Investigating the Impacts of Decentralisation on Access to Primary Health Care in Fiji: A Qualitative Multiple-Case Study

Abstract

Background: Globally, since the 1970s health sector decentralisation has been widely implemented as a reform mechanism, particularly by developing countries. With the aim of improving access to health care, in 2009 Fiji initiated decentralisation in one administrative division. This research set out to answer the following question: What are the impacts of decentralisation on access to adult outpatient health services in the Suva Subdivision? Methods: Using a qualitative multiple-case study design, semi-structured interviews were conducted across seven study sites (three decentralised health centres, a non-decentralised health centre, a divisional hospital, a private general practice, and the Ministry of Health central office) in 2014. Reflecting a triangulated approach, interviews were conducted after informed consent with patients, providers and administrators. Supplementing those data, utilisation and expenditure data before and after decentralisation, and policy documents concerning the design and implementation of the decentralisation initiative were analysed. Findings: Implementation of decentralisation was rushed, with administrators having to make decisions ‘on-the-run’. Rushed implementation meant that extended hours and expanded scope of service were not matched with increases in health professional staffing, and diagnostic and pharmaceutical services were not similarly extended. Although workload was moved from the centre to the periphery, decision-making remained centralised. Providers were faced with increased and changing utilisation patterns and shortages in staffing, equipment, medicines and consumables. Providers struggled to deliver quality health services, and actively ‘worked the system’, often outside of formal structures, to provide health care. Patients were positive about the extended hours, but access was negatively affected by lengthy wait-times, brief engagement with doctors, out-of-stock of medications and a lack of basic and diagnostic equipment in decentralised health centres. Patients described having to ‘run-around’ between health centres and divisional hospital to complete their treatment, entailing increased costs, time and travel in seeking health care. Implications: All three groups of participants regarded decentralisation favourably. However, there is much scope to further improve access through strengthening decentralised health centres. This research has implications for advancing understanding on models and implementation of decentralisation, and frameworks of access. The importance of transferring decision space as well as workload in decentralisation initiatives was highlighted. Theories of access emphasise provider and patient characteristics in shaping access, but the role of policy and its implementation are not adequately reflected, although they are central to improving access. Finally, existing frameworks on access can be enhanced by understanding the interactions between the dimensions of access and drawing out supply and demand aspects of each dimension.