UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental healthMr. Dainius Pūras

Country visit to Fiji, 28 November to 5 December 2019

Preliminary observations

Suva, 5 December 2019

 

Members of the press, 
Ladies and gentlemen,

Bula Vinaka,

I would like to begin by sincerely thanking the Government of Fiji for inviting me to assess in a spirit of dialogue and cooperation, the realization of the right to physical and mental health in Fiji. I highly appreciated the level of support towards the good realization of my official visit.

During my 8-day mission I travelled to Suva, Nadi, Taveuni, Labasa and surroundings to visit health facilities and meet with public officials, medical staff and a range of other stakeholders. In the capital Suva, I met with the Honourable Attorney General, with the Honourable Minister of Health and the Permanent Secretary of Health and Medical Services, with the Honourable Minister of Education, Heritage and Arts and Permanent Secretary for Education, Heritage and Arts. I held meetings with the HIV/AIDS Board, the Director of Climate Change and with officials from both the Ministry of Women, Children and Poverty Alleviation and the Fiji Corrections Service. Further, I met with the Director of the Fiji Human Rights and Anti-Discrimination Commission and visited the divisional hospital in Lautoka; sub-divisional hospitals in Vunidawa and Taveuni; the St Gilles Psychiatric Hospital; the Hospital Ship "Veivueti"; health centres in Sawakasa, Nasau, Punja, Kamikamica and Seqaqa; the new Makoi Maternity Unit in Suva, as well as nursing stations in Qamea, Bouma and Coqeloa.

I had the opportunity to also meet with many representatives of civil society and grass-roots organizations in each of the places I travelled to, as well as with representatives of United Nations entities based in Suva. I take this opportunity to thank the Regional Office for the Pacific of the Office of the United Nations High Commissioner for Human Rights for its crucial support to my visit. 

During my mission, I was interested to learn about progress made and existing challenges. There is strong political will in Fiji to advance the human rights agenda. Fiji is one of the key players in the Pacific region with solid leadership on combatting the negative impact of climate change. It plays a role model for the other Pacific Island Countries as a member of the United Nations Human Rights Council and beyond.

Before continuing, I would like to inform that in this room, you will find a document that explains my responsibilities as the United Nations Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, as well as the in-focus issues for this official visit to Fiji. I am an independent expert who reports to, and advises, the United Nations Human Rights Council and United Nations General Assembly on the realisation of the right to health.

Legal framework

Fiji is a State party to all core nine international human rights treaties, in particular those enshrining the right to health, including the International Covenant on Economic, Social and Cultural Rights, ratified in August last year, as well as the International Conventions on the Elimination of All Forms of Racial Discrimination, on the Elimination of All Forms of Discrimination against Women, and on the Rights of the Child.

I welcome Fiji's increased engagement with international human rights mechanisms which goes beyond recent ratification of key international instruments. The country performs an active role at the Human Rights Council. It issued a standing invitation to the Council's Special Procedures in 2015 which has since been followed by country visits at a pace of one visit per year. Just few weeks prior to my visit, Fiji underwent the third cycle of the Universal Periodic Review (UPR)

At the national level, the right to health is protected by article 38 of the 2013 Constitution. Accordingly, the State must take reasonable measures within its available resources to achieve the progressive realisation of the right of every person to health, and to the conditions and facilities necessary to good health, and to health care services, including reproductive health care. A person must not be denied emergency medical treatment, and if the State claims that it does not have the resources to implement the right, it is the responsibility of the State to show that the resources are not available.

There are different legislations governing the provision of health services in Fiji, the main one being the Public Health Act (1935). Furthermore, Fiji counts with a modern and bold vision in many areas including in health related policies.

The healthcare system

Following its independence from the United Kingdom of Great Britain in 1970, Fiji inherited a subsidized health care system. In the 70s, primary health care underwent a decentralization process largely facilitated by Fiji communal culture and the involvement of health workers with the community through home visits, village health days and an advisory role on public health issues.

At present, the health system continues to rely on the strategic role played by the 1,583 community health workers to extend the coverage of primary health care through improved partnerships with communities. These workers are selected within their communities and while their work is voluntarily in nature, the Ministry of Health has recently increased allowances allocated to them which are paid against the submission of health reports due monthly.

During my mission, I met with many community health workers who travelled from their own villages and settelments to the nursing stations I visited. I learnt first-hand about their work, challenges, views and recommendations to strengthen the health care system. Community health workers take pride in the work they do and showed a general sense of gratitude towards increased allowances, although also shared that their timely distribution could improve.  

Through home visits, these workers deliver key health messages within their communities and refer residents to essential health services, sometimes carrying out the transportation themselves. They also play an essential role in reaching out to patients, especially those living in remote locations, when they miss check-ups or need specific medical follow-ups.

At the next level, the health system includes nursing stations generally staffed by one nurse, although in rare occasions the nursing station may count with a medical practitioner such as in the case of Coqeloa. Nursing stations refer patients to higher level health facilities as needed. I visited three nursing stations including the one on Qamea Island which is only reachable by boat from Taveuni. This nursing station is currently replacing the village's health centre which submerged into the sea during a landslide in December 2016. This is one of many examples that illustrate the negative effects of climate change on the right to health. The Government is currently building a new health centre up the hill in Qamea.

The following level of services are health centres which are staffed by either a doctor or a nurse practitioner with one or more nurses. However, the number of staff actually ranges to up to 20, subject to the type of services offered, the location and the population covered. Some, such as the one I visited in Seqaqa, have a pharmacy, laboratory, x-rays, dental unit, health inspector, dietician, clinic nurses and other nurses who conduct school visits and zone nurse activities. During my visits to health centres, including those in remote locations such as the one in Nasau, I observed facilities, equipment and services provided and talked to medical staff and some patients.

I could observe, but also received information about, the recording of health information of all clinical cases followed up by each centre and nursing station, which is done manually on white boards. These records do not disclose confidential data but it would be a positive step forwards that they are automated. This will allow to better maintain medical records and access information efficiently and faster, saving time.

The next level of health services correspond to sub-divisional hospitals, which provide inpatient care and outpatient services and the following level includes divisional hospitals. I also had the opportunity to visit different of these two instances.

An important right-to-health challenge in Fiji refers to accessibility of health services, notably linked to the geography of the country which comprises more than 300 islands and atolls (about one-third of which are inhabited) with population of a bit more than 900,000. Issues of accessibility due to population dispersion through many islands are exacerbated in the case of persons with disabilities, who cannot easily reach health and other basic services and often stay at home, notably if they live in remote and hard-to-reach locations.

The Government has developed good initiatives to address the geographical accessibility of health services, including through the Hospital Ship "Veivueti", the first of its kind in the Pacific region. The Hospital Ship is a full-fledged floating health facility, designed to provide medical services as well as rapid response during emergencies. It started to operate earlier in 2019, following a week-long trial test. During my visit to the Hospital Ship, I learnt about the many surgeries performed during the trial test and about the Ship's following visits to 10 islands in a 20-day period to deliver medical services. Shortly after my visit, the Hospital Ship planned to visit the Western Division to help clear up the patient's waiting list in Lautoka hospital.

An additional commendable effort refers to Fiji's Emergency Medical Assistance Team (FEMAT) and its surgical outreach. FEMAT was accredited in May 2019 by the World Health Organization as a Type 1 Fixed Emergency Medical Team, ready for domestic and international deployment. FEMAT provides a broad range of medical and emergency services for up to 100 patients per day. Its capacity includes self-generation of energy, a water treatment facility, desalination kits, waste incinerators, tents to accommodate the 20-member team and patients as needed, as well as showers, amongst others. It is the first of its type in the Pacific islands.

FEMAT's surgical outreach includes surgeons, anaesthetist, nurses, health workers and logistics and has been deployed to hospitals to carry out surgeries such as big lumps, hernia, hydrocele, breast lumps and circumcisions. I witness the deployment of FEMAT and met with members of the outreach programme in Vunidawa hospital where the surgery outreach team conducted around 60 surgeries in one week.  

Throughout my visit to Fiji, I appreciated the existing political will to invest in all main elements of the health care system, including primary and specialized health care. I was also informed about efforts to modernize hospital care by investing in infrastructure, about a substantial increase in salaries for doctors and by the undertaking of public private partnership in Lautoka hospital. On this, any public private partnership should come with clear and effective institutional policies and measures that put the public interest at centre of all interactions.

During my visit, I followed up on the measures undertaken to address the outbreak of measles which was officially declared on 7 November 2019. This is a serious challenge not only for the Ministry of Health, but for many other agencies, and to society in general. I would like to commend authorities in charge for the very good management of this complex issue.   

The mission of the Ministry of Health and Medical Services is "To empower people to take ownership of their health. To assist people to achieve their full health potential by providing quality preventative, curative and rehabilitative services through a caring sustainable health care system." This involves a shift from the usual focus on addressing certain diseases through vertical programmes, to addressing determinants of health. I consider that the formulation of such vision is in itself a sign of political will and a sign that Fiji is on the right direction towards the full realization of the right to physical and mental health.

However, such ambitious goals require sustainability and good management of change in all levels of implementation where the key to success is critical analysis, recognition of gaps and identification of measures to address these gaps. Some of the later include the need to address inequalities, violence and discrimination as major determinants that threaten the effective realization of the right to health.

Mental health

Ladies and gentlemen,

Mental health needs to be recognized as equally important as physical health. All main elements of mental health services should be addressed, including both promotion and prevention of mental health related issues such as suicide, bullying and other forms of violence. This includes awareness programmes and campaigns, as well as effective preventive activities with the meaningful involvement of the people and the communities. Equally important is care and support for persons with psychosocial, cognitive and intellectual disabilities, as well as with other mental health conditions.

In the full-fledged country visit report that I will present to the Human Rights Council in June 2020, I will elaborate on recommendations towards the development and implementation of a national mental health policy. This should be in line with the principles and standards of the Convention of the Rights of Persons with Disabilities which Fiji ratified in June 2017. In this connection, the main targets of investment should be community-based rehabilitation, care and support with the engagement of all health care workers involved in the provision of mental health care. In other words, health care staff -from community health workers, nurses and doctors- working in all levels of health services should take care of the population's mental health in the same way they now take care of their physical health.

Psychosocial interventions should be available to children and adults with mental health conditions so that mental health care does not rely mainly on treatment with psychotropic medications. Counselling services are extremely important in this regard. In my discussions with stakeholders and physicians, I learnt about a counselling services gap within the public health care. These services are mainly provided by civil society organizations and even doctors in health care centres and in hospitals refer patients to them. These civil society organizations which already count with the trust of health care providers should receive increased financial support by the Government. Finally, child mental health services need to be developed, as well as early intervention services for children with developmental disabilities and their families.

The right to health of women and children

During my visit, I learnt about remaining discriminatory attitudes by health care workers and their frequent incapacity to respond to the health needs of victims of gender-based violence. This is in part the result of remaining vertical structures of a seemingly medical hierarchy strongly entrenched and upheld in the health care system, often at the expense of women's rights. In particular, maternal health care continues to be reliant on paternalistic and patriarchal attitudes.

I welcome Fiji's acceptance of a number of UPR recommendations that are relevant for the realization of the right to health in-country, including a provision on termination of pregnancy already in the Fijian Crimes Act 2009 regarding legal abortion in the cases of incest, rape, severe medical condition of the mother or the foetus, in line with the UPR recommendation to "legalize voluntary termination of pregnancy in cases of rape, incest, grave deformation of the foetus or risks to the health or life of the mother."

While I witness the Government's efforts to increase capacity for maternal health, through for example the new Makoi Maternity Unit, I also learnt about cases of obstetric violence with issues around undermining informed consent for procedures like C-Section and episiotomy. I was additionally informed about cases where health care personnel may not share information or may not seek informed consent before procedures, overriding the views and autonomy of women. The cultural perception is that "They know best" and the legacy of paternalistic culture translates into patients, especially pregnant women, being scared, apprehensive to question doctors or nurses, and fearing retaliation through poor quality service or care.

The health workforce, including doctors, nurses, and other health workers need to be trained not only on clinical skills and knowledge, but also on how to communicate with users of health services and how to manage difficult situations. It is important that in all levels of healthcare policies and services a spirit of partnership and mutual respect and trust replaces paternalistic attitudes and the misuse of power asymmetries between health care providers and users. Training in human rights and medical ethics should be strengthened as this is an important part of medical and health education.

I also learnt about challenges for pregnant women in islands such as Taveuni or Qamea to reach hospitals on other islands such as Labasa so as to deliver their babies. For low-income women, the travel involves trips by public bus and boat which they have to do alone to and from the hospital. The latter carrying their new-born babies throughout bumpy rides that might expose them and the new-borns to injuries. Ambulance rides by road and water could be provided in these cases.

An additional issue of concern that deserves more attention and investment refers to violence against women and children. There are good attempts made by the Government in recognition of this serious societal problem and awareness raising. In particular, I welcome Fiji's recent acceptance of various UPR recommendations related to this issue, including those referring to making full use and implementation of existing legislation and policies to combat violence against women and other vulnerable groups. For this, measures should be based in evidence and human rights. The realization of right to health and of the Sustainable Development Goals, Agenda 2030 (SDGs) will not be possible if violence is not addressed as a major human rights and public health issue. Efforts should be directed to stop the vicious cycle of violence, starting from violence against women and children in families, as a priority.

Virtually all stakeholders I met with recognized the existence of the phenomenon of bullying in schools. I was optimistic to learn about the Ministry of Education plans to carry out research on the causes and international best practices to address this issue.

Sexual and reproductive health rights continue to be an issue of concern for women in Fiji. I was informed that breast and cervical cancer remain the top five causes of death for women. Yet women in Fiji continue to present themselves in the late stages of cervical and breast cancer.

Linked to sexual and reproductive health rights is the lack of a comprehensive sexuality education in school curricula, which leads to gaps of knowledge and understanding of these rights. I learnt that, from the cases decided in 2018 by the High Court of Fiji, the youngest perpetrator of sexual violence was 11 years old. Further, teenage pregnancies continue to prevail in Fiji. Efforts are needed to establish and provide effective and comprehensive sexuality education in schools.

The impact of climate change on the right to health

In recent years, a wide range of issues have emerged in Fiji from the problems created by climate change, climate-induced mobility and the presence of the world's first climate change refugees. Fiji is especially vulnerable to adverse health impacts of climate change for its small geographical size, exposure to extreme climate events and the economy dependent on natural resources.

Overall, climate change negatively affects the determinants of health, such as clean air, safe and sufficient water, food and shelter, but it also has direct impacts on human health including injury, disease and death from extreme heat and cold, cyclones, floods and droughts. Indirect impacts include increases in vector-borne, water-borne, cardiovascular, respiratory and renal diseases and psychosocial impacts from increase in the range and number of disease spreading vectors, compromised food and water sources, livelihood losses and population displacement.

As previously mentioned, Fiji has developed capacity to rapidly provide health assistance in events of disaster. I will elaborate more on this in my country mission report.

Additional challenges

Fiji has an importance incidence of Non-communicable diseases with cardiovascular disease, diabetes and stroke leading the causes of death in-country. I was also informed about the increasing incidence of drug abuse, notably among the youth, and about care-related challenges faced by older persons. The report will elaborate further on all these.

Members of the press, 
Ladies and gentlemen,

Fiji has very good opportunities to reach health related SDGs, including universal health coverage. To achieve these goals, there is a need to continue investing in sustainable health care system with special focus on primary care. But this is not enough. Major determinants of health, such as inequalities, discrimination and violence should be addressed with measures that are adequately supported with resources and that are in line with human rights based approach and based on scientific evidence.

Thank you.

Vinaka