Republic of Fiji Hospital & Health Service Review October 2017
Disclaimer: The views expressed in this paper/presentation are the views of the author and do not necessarily reflect the views or policies of the Asian Development Bank (ADB), or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this paper and accepts no responsibility for any consequence of their use. Terminology used may not necessarily be consistent with ADB official terms. Outline
• Introduction • Stakeholders • Methodology • Supply Assessment • Demand Modelling • Gap Analysis • Comparison to other Methods & Approaches • Findings, Results & Recommendations • Applicability Introduction
Fiji’s health system faces many of the same challenges as other DMCs from population growth and ageing, resulting in increasingly unsustainable costs. Using a population-centric approach, the health
service demands of the Fijian population have been modelled into the future to assess and quantify
infrastructure and service requirements. Current capacity and service delivery, future public and private sector investment in health services and the changing health and demographic profile of the
population are taken into consideration. The results highlight clear opportunities for investment. Republic of Fiji
General Features
• Trends in urbanisation within certain age groups • Population aged 15 to 44 more likely to be urban dwellers • Relative parity for those aged 45 to 60 • Those over 60 years more likely in rural environment • Gradual growth in population • Ageing population and longer life expectancies • Decreasing birth rate
120 30 100 25 80 20
60 15
Age Ratio 40 10 20 5 0 0 1946 1956 1966 1976 1986 1996 2007 Dependency Ratio Child-Woman Ratio Median Age Health-Related Features
• Non-communicable disease dominate top causes of death and disabilities
Causes of death and Causes of Premature death Causes of disability Rank Causes of death by rate disability (YLLs) (YLDs) (DALYs) 1 Diabetes Diabetes Diabetes Diabetes 2 Ischaemic heart disease Ischaemic heart disease Low back and neck pain Ischaemic heart disease 3 Cerebrovascular disease Lower respiratory infect Skin diseases Lower respiratory infect 4 Chronic kidney disease Cerebrovascular disease Sense organ diseases Cerebrovascular disease 5 Lower respiratory infect Chronic kidney disease Iron-deficiency anaemia Chronic kidney disease 6 Asthma Neonatal preterm birth Depressive disorders Asthma 7 Hypertensive heart disease Congenital defect Asthma Low back and neck pain 8 Other cardiovascular Self-harm Other musculoskeletal Neonatal preterm birth 9 COPD Asthma Intestinal nematode Congenital defect 10 Self-harm Other cardiovascular Migraine Skin diseases
• Most common risk factors of high-fasting plasma glucose, high body-mass index, dietary risks, high systolic blood pressure, tobacco smoke and high total cholesterol. Stakeholders Fiji Bureau of Statistics Ministry of Health & Medical Services Fiji Medical and Dental Council and Medical Assistant Council Fiji Pharmacy & Poisons Board Fiji Optometrist Association Colonial War Memorial Hospital Lautoka Hospital MIOT Pacific Hospital Fiji National University Methodology
Opportunity Situational Evaluation Analysis
Supply Gap Analysis Assessment
Demand Modelling Supply Assessment
The supply was assessed using the following sources: • Patient records, PATISPlus • Disease registries • MOH annual reports 2005 to 2015 • Hospital inpatient admissions and outpatient statistics 2010 to 2016 • Survey of major infrastructure/physical capacity • Health workforce councils and professional registration bodies • Local health service and workforce studies Divisional Hospitals Sub-Divisional Hospitals Area Hospitals Specialist Hospitals Private Hospitals Inpatient Care
• 73,194 admissions in 2008 increasing to 78,297 admissions in 2015 • From capacity of: • 1,533 general public beds • 186 specialist public beds • 49 private beds • 86 public mental health beds • Planned capacity of further 320 public beds
90,000 81,797 78,297 76,785 74,976 80,000 73,194 71,500 71,987 70,000 67,071 60,000 50,000 40,000 30,000
Inpatient admissions Inpatient 20,000 10,000 - 2008 2009 2010 2011 2012 2013 2014 2015 Inpatient Care
• Overseas referrals with public funding in specialties of: • Cardiac • Oncology • Renal • Surgical • Ophthalmology • Others • Unknown quantum of private overseas referrals
250 203 200
150 100 93 85 Patient referrals Patient 100 67 54 50
- 2010 2011 2012 2013 2014 2015 Outpatient & Ambulatory Care
• Current supply includes 12 Level A Health Centres, 10 Level B Health Centres, 62 Level C Health Centres, 98 Nursing Stations, 10 Chemotherapy Places, 30 Renal Dialysis Places, and an estimated proportion of private outpatient capacity • An assumption of private sector outpatient visits have been applied based on self-reported figures within the MIOT Pacific Hospital • 2015 OPD stats:
2,500,000 5.1 visit/population 5.1 visit/population 2,000,000 1,914,821 1,714,172 8.6 visit/population 3.5 visit/population 1,500,000 1,166,112 1,200,666
1,000,000 Outpatient visits Outpatient
500,000
- Central Western Northern Eastern Emergency & Intensive Care
• Three divisional hospitals are equipped with 24-hour emergency departments • Sub-dividual hospitals with some capacity for urgent care • Emergency trolleys have not been included as an emergency place
Facility Emergency Care Places Divisional Hospitals Colonial War Memorial Hospital 16 Labasa Hospital 11 Lautoka Hospital 17 Sub-divisional Hospitals 2 per facility Total 80
• Intensive care services provided by the public Divisional Hospitals only, primarily at CWM Hospital
Facility Intensive Care Beds Colonial War Memorial Hospital 15 Labasa Hospital 3 Lautoka Hospital 3 Total 21 Operating Theatre & Medical Imaging Care • 13 operating theatres from Divisional Hospitals • Sub-Divisional capacity in operating theatres only used when visiting surgical teams came from the CWM hospital in Suva or from international countries
Facility Operating Theatres Divisional Hospitals CWM Hospital 8 Labasa Hospital 2 Lautoka Hospital 3 Sub-divisional Hospitals 2 per facility Private Hospitals MIOT Pacific 2 Total 51
• Current supply of medical imaging devices in Fiji includes three CT machines, one MRI device, six X-Ray machines, three mammogram machines, and three fluoroscopy devices provided by the Divisional Hospitals and MIOT Pacific Private Hospital Health Workforce
Pharmacist, 65, 2% Environmental Administrative Staff, Health, 111, 3% 153, 4% Secretary/Typist, 34, 1% Dietician, 69, 2% Biomedical Personnel, Stores Officer, 28, 1% 17, 0% Physiotherapist, 26, 1% Other, 69, 2% Lab/Imaging Assistant, 21, 1%
Radiographer, 55, 1% Medical, 504, 13% Laboratory Technician, 158, 4%
Para-Dental, 119, 3%
Dental Officer, 50, 1% Nursing , 2476, 62% Orderlies, 48, 1% Demand
Demand for health services in Fiji is increasing: • Increased health seeking behaviour/ health literacy • Improved accessibility • Population growth • Increasing life expectancy • Increased prevalence of non-communicable diseases • Rising income levels Demand Modelling
• Based on international reference files of per capita rates developed from current and historical service utilisation rates from advanced health systems with comprehensive data collection, projected into the future • Consider local Fijian sociodemographic, economic, political, environmental and technological differences • Informed by Fiji’s annual health statistical reports and current supply rates of services • Application to population projections from Fiji Bureau of Statistics • Available across full range of service types Population Projections
2015 2020 2025 2030 2035 % change p.a. Central 374,119 392,678 410,973 431,021 454,576 1.08% Western 334,675 342,769 350,241 358,569 369,655 0.52% Northern 134,894 133,998 132,140 130,208 129,559 -0.20% Eastern 40,431 41,290 42,631 43,349 44,485 0.50% Total 884,119 910,734 935,984 963,147 998,275 0.65%
85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4 -6000060,000 -4000040,000 20,000-20000 0 20000 0 20,00040000 40,00060000 60,00080000 Female 2015 Female 2035 Male 2015 Male 2035 Acute Inpatient Services
• Increase of acute overnight and same day services from 105,732 admissions by 2020 to 207,739 admissions by 2035, growth rate of 6% per annum
250,000
200,000
150,000
100,000 Admissions
50,000
0 2015 2020 2025 2030 2035 Central Division Eastern Division Northern Division Western Division
• Operational assumption of 85% overnight occupancy and best-practice ALOS • Converted to capacity, 1,842 acute overnight beds and places by 2020 to 2,370 by 2035 Mental Health Services
• Increase of mental health services from 883 admissions by 2020, to 2,107 admissions by 2035, growth rate of 9% per annum
2,500
2,000
1,500
1,000 Admissions
500
0 2015 2020 2025 2030 2035 Central Division Eastern Division Northern Division Western Division
• Operational assumption of 85% overnight occupancy and best-practice ALOS • Converted to capacity, 96 beds and places by 2020 to 131 by 2035 Outpatient Services
• Increase of outpatient services requirements from 7.1 million by 2020, increasing to 9.8 million by 2035, growth rate of 3% per annum • Converted to capacity, 1,362 consultation rooms by 2020 to 1,901 by 2035
12,000,000
10,000,000
8,000,000
6,000,000
Consultations 4,000,000
2,000,000
0 2015 2020 2025 2030 2035 Central Division Eastern Division Northern Division Western Division Renal Dialysis & Chemotherapy
• Increase of renal dialysis services from 26 places by 2020, to 129 places by 2035, growth rate of 26% per annum • Assumption that renal dialysis is provided twice a week, increasing to an evidence-based rate of three times a week by 2035 150
100
Places 50
0 2015 2020 2025 2030 2035 • Increase of chemotherapy services from 14 places by 2020, doubling to 23 places by 2035 30
20
Places 10
0 2015 2020 2025 2030 2035 Central Division Eastern Division Northern Division Western Division Rehabilitation & Long Stay Care
• Increase demand for non-acute services from 2,279 admissions by 2020, to 7,974 admissions by 2035, a growth rate of 17% per annum • Converted to capacity, 106 non-acute beds and places by 2020, growing to 201 by 2035
9,000 8,000 7,000 6,000 5,000
4,000 Admissions 3,000 2,000 1,000 0 2015 2020 2025 2030 2035 Central Division Eastern Division Northern Division Western Division Emergency, Intensive Care & Operating Theatre Services • Emergency Services • Increase of emergency services from 260,349 occurrences by 2020, to 429,603 occurrences by 2035, a growth rate of 4% per annum • Converted to capacity, 118 emergency care places by 2020, to 203 places by 2035 • Intensive Care Services • Increase of intensive care services of 1,650 episodes by 2020, to 4,366 episodes by 2035, a growth rate of 11% per annum • Converted to capacity, 45 intensive care beds by 2020, to 183 places by 2035 • Operating Theatre Services • Increase of operating theatre services from 95,540 occurrences by 2020, to 151,437 occurrences by 2035 • Converted to capacity, 69 operating theatres by 2020, to 110 theatres by 2035 Medical Imaging Services
• Increase of total medical imaging services from 155,053 scans by 2020, to 367,055 scans by 2035 • Converted to capacity, 37 major medical equipment by 2020, to 89 by 2035 • Central Division projected to undergo the largest demand
45 40 35 30 25 20 15
Major Medical Equipment Major Medical 10 5 0 2015 2020 2025 2030 2035 2015 2020 2025 2030 2035 2015 2020 2025 2030 2035 2015 2020 2025 2030 2035 Central Division Eastern Division Northern Division Western Division
CT MRI Mammography X Ray Workforce
• Demand modelling indicates: • 1,386 FTE medical practitioners are required in 2020, growing to 1,700 by 2035, a growth rate of 1.5% per annum • 4,509 FTE nursing staff required in 2020, growing to 5,930 by 2035, a growth rate of 2.1% per annum • 266 FTE oral health practitioners required in 2020, growing to 272 in 2035, a growth rate of 0.2% per annum • 1,584 FTE allied health professionals in 2020, growing to 1,845, a growth rate of 1% per annum
60
50
40
30
20
10
Practitioner/ population 10,000 Practitioner/ 0 2015 2020 2025 2030 2035 Nurses Doctors Other Methods & Approaches
Crude (population and utilisation- rate based approach
Population Mixture -based approach approach Demand Methods
Econometri Nominal c-based group approach approach Findings, Results & Recommendations Gap Analysis
Supply – Demand = Gap
• Comparison of supply against projected demand for Fiji’s population • Calculated at the level of built capacity (e.g. beds, operating theatres, emergency department bays, etc.) and converted back into activity volume estimates, due to limitations in the supply- level information, with exception of outpatient care • Current supply for all health services held constant for all service types and applied as future supply, with the exception of acute inpatient care services, which has known reported increases in capacity planned and committed by the Government • Limitation in available information for private sector provision and growth • The current and future expected supply is used to calculate the gap in services from 2015 through to 2035 Acute Inpatient Services
• By 2020, a gap of 119 acute beds and places is projected, increasing to a gap 417 beds and places by 2035
2,500
Gap 2,000
1,500 Beds and and Places Beds 1,000
500
- 2015 2020 2025 2030 2035 Supply Demand Mental Health Services
• Gap is projected to increase from 10 beds and places by 2020, to 45 beds and places by 2035 • Due to centralisation of current service provision, in the future the largest proportion of gap in services will be experienced in the Western Division
140
120 Gap 100
80
60
Beds and and Places Beds 40
20
- Supply 2015 2015 2020 2025 2030 2035 Central Western Northern Eastern Outpatient Services
• Gap in 1.1 million outpatient consultations emerges by 2020, growing to a gap of 3.8 million by 2035 • Converted to consultation room capacity, this converts to a gap of 255 outpatient consultations rooms by 2020, increasing to 897 outpatient consultation rooms by 2035 • Largest gaps experienced by the Central and Western Divisions 10,000,000 9,000,000 8,000,000 Gap 7,000,000 6,000,000
5,000,000 Consultations 4,000,000 3,000,000 2,000,000 1,000,000 - Supply 2015 2020 2025 2030 2035 Central Western Northern Eastern Renal Dialysis & Chemotherapy
• Renal dialysis • Gap of 19 renal dialysis places emerges by 2025, growing significantly to 99 places by 2035 • Due to centralisation of current service provision, in 2035, the Western Division accounts for 40% of the gap • Chemotherapy • Gap of 4 places by 2020, increasing three-fold to a gap of 13 places by 2035 • Due to centralisation of current service provision, in 2035, the Western division accounts for 54% of the gap Rehabilitation & Long Stay Care
• Gap of 66 beds and places by 2020, growing to 161 beds and places by 2035 • Due to centralisation of current service provision, in the future the largest proportion of gap in services will be experienced in the Western Division
250
200
150 Gap Admissions 100
50
- Supply 2015 2020 2025 2030 2035 Central Western Northern Eastern Emergency, Intensive Care & Operating Theatre Services • Emergency care • Gap of 40 emergency care places will exist by 2020, more than tripling to 125 places by 2035 • Largest proportion of gap is experienced in the Central and Western Divisions, in total representing 88% of the total 2035 gap • Intensive care • Gap in intensive places increases from 24 places by 2020 to 80 intensive care places by 2035 • Central and Western Divisions represents 43% and 37% of the gap in 2035, respectively • Operating theatre • By 2020, calculated gap in operating theatres is 18, increasing to a gap of 59 operating theatres by 2035 Medical Imaging Services
• By 2020, a gap of four MRI machines, three CT machines, eleven X-Rays and four Mammography machines • Central and Western Divisions are projected to have the highest proportions of gap
100 90 80 70 60 50 Gap 40
Medical Imaging Devices Imaging Medical 30 20 10 - Supply 2015 2020 2025 2030 2035 X Ray CT MRI Mammography Opportunities & Key Priorities
Gap ÷ Demand Comparative Need • By service type • By geography • By future year • Acute inpatient services:
25%
20%
15%
% Gap % 10%
5%
0% 2020 2025 2030 2035 Central Western Northern Eastern Opportunities & Key Priorities
• Renal dialysis services:
140%
120%
100%
80%
% Gap % 60%
40%
20%
0% 2020 2025 2030 2035 Central Western Northern Eastern Opportunities & Key Priorities
Service Division Radiotherapy* Central Renal dialysis Northern and Western
High Acuity Chemotherapy Northern Rehabilitation and long stay care Western, Northern and Eastern
Intensive care Western
Medical imaging (MRI and Fiji-wide mammography)
Chemotherapy Western and Eastern Medium Acuity Intensive care Northern Emergency services Central and Western Outpatient care Central and Western
*not included in analysis, however complete absence of service in Fiji has significant implications on treatment options available to citizens and residents Applicability
• Identification of key priority areas • Public infrastructure investment plans • Engagement with private sector • Private and PPP investment plans • Clinical graduate and traineeship volumes • Regulation and control over licensing of private facilities