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<Health Reforms: a Case Study of Fiji Centre for International Health Health Reforms: A Case Study of Fiji Audrey Aumua This thesis is presented for the Degree of Doctor of Philosophy of Curtin University February 2014 Certificate of Authorship To the best of my knowledge and belief this thesis contains no material previously published by any other person except where due acknowledgement has been made. This thesis contains no material which has been accepted for the award of any other degree or diploma in any university. Audrey Aumua Signed: On: 10/02/2014 ii ii Copyright Statement I warrant that I have obtained, where necessary, permission from the copyright owners to use any third-party material reproduced in the thesis (i.e. questionnaires, artwork, unpublished letters), or to use any of my own published work (e.g. journal articles) in which the copyright is held by another party (e.g. publisher, co-author). Audrey Aumua Signed: On: 10/02/2014 iii iii Acknowledgements This thesis would not have been possible without the many people in the Fiji Health System, together with public sector officials, traditional chiefs and community leaders, non-governmental organizations and political leaders who gave so freely and willingly of their time, and allowed me to enter their space and learn from them. It is my hope that the results of this thesis will benefit the people of Fiji and in some small way help improve the health outcomes of this island nation. I owe much gratitude to Dr. Janice Lewis and Associate Professor Jaya Earnest for their support throughout this study. My special thanks to Jan who started out on the study with me and to Jaya who travelled with me to the end. I am indebted to you both. My appreciation to Professors’ Charles Gilks, Maxine Whittaker, and Alan Lopez of the University of Queensland for their support to me whilst in their employment. To Nicola Hodge and Fallon Horstmann my grateful thanks for their administration assistance and constant encouragement from the sidelines. To my grandfather Ratu Osea Vutikalulu of ‘Mataqali Nacobogi’ who inspired me as a child and whose memory has been what has sustained me over the years of this project. This work is dedicated to him and the clan of Naloto of which I am a descendant. I acknowledge my parents, my mother Miriama Tinai Tabuavou Vutikalulu and my father Donald Francis who launched me on this journey but sadly did not live to see the end. Their belief in me is a constant source of strength. Lastly I pay tribute to my husband Steve whose interminable source of faith and support has sustained me throughout. To my sons Ephrim, Levi and Denzil who uncomplainingly and patiently waited for me to get to the finish line. I may have been the student in this process, but it is from my children whom I have learnt the most. iv iv Included Publications and Manuscripts 1. Aumua A, Lewis JA & Roberts G. 2009. Fiji’s Health Management Reforms: (1999-2004) A Case Study. Pacific Health Dialog 15(2): 13-20. 2. Aumua A & Hodge N. 2012. Pacific in crisis: The urgent need for reliable information to address non-communicable diseases. Pacific Health Dialog: Special Edition on HIS 18(1): 191-192. 3. Walker S, Rampatige R, Wainiqolo I & Aumua A. 2012. An accessible method for teaching doctors about death certification. Health Information Management Journal 41(1): 4-10. v v Conference Presentations 1. 2009. Fiji’s Health reforms 1999-2004. Fiji Health Research Council: Conference on Health systems Research. Suva, Fiji. 2. 2009. Fiji Health Reforms: the policy experience. Pasifika Medical Association Conference. Auckland, New Zealand. 3. 2011. Fiji Health Reforms: A case study. World Health Organization, Country and Staff training workshop. Suva, Fiji. 4. 2012. Experience of Fiji Health Reforms 1999-2004: Implications and learnings for Fiji and the region. World Bank Flagship Course / Harvard School of Public Health. Nadi, Fiji. vi vi Contents Certificate of Authorship.......................................................................................... ii Copyright Statement ............................................................................................... iii Acknowledgements ................................................................................................. iv Included Publications and Manuscripts .................................................................... v Conference Presentations ........................................................................................ vi List of Figures ....................................................................................................... xiii List of Tables ........................................................................................................ xiv List of Abbreviations ............................................................................................. xv Glossary of Fijian Terms ...................................................................................... xvii Abstract .............................................................................................................. xviii Chapter 1: Introduction and Overview ..................................................................... 1 1.0 Introduction ............................................................................................... 1 1.1 Background of the Study ............................................................................ 1 1.2 Republic of Fiji .......................................................................................... 3 1.3 Aim and Objectives ................................................................................... 4 1.4 Significance and Contributions of the Study............................................... 7 1.5 Contextual Challenges for the Study .......................................................... 9 1.6 Overview of the Thesis ............................................................................ 11 Chapter 2: Literature Review ................................................................................. 13 2.0 Introduction ............................................................................................. 13 2.1 Global Health Reforms ............................................................................ 15 2.2 Health Policy and Analysis ...................................................................... 18 2.3 Approaches to Health Policy Process ....................................................... 21 2.4 Implementation ........................................................................................ 26 vii vii 2.5 External Influence and Development Ideology ......................................... 28 2.6 Methods and Tools of Analysis of Reforms.............................................. 29 2.7 Decentralisation as a Health Reform Strategy .......................................... 30 2.8 Developing Nations and Health Reforms ................................................. 31 2.9 Health Reforms in the Pacific Region ...................................................... 34 2.9.1 Health Reforms in Fiji ........................................................................ 35 2.10 Why is Health Policy Analysis Important?................................................ 35 2.10.1 Health Policy Analysis and Developing Countries ............................ 38 2.10.2 Key Issues in the Literature of Health Policy Analysis ...................... 39 2.11 Conclusion ......................................................................................... 44 Chapter 3: Methodology ........................................................................................ 45 3.0 Introduction ............................................................................................. 45 3.1 Case Study Methodology ......................................................................... 45 3.2 The Fiji Case ........................................................................................... 46 3.3 Theoretical Framework used for the study................................................ 47 3.4 Research Methods .................................................................................... 49 3.5 Stages of the Research ............................................................................. 50 3.5.1 Stage 1: Establishment of Case Study Database .................................. 50 3.5.2 Stage 2: Preliminary Document Analysis ............................................ 51 3.5.3 Stage 3: Key Informant Interviews ...................................................... 51 3.5.4 Stage 4: Development of Case Study Protocol .................................... 52 3.5.5 Stage 5: Data Collection ..................................................................... 52 3.5.6 Stage 6(a): Data Source 1 (Document and Archival Documentation) .. 53 3.5.7 Stage 6(b): Data Source 2 (Open-ended Individual Interviews with Three Groups) ................................................................................................ 55 3.5.8 Stage 6(c): Data Source 3 (Focus Groups with Reform Implementers) 61 3.5.9 Stage 7: Data Management and Analysis ............................................ 63 viii viii 3.5.10 Stage 8: Analysis .............................................................................. 65 3.5.11 Stage 9: Quality Criteria in the Study ................................................ 68 3.5.12 Stage 10: Reflexivity ........................................................................ 72 3.6 Chapter Summary ...................................................................................
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