on what is said, but what isn’t, who has

been heard and who silenced, and lastly and most importantly, is there an observable

genealogy of ideas that inform the assumptions that underlie the policy?

The first four questions outlined in the WPR analysis technique, what is the underlying or

unexamined assumption, what deep seated assumptions underlie this representation of the

problem are then examined in turn, looking at two overall themes, one of expertise sitting

solely with one set of individuals and structures, and the absence of culture as an explanatory

view. The first part of question four, who is silenced and where are the silenced is also

answered in turn.

Finally, these are brought together by addressing the second part of this question: ‘can the

problem be conceived differently’. The reason for doing so, is that one possible way of

conceiving of this differently, falls out of both broadly defined unexamined assumptions.

Not just iTaukei culture

While reference is principally made to an idealised version of indigenous iTaukei culture

(Ravuvu 1983), this has been done as a way of presenting an example that suggests silences

39
and alternative approaches to healthcare that apply to culture in general and is not intended as

a tacit means of silencing or ignoring other cultures, knowledges, or world views. Fiji’s

population is made up of a number of diverse cultures, both indigenous and from elsewhere

(CIA, 2019), each of which have diverse ways of knowing the world. In addition, great

variety exists amongst iTaukei communities in regards to cultural norms and values, and their

expression is determined by many aspects such as urbanisation, religious affiliation, distance

from major centres, if they live in a village setting, or as galala, settlers who live on their

customary land or lease land from their land-owning clan rather than in villages but with

looser ties to their cultural homes (Overton, 1993, p. 51) and so on. Fiji is truly a

multicultural country and any attempt to generalise even one of these cultural groups, runs

the risk of oversimplifying a complex situation.

Limitations

With the arrival of COVID-19 and the temporary suspension of international travel, it is

impossible to interview key stakeholders in Fiji, as was originally intended. The operation of

power has to be determined through documentary evidence alone. This is a clear weakness in

this study. There is the potential that voices that would contribute informally to policy

formation are obscured as their contribution may not be in written form but rather within the

island concept of talanoa (Farrelly & Nabobo-Baba, 2014), telling stories in which many

voices outside the traditional power structures get to be heard.

40
CHAPTER THREE: WPR ANALYSIS OF STRATEGIC PLAN

Analysis references and supporting documents

Throughout this analysis references will be made to the strategic plan by page and paragraph

number. For example, 10/3.3.1 refers to page ten, paragraph 3.3.1 of the document. The

quotes from the strategic policy used in the following are found at Annex one. It is suggested

for clarity the reader refer both to the strategic policy and the Annex as well as the following

analysis.

Problematization: Access to healthcare

The principal discourse for this to makes sense is that access to healthcare is the principal

or only barrier to people seeking healthcare in a timely manner. Contained within this is

the assumption that the care that is presented is appropriate. This also presumes biomedicine

is universally accepted by the population, in the face of evidence to the contrary (McPherson

2003, 2008). It ignores that fully a third of Fiji's population lives in the Suva/Nausori

corridor, where health care is only a bus ride away. It is beyond the scope of this thesis to

enquire to the impact of long waiting periods, and an overstretched public health service on

late presentations, but given well over two thirds of the population live on the main islands

for whom a secondary or tertiary healthcare facility is relatively accessible by public

transport, the high rates of late diagnosis, a recognised cause of complications (1/message

from the minister), the expansion of subdivisional hospitals and medical centres whilst

laudable (20/4.1.1; 22/4.2.1) is alone unlikely to have a large effect on late presentations.

This discourse relies on a binary of remotely located and urban healthcare consumers as two

separate groups. In 22/4.2.1, it is stated that there is a need to provide services closer to

people's homes, but no evidence is presented which suggests how this conclusion was
41
determined. As the implication is that there is a population who didn't access care at all, what

research that could be done was only conducted on those who actually presented for care at

some point, meaning those that didn't present cannot be included in the data.

This has the effect of silencing a significant population, those who should trouble health

professionals the most: those that never engage with the health system at all or do so

haphazardly. The concept of survivorship bias, ‘a logical error that leads to false conclusions

by concentrating on the people or things that made it past a particular selection process’

(Yeong, 2020), has relevance here as evaluations can only be based on those who have

presented for care. If this is the case, then it has deep implications for the policy, as we are

basing policy settings on those who already engage with the health system, not enquiring why

others are not.

Suggested genealogy of ideas

But how did the current policy end up looking like it does, in apparent contrast to decades of

research from many parts of the world? A hint to this may lie in Fiji’s historical governance .

A suggested genealogy of ideas is presented to provide context. It must be acknowledged this

is done purely to suggest a sequence of ideas for the problematization and the two

unexamined assumptions which lie at the basis of this analysis to make sense. It can be seen

as being at odds with Foucault’s description in so much as it eschews complexity. Foucault

speaks of the necessity to focus on particulars, on what he calls ‘a field of entangled and

confused parchments’ (Prado, 2000, p. 34) and Fiji, with its complex history, is especially

resistant to an essentialist narrative. What follows is but an overview of historical factors and

deliberately chooses not to engage with the complexities that inevitably exist when different

sets of ideas come into contact, as the analysis which follows, tends to focus attention on that

complex, layered understanding, the focus on the particular rather than the general will

inevitably produce.

42
The colonial experience, never mind how benign, pits a colonising power with knowledge

and power, against a colonised population whose knowledge is undervalued, their voice

silenced and whose agency is curtailed save in the service of empire (Said, 1994; Keown

2005). For this to occur, other knowledges had to be both supplanted and supressed.

What this amounted to in Fiji was a devaluation and eventual loss of much traditional

knowledge as the indigenous population were encouraged to adopt new ways (Bayliss-Smith

1988). They were to forget their old Gods, Jehovah had called them (Thornley, 2005); they

were to become consumers, selling some of their crops for clothing and other items they had

lived without for millennia as well as to pay tax to the colonisers to administer the colony;

their traditional (and historically incredibly fluid) indigenous political structures were
12
subsumed and ossified (Derrick, 1957; Gravelle, 1983; Routledge, 1985) , so their

traditional leaders became instruments of colonisation and eventually when independence

came, their political leaders.

In the field of healthcare, biomedicine, first practiced by colonisers but increasingly in the

hands of indigenous practitioners has supplanted old knowledge. Fiji of course already had a

holistic tradition of healthcare (Spencer, 1966; Weiner, 1984; Cambie, 1994, Chand, 2018).

Many were (and indeed are) experts in herbal lore; there were bonesetters skilled in setting

broken limbs; masseurs adept at addressing muscular aches and pains; midwifery was a skill

passed down from mother to daughter; some with particular family linages were understood

to possess both the knowledge and supernatural powers (mana) to diagnose and treat a wide

range of indigenous illnesses.

Little has changed since Fiji gained independence in 1971, A dominant Western biomedical

system of healthcare continues to enjoy a privileged status. It is a symbol of modernity and

reflects the power of those elites, some of whom are descendants of the same traditional
12
while traditional land ownership claims have long been settled, there is a much more fluid situation when it
comes to succession to traditional titles, which remains a vexed issue for many communities (Tuimaleali’ifano,
2006)
43
leaders who offered Fiji to the British Crown 150 years ago who, just as the colonisers and

missionaries attempted to do, crowd out other ways of knowing in the face of their own

superior knowledge13.

The focus on social determinants of health (WHO, 2020) within the policy assumes there are

things that needs to change and that addressing those wrongs (education levels, physical

access to healthcare, lack of knowledge, exercise rates, diet) will bring about the good

changes the strategic policy hopes to bring about. It implies there is something wrong with

the population, and medical professionals alone know what is wrong with the population;

they have done the research; they have studied extensively; they have consulted international

experts; brought them in to advise (or in this case write the strategic plan) and applied

modern means of evaluation, asking questions that seek to answer the problems they conceive

of as being problems and therefore they know the solutions.

During the colonial period and the 50 years since independence, the population have been

expected to be compliant and to a considerable extent that continues to be the case. The

country has been led by former military leaders since 1986 and for at least part of that time

there were restrictions on free speech with Morris’s report into self-censorship in the Media

(Morris, 2017, p. 29) showing a continued wariness amongst senior journalists to even

acknowledge their own self-censorship, such is the residual climate of fear. Indigenous

culture also tends to be rather status-conscious: the language is very specific in means of

showing respect; taboos on physical position reinforce age and gender hierarchies; even the

gaze is everted when speaking to an elder as means of showing humility and respect (Ravuvu,

1983; Meo-Sewabu, 2016). In other words, alongside the colonial experience and the

13
While early healthcare workers used (and continue to employ today) indigenous herbal remedies, particularly
when financial issues and availability restricted access to medicine, the rather tricky area of causation continues
to be problematic to both practitioner (who likely as not still believed in part the indigenous supernatural
explanations) and the population, as an example of ‘superstition’, an acknowledgement the old gods are still to
be silenced. The integration of traditional beliefs and Christianity is a complex issue, one often
unacknowledged, though beginning to be examined by writers such as Jacqueline Ryle (Ryle 2018), often in the
light of climate change.
44
reluctance of at least some of the population to contribute openly lest their perceived criticism

of the government land them in trouble, sits an indigenous system in which elites are

expected to be followed unquestioningly, and significant parts of the population effectively

silenced.

Underlying assumption one: expertise sits solely with medical authorities

Thus, an underlying assumption in this strategic policy is that expertise sits solely with

medical authorities. The design approach (5/1.4), indicated that most of the consultation was

principally with health professionals. It was acknowledged that visits were made to

communities, but the key activities of participatory workshops were done it appears with

health professionals alone14.

In a culture where respect is generally shown to those in authority, it is unlikely that those

members of the public who were consulted, would be likely to be open in offering their

opinions15. As the overriding concept of the appropriateness of the model of healthcare

provision is unchallenged as the policy acknowledges, saying that the ‘most viable option for

combating NCDs is continuing to focus efforts on prevention’ (10/3.3.1 my italics), this gap

is unlikely to be apparent. Throughout the design approach, the assumption is that expertise

sits with healthcare professionals. This can only make sense if the current approach is the

only one that could be applied, therefore there is no need to engage consumers to address

questions already determined by those with the expertise, or to answer research questions

other than those posited by people formulating the policy.

Ideas around medical pluralism, ‘a social practice that produces hybrid (i.e., a mixture of

traditional and modern) forms of medicine’ (Ferzacca, 2001 p 210) are silenced despite its
14
Anecdotal evidence suggests that community consultations are usually done as a means to inform people what
the government intends to do, not as an opportunity to seek peoples’ input; certainly, the policy is not explicit in
how the public were actively consulted
15
During iTaukei meetings, young people, women and most certainly LGBTIQ+ people are both not expected to
contribute, they are often actually physically distanced from those taking part in discussions. Young men are
expected to serve their elders Yaqona in silence whilst women, if they are present at all, are usually found at the
rear, in all likelihood unlikely to hear what’s taking place, let alone contribute. This suggests the need to consult
not just community members as a whole but pay attention to ensure all members are able to contribute.
45
presence in many parts of the world (Baer 2011). Many have observed the pluralistic life of

many people in modern Fiji (Vunaibola, 2011; Meo-Sewabu, 2015; Naboro-Baba, 2006;

Veitayaki, 2012), suggesting this might also apply to the field of medicine. Baer observes this

practice as one which ‘reflects hierarchical relations to the larger society’ (Baer 2011, p.

411), making it especially pertinent in so much that with the aforementioned stratified nature

of Fijian society, hesitating to acknowledge this description of healthcare in Fiji, this

alternative way of framing or understanding healthcare in Fiji, is a clear case of subjugated

knowledge. While efforts are being made to include indigenous ways of knowing in health

care in Australia (Brown; "Gnangara (Traditional Healers) Program," 2014), these have so far

not entered the mainstream. India, on the other hand, has a long history of medical pluralism

recognised by three systems: the biomedical system, the Ayurveda system and what

“indigenous therapy” (Lambert, 2012). Lambert does however point to the challenges of

indigenous therapies been given the same status as the first two, which suggests that as in

Fiji, India sees a hierarchy of medical systems with the indigenous systems failing to gain the

same status as other systems. The WHO Traditional Medicine Strategy (WHO, 2002, 2013b)

speaks of traditional and complementary medicine (T&CM) acting alongside Western

biomedicine. The policy seeks to build the knowledge base of active management, strengthen

safety and proper use of traditional and complimentary medicines. Of particular interest is

strategic goal 4.3 (WHO, 2013b, p. 54) which is to integrate T&CM into healthcare delivery.

It states:

Mindful of the traditions and customs of peoples and communities, Member States
should consider how T&CM, including self-health care, might support disease
prevention or treatment, health maintenance and health promotion consistent with
evidence on quality, safety, and effectiveness, in line with patient choice and
expectations.

(WHO, 2013b, p. 54)

46
With the interlocking systems of post-colonial power structures and cultural traditions of

silencing in place (McPherson, 2003), we see the absence of the concept that people are

experts in their own lives, which subsequently appears to be a viable alternative way of

framing the problem. A way to reframe this might be to instead of simply calling upon

medical professionals alone, consider how the combined knowledge of medical professionals,

folk healers, and others to whom people turn to, could w3 be best be employed for the benefit

of the entire population. Consequently, the fact that others besides MHMS staff might have

input into producing positive health outcomes is left unproblematic.

With this silencing of the holistic approach of indigenous healthcare, one which

acknowledges the interconnectedness of spiritual, physical, social, and environmental factors

in a person’s wellbeing (Dudgeon, 2014), the adoption of a reductionist approach is perhaps

inevitable. Evaluation methodologies that seek to reduce healthcare to a set of measurable

KPIs (2/forward from the permanent secretary) have the potential to atomise healthcare. To

divide healthcare into promotive, protective, and preventive care, separate from clinical care,

(19/strategic priority 1) may appear reasonable. However, research suggests that this

perpetuates the overall problem of the separation of the physical manifestation of disease

from the complete experience of disease, including the social role a person adopts or the

process by which illness becomes a social event (Singer, 2019).

Underlying assumption two: Culture plays no part in understanding health outcomes

Just as we see a silencing of people, their culture too is unacknowledged. Throughout the

policy, culture is mentioned only once and that in a negative fashion (8/2.2) as being a factor

contributing to poor outcomes for women, adolescents, and children.

The absence of the incorporation of culture in the policy suggests an assumption that cultural

practices are a barrier to good change. While there can be little doubt that women in

47
particular find themselves silenced in a male dominated culture, one in which intimate partner

violence is still prevalent (Biersack, 2016), and there are strong cultural barriers to LGBTIQ+

people being heard16 (Besnier, 2014), for a government to see culture only in terms of its

negative features is troubling. Acknowledgement that cultural practices can also be life

affirming or even relevant is absent, as is the concept of culture being more than a set of

practices17. The idea of reductionism, a consistent theme throughout the policy, is at work

here. Rather than seeing culture as an overarching set of values and ways of seeing the world,

something in which all aspects of a person’s life have meaning, a singular part of cultural

practice is isolated and critiqued. There is no intent to downplay the impact of intimate

partner violence, but if we identify a social phenomenon as something that occurs within a

culture, then addressing that within the cultural framework makes sense. iTaukei culture has

numerous means of acknowledging social problems and addressing them (Arno, 1976).

Several NGOs currently work in the women’s’ peace and security movement do exactly that

(Bhagwan-Roll, 2016) (IWDA, 2016), in the acknowledgement that working within the

cultural framework is the only way to bring about changes in behaviour. The We Rise

Coalition in Fiji (IWDA, 2016), made up of four vibrant feminist organisations, all of whom

are addressing intimate partner violence head on, seeking to both advocate for policy change

and working with community members themselves to bring about attitudinal change.

There is perhaps a larger set of factors at play. Another discourse needed for the absence of

culture in health strategic policy to make sense takes its cues from a rights-based discourse, in

which all citizens are equal. Fiji's post-independence history has been marked by much

political instability, with four military coups between 1986 and 2006 (Robertson, 2017;

16
Though Fiji historically has had a far more fluid understanding of gender than is currently the case. See
Presterudstuen 2014 for more information
17
It is noteworthy the Regional Culture Strategy to which Fiji is a signatory, (SPC 2012; Goro 2016) specifies
the necessity of treating culture as having tangible and intangible aspects. Goro, in the Regional cultural strategy
mid-term review (Goro 2016 p14) states that culture in health although it is an integral part of development
continues to be ignored with it comes to systematic, planning, knowledge management and regional level
interventions. She goes on to state that as this thesis demonstrates, ‘governments in the Pacific Islands still treat
culture in isolation form other national policies’ (ibid p15).
48
Frank, 2009) largely factored on questions of race, with much ugliness present as nationalist

indigenous leaders sought to play on indigenous people’s fear of the wealthier Indo-Fijians,

particularly regarding land rights (Lal, 1992; Research Directorate, Immigration and Refugee

Board, Canada 1996). Until the adoption of the 2013 constitution, (Republic of Fiji, 2013),

race was a determining factor in access to education and voting rights, and a host of other

legislative barriers were imposed on the non-indigenous (Ghai, 2007). The 2013 constitution

fundamentally changed this, with equal voting rights being granted to all communities and

the redefinition of the term Fijian to apply to all citizens of Fiji, not just those of an

indigenous background (Saati, 2020). As a result, there has been a growing trend towards

enshrining that equality into other areas, including the author suggests, health. If it is no

longer politically desirable for culture and race to be defining characteristics of an individual

or a group of citizens, then it makes sense to focus on socio-economic, age cohort and setting,

anything except the divisive issues of race and by extension, culture.

While a rights-based approach may have albeit inadvertently lead Fiji to pursue a one size fits

all health system, this is also contradictory in the light of agreements and conventions to

which Fiji is a signatory. As discussed in the literature review, Fiji is a signatory of The

Convention of The Intangible Heritage which states:

States Parties shall endeavour to ensure the recognition of, respect for and
enhancement of those health practices that are recognized by communities, groups
and, in some cases, individuals as part of their intangible cultural heritage and that
contribute to their well-being, including their related knowledge, genetic resources,
practices, expressions, rituals and beliefs, and to harness their potential to contribute
to achieving quality health care for all.

(UNESCO 2018)

It is clear that by not even acknowledging cultural factors, let alone describing them in

exclusively negative tones, the strategic policy is running at odds with this framework. Also,

the Declaration on the Rights of Indigenous People (UNGA, 2007) in article 23 states:
49
‘indigenous peoples have the right to be actively involved in developing and determining

health, housing and other economic and social programmes affecting them and, as far as

possible, to administer such programmes through their own institutions’ (UNGA, 2007, p. 18)

Fiji is also a signatory of the Yanuca declaration (WHO, 1995) whose undertakings are

outlined in its Healthy Islands Framework (WHO, 2015). That framework specifically calls

upon signatories to enable health issues to be addressed ‘in partnerships among communities,

organizations and agencies at local, national and regional levels’ (Galea, 2000, p. 170). For

this to be the case it would be presumed that policy makers would not only consult

stakeholders, but actively seek to engage communities in all levels of planning, something

about which the document is silent.

In other words, the integrated understanding of health and wellbeing consistent with iTaukei

culture is in fact embedded in several of the key conventions to which Fiji is a signatory. A

question that emerges is: would it be possible to integrate culture as discussed in the two

conventions mentioned above with health delivery in Fiji?

As it happens, Fiji has a well-developed traditional iTaukei structure which sits alongside

government administration. Each village has a traditional hereditary leader turaga ni vanua

(chief) as well as a voluntary local government representative turaga ni koro (village

headman) and a voluntary nasi ni koro (community health worker) (Aubrey, 2014; Ravuvu,

1983). The traditional leader is answerable to tikina (district) traditional leaders as well as

provincial high chiefs and has carriage of traditional (vanua) questions, whilst the elected

village headman is, alongside the community health worker, answerable to district and

provincial government administration. This structure is ripe for exploitation in integrating

both sides of community leadership, the traditional and adminstrative, in creating integrated

health programs that acknowledge traditional knowing as well as biomedical knowledge,

much as occurs today in rural Australia with Ngangkari workers (Panzironi, 2013) where

traditional health practitioners help bridge the gap between two vastly diverse cultures.
50
The policy is silent on the concept of cultural safety (McEldownie, 2011) as a factor which

might influence the uptake of both preventative and clinical care. Evidence from Australia

and New Zealand suggests that incorporation of cultural safety within an ethic of care is

important in producing positive outcomes, whilst ‘two eyed seeing’ (Siversten, 2019) focuses

attention on spirituality as a ‘powerful determinant of health’ amongst older indigenous

Australians.

Contained within these lies the concept that cultural practices can also be supportive and life

affirming; that culture is defined by more than a series of practices but represents a range of

values and attitudes as well as actions and behaviours. While the policy does speak to

integration, it only does so in terms of constituent parts of the MHMS program (2/ forward;

23/4.2.2), not in embedding healthcare within a cultural setting. Linking promotive,

protective, and preventive efforts with clinical care does attempt to contextualise clinical care

and acknowledges the importance of preventative and primary care that is central to

combating NCDs (10/3.1.1). Setting aside for the moment the implication that current

practices are adequate in the light of ever increasing NCD rates contained in (10/3.1.1), it is

noteworthy that it does so without explicit attempts to culturally embed such efforts.

Analysis summary

What this analysis uncovers is the underlying assumptions upon which this policy sits are

flawed. The intention is not to challenge universal health coverage as a social good, but if we

haven’t investigated the reasons for late patient presentations, failed to recognise the rights of

Fijian citizens to culturally appropriate healthcare, ignored findings from an SPC

investigation into cultural policy, failed to consciously engage those living on the margins of

large urban centres, often displaced because of previous government policies and most

importantly, ignored the evidence found in many indigenous health programs implemented in

many parts of the world which deliver culturally safe healthcare care in a manner which

51
increases adherence to programs aimed at delivering good health outcomes, then we can have

little confidence the current depressing state of affair won’t continue.

52
CHAPTER FOUR: CONCLUSION

In this thesis, the Fijian Ministry of Health and Medical Services 2020-25 strategic policy has

been revealed to be based on the problematization that access to healthcare is the main barrier

to people being able to attend to their healthcare needs. This is informed by the goal of

achieving universal health coverage in line with SDG3 and WHO policies.

Evidence has been presented that despite many challenges, Fiji manages to considerably

exceed the numbers of health professionals per head of population as recommended by

WHO. While the distribution of healthcare workers is always a critical factor, Fiji has a well-

established secondary and tertiary rural healthcare system and is focusing on further

increasing these numbers. In acknowledging these efforts, it needs to be born in mind that the

clear majority of people live on the two main islands, for whom a nursing station or health

centre is already within comparatively easy reach. Setting aside the problem of long waiting

times and the challenges of access to healthcare for those living on the outer islands and rural

parts of the country, the goal of universal health cover is already close to being achieved.

Therefore, it is reasonable to presume that other factors aside from access are at play for the

lack of success in stemming NCD rates.

The analysis revealed the problematization of access is informed by two interrelated

assumptions located in the appropriateness of current biomedical method of delivering

healthcare, and iTaukei cultural understandings of health and wellbeing in healthcare

delivery.

The literature review and the analysis revealed little evidence that Fiji is in fact adhering to

the international, regional and domestic declarations, conventions and policies regarding

indigenous cultural rights and the importance of intangible cultural heritage to which Fiji is a

signatory. These provide a firm basis for the delivery of healthcare in a manner best suited to
53
the cultural understandings of healthcare found amongst many indigenous people including

Fiji’s indigenous iTaukei population.

Determinants of health have been shown to be key to good health and wellbeing (Marmott,

2005). The strategic policy explicitly focuses on social determinants, which it is suggested,

both problematize people, and by employing a Cartesian body/soul dichotomy, fails to

acknowledge a person’s concept of health and wellbeing, in particular in regards to the

iTaukei people, a population with a demonstrated holistic approach understanding of their

health and the causes of illness.

A cultural determinants approach, which addressors factors negatively impact a person’s

health and wellbeing, and deliberately aims to incorporate that individual’s cultural

framework for understanding their health and wellbeing in healthcare delivery, is a possible

approach that could be incorporated in Fiji. It is suggested here that following on from

evidence found in the case study from NZ there is the likelihood that the application of such

an approach in Fiji might be profitable.

The WPR analysis revealed the concept of medical pluralism to be absent from the strategic

policy. Many iTaukei people practice a form of medical pluralism, seeking healthcare from

several sources, of which the MHMS is but one. The literature review revealed there has been

little research as to the extent this occurs, and why, and we also do not know what is the

impact of people’s health practices on their health outcomes. Are there instances when people

will seek care early and others where they do not? Do some people manage to incorporate

iTaukei systems of causation with biomedical treatments, and some not? These are areas that

are under-researched and understanding how people practice healthcare on the ground

coupled with gaining a better understanding of the reasons people who don’t present at all or

in a timely fashion could well help inform future health policy interventions.

54
The genealogy of ideas focuses attention on the long shadow of Fiji’s colonial past, when

traditional ways of knowing were in some cases silenced. This combined with the author’s

theory, that Fiji is avoiding focusing on divisive racial and cultural identity, suggests a

plausible reason for the silencing of cultural concepts in health care policy.

The lack of effective consultation outside of the medical fraternity and the lack of any

evidence suggesting research has been done to understand those whose engagement with the

medical system is sporadic, places focus on the assumptions that inform this strategic policy

being essentially flawed. In a country where to “talk up” is frowned upon (Ravuvu, 1983, p,

104), extra efforts are needed to bring into focus their points of view and suggests an area for

further research.

In addressing the question, can the problematization of access to healthcare be framed

differently, the possibility of problematizing access with a focus on the appropriateness of

the care presents tantalising possibilities. With Fiji’s iTaukei hierarchy and the strong

connection to Vanua of its traditional leaders sitting alongside a well-trained and resourced

medical system, the possibility to incorporate traditional understandings of health and

wellbeing with the delivery of timely health interventions, not only acknowledges the

international, regional and domestic agreements to which Fiji is a signatory, but, as has been

demonstrated elsewhere, is an effective means of addressing challenges in helping bring

about good health outcomes amongst indigenous people .

55
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67
ANNEX 1

MHMS Strategic Policy

unexamined or

underlying page section quote from strategic plan

presumption

access and or The decentralisation of specific

availability of care services to divisions will assist us in

Message
is the principle achieving our aim of reduction in
1 from the
reason for either complications, as our people will be
minister
non or late able to access services more

presentation efficiently

There is a need to provide services

closer to people’s homes and to

improve services for our young

population, both in schools and at

health facilities.
22 4.2.1
We will therefore continue to

decentralise maternal health services

to subdivisional hospitals to provide

quality maternal health services closer

to the community.

20 4.1.1 We will seek ways to expand the

Outcome 1.1 availability of promotive, protective

– Reduce CD and preventive care in communities,

and NCD and innovative ways of doing this for

prevalence, people living in hard-to-reach

68
 locations; for example, through

especially telehealth, specialist mobile clinics,

for CHWs, expanding outreach and

vulnerable exploring value-added links with

groups CSOs and other development

partners.

By ensuring improved outreach in

collaboration with nursing stations,

health centres and community health

workers (CHWs), and support to

23 4.2.2 families and individuals in the

community (in particular women who

often are the primary caregivers), we

also aim to reduce the burden on our

hospitals.

Our aim is to improve the overall

Message service experience of our patients. We

1 from the will do this by providing clinical

Minister services in a standardised manner

standardisation is
across the country.
the best way of
4.2.3 Our aim is to improve the overall
delivering
Outcome 2.3 experience of our customers. We will
healthcare
– do this by providing clinical services
24
Continuousl in a standardised manner across the

y improve country….... By the end of 2025 we

patient want to have achieved the following:

69
 safety, and Improved access to standardised

the quality treatment services including timely

and value of diagnosis, treatment, and efficient

services referral.

Underpinned by good health systems,

it is imperative we provide high-

quality clinical services to our

patients, including: inpatient and

outpatient services, oncology,

accident and emergency, surgery, oral

health, eye care, physiotherapy,

that biomedicine is
mental health, dermatology,
the most
paediatrics, and obstetrics and
appropriate way of 23 4.2.2
gynaecology services. These services
delivering
are supported by the very important
healthcare
functions of radiology, pathology,

nutrition, pharmacy, laboratory, and

cleaning and security services. It is of

paramount importance that these

clinical and support services work

well together as part of the one system

approach.

expertise sits with Phase 3 – Consultations: We

1.4 Design
medical authorities. consulted widely across all divisions –
5
approach
There is no need to including hospitals, health centres and

consult with the divisional staff – representing public

70
 health, clinical services, support

services and corporate staff. We ran

participatory workshops to share

information, build consensus and gain

feedback. We visited divisional offices,

subdivisions, hospitals, health centres,

nursing stations and communities. We

general population spoke to 157 staff in total and

provided updates through a bespoke

newsletter. The approach

incorporated inputs from a wide

cross-section of departments and

activities. We ensured our process was

harmonised with the whole-of-

government approach to planning.

We aim to use this approach to

progress towards achieving Universal

provision of
Foreword Health Coverage with a focus on
universal
from the quality health
healthcare will 2
Permanent care which is necessary for good
cause a lowering of
Secretary health. This will assist us in
NCD rates in Fiji.
progressing towards our vision of a

healthy population.

decentralisation of 4 1.2 Plan in a 2.2. Strengthen and decentralise

healthcare will page effective clinical services, including

have a positive rehabilitation, to meet the needs of the

71
 population

The decentralisation of specific

services to divisions, will assist us in

impact on health
achieving our aim of reduction in
outcomes 23 4.2.2
complications, as our people will be

able to access services more

efficiently

We aim to reform public health

services to provide a more population-

based approach for disease prevention

Foreword
and addressing the health impacts of
from the
2 climate crisis. This integrated
Permanent
approach to public health is further
Secretary
expanding the defined, with a focus on expanding the

availability of availability of promotive, protective

promotive, and preventive care across all islands.

protective and An integrated approach to public

preventive care is health. Here we define public health

necessary as preventing disease, prolonging life

and promoting health through the

Strategic
19 organised efforts of society. Core to
Priority 1
this is ensuring we seek ways to

expand the availability of promotive,

protective and preventive care across

all islands.

10 3.3.1
current means of Ultimately, the most viable option for

72
providing
combating NCDs is continuing to
preventative and
focus efforts on prevention and
primary healthcare
primary healthcare
are adequate

Through an integrated approach to

public health and by strengthening the

continuum of care for patients, we will

1.1 Strategic improve the health and well-being of

3
Intent all Fijians and combat the social

determinants that affect people’s

lives, especially the lives of the most

vulnerable and marginalised.

These outcomes and risks relate to the

disadvantage that many Fijian

3.1.3
social determinants adolescents experience across the

of health social determinants of health

To tackle the social determinants of

health, strengthen the prevention of

NCDs and CDs, improve service

reach and access, and push forward

our research and innovation, we must

27 4.3.7
promote health systems as everyone’s

business i.e. government ministries,

communities, civil society,

universities, citizens and the private

sector

73
 The largest component of health

expenditure is the health workforce. In

Fiji, as elsewhere, there is a shortage

of skilled professionals.Fiji has made

progress in recruiting more skilled

shortage of skilled health professionals to work in the

professionals is a 14 3.3.1 sector. There are skills shortages in

significant problem specific cadres and specialisations. A

significant proportion of the ministry’s

existing workforce is nearing

retirement and a large group of

employees are still in the formative

stages of their development.

74
ANNEX 2: WPR CHART: WHAT’S THE PROBLEM REPRESENTED TO BE?

(WPR APPROACH TO POLICY ANALYSIS)

Question 1: What’s the problem (e.g. of “gender inequality”, “drug use/abuse”, “economic

development”, “global warming”, “childhood obesity”, “irregular migration”, etc.)

represented to be in a specific policy or policies?

Question 2: What deep-seated presuppositions or assumptions (conceptual logics) underlie

this representation of the “problem” (problem representation)?

Question 3: How has this representation of the “problem” come about?

Question 4: What is left unproblematic in this problem representation? Where are the

silences? Can the “problem” be conceptualized differently?

Question 5: What effects (discursive, subjectification, lived) are produced by this

representation of the “problem”?

Question 6: How and where has this representation of the “problem” been produced,

disseminated and defended? How has it been and/or how can it be disrupted and replaced?

Step 7: Apply this list of questions to your own problem representations.

Adapted from: C. Bacchi and S. Goodwin (2016) Poststructural Policy Analysis: A Guide to

Practice. New York: Palgrave Macmillan, p. 20.

75