Response to the 2017-18 National Budget- Hon. Parmod Chand
Parliament of Fiji
July 10, 2017
Madam Speaker, thank you for allowing me to present my thoughts on the 2017-18 Appropriation Bill, specifically in response to the Health budget and issues for the Northern division.
Regretfully, I focus my comments on state of our national Healthcare system and the budget allocations presented to us. While the health budget is still centrally managed, the issues I will raise are magnified for the electorate in the Northern division where I am from and where I live, and undoubtedly similar for the West and outer islands.
In the health budget the current Government has presented to the people of Fiji, unreal, piecemeal solutions that will not cure our health and medical services delivery.
The increased allocations for projects are mere promises that have been untouched in the last three years under (Requisition-R). Every public servant knows that projects pegged under “Requisition” have a small-to-nil chance of coming to fruition — in essence it is aspirational or wishful.
There are no new projects for which funds have been actually committed. Even the talked up National Kidney Research and Treatment Centre to be managed by nephrologist Dr. Amrish Krishnan, costing $1M — is under “R”!!
Additionally, the government should have allocated funds to provide free kidney dialysis to low income earners. But the $300,000 allocation has not changed despite pleading by kidney patients. And this Budget has made allocations for other things like hiring of consultants to improve Government’s image, marketing grants, golfing, and to Fiji Broadcasting Commission.
AID by Donor partners factored in on page142 of the Budget Estimates is largely technical support with an attached dollar value, not addressing the true budgetary allocation per se.
Let’s look at the ratio’s, Madam Speaker. For Health and Medical services, the ratio of Health to Government Expenditure to date for Fiji is 9.4%. The World Health Organisation (WHO) recommended ratio is 14.4%, while for Low & Medium Income Countries (LMIC), the average recommended ratio is 11.6%.
Let us look at the 2017-18 Budget then in terms of Health to GDP ratio’s. Fiji’s ratio is 4%. WHO recommends a 5% minimum ratio. The Low & Minimum Income Countries recommended ratio is at an average of 6.6%.
Fiji’s 2017-18 Budget in terms of Health to GDP ratio is 4% — again, far below the recommended ratio.
I now turn to our Health expenditure breakdown. While the State bears the burden of 66% for health expenditure, the Out of Pocket (OOP) cost borne by the taxpayer is 34%.
This means that taxpayers are shouldering additional burden on top of their taxes- 34% is for health expenses, most of the time unplanned for, that they pay out of their pockets.
Madam Speaker, for our vulnerable and poverty stricken people, getting sick means they are further entrenched in the darkness of poverty. For those in the middle class, it means they can dive into poverty. It means that houses become mortgaged and loans need to be taken just to ensure that their loved one’s can undergo medical treatment. This is the sad, painful but unmistakable reality.
The state of our healthcare in Fiji right now means that if you become ill, if you have the means you have a fighting chance. If you are poor, the odds are heavily stacked against you.
Madam Speaker, Turning to our medical professionals…
The announced recruitment of three tranches of Specialists is wishful thinking. When the bold promise of 33 specialists in the first tranche was announced, this is on top of previous promises of additional medical personnel over the previous 3 budgets. So, where are they? By now, Fiji should be teeming with these medical professionals, should it not?
We are aware that there is just one ENT (Ear, Nose, Throat) specialist that was recruited in 2014. The lack of specialists is alarming.
Our local medical personnel are being submerged at the expense of wholesale expatriate recruitment. The recruitment drive in India early this year may help but we need to build on our local expertise as much as we can.
There are obviously 75 places for local recruitment at the ground level – these 75 internship level spots need to be filled every year, but this number has just been met in 2015 -17. This means we are still playing catch-up in terms of health internship manpower needs. There are batches of medical students from Cuba, and other overseas destinations due here shortly to address the shortfall in numbers, but the sudden urge to raise these numbers overnight, is an exercise in futility.
To aggravate the situation, our “Fijian Made” medics returning from abroad are given a difficult time upon their return. They could add quality to our current set up in specialist areas but it’s not happening.
Obtaining a full complement of additional doctors is not the total solution. What will the additional numbers mean when the ministry cannot provide the appropriate beds, medication, technology, or if the consumables are out of stock?
We understand that new specialist units such as the Neurological, Urology, Cardiac teams remain without medication and operative equipment. Most are not fully operational, yet our “Fijian Made” medics have been trained locally and exposed internationally for these roles. Can we see the mismatch in these issues?
Health systems are not built on numbers alone. The building blocks of healthcare include:
adequate and appropriate facilities and infrastructure;
sufficient supplies of medicine and consumables; adequate health financing;
improved health information and research; cross cutting leadership & governance; and
a content, inspired, compassionate and accountable workforce all working towards exemplary healthcare service delivery.
Our medical graduates do not always move to green pastures on their own accord, but are pushed out by poor administrators, planners and politicians — evident now by this year’s fast-tracked amendment to the Medical & Dental Practitioners. To our healthcare system’s demise, the push factor is greater than the pull factor.
Increasing the intake at medical schools, middle level study in areas of clinical interest and provision of scholarships serve to keep the locals on their own turf.
Turning now to our Nurses Pay Rise…
Madam Speaker, The much lauded civil service reforms seems to have been short-circuited with the pay rise for salary increases.
Shockingly the “Job Evaluation Questionnaire’s” circulated by PWC to nurses as part of the civil service reforms seemed like generic, off-the-shelf templates that offered no appreciation for the complicated pressures, structures and often overlapping roles shouldered by our nurses, nor the extra effort needed on top of workloads, to complete these unnecessary & complicated details.
The nursing pay rise is a welcome relief, but is as at odds with the ratio of the pay rise given to doctors last year, and which a cohesive and seamless job evaluation exercise would have addressed.
The nurse practitioners’ salary increase by 75% is commendable, but there are just under 40 nurse practitioners who will benefit from this.
Our midwives in the maternity areas are struggling and a 25% incentive would have been more appropriate. Again, a cohesive and seamless job evaluation exercise would have addressed these disproportionate increases.
But then, what of the state of the nursing cadre who have been weaved into the administrative services by way of career progression, are they entitled to the 25% increase? What of the specialist nursing structures, should they be realigned? If the lack of re-alignment continues unaddressed, corrupt practices can emerge.
The nurses’ salary increase of approximately 15% is acknowledged and appreciated. But again, a cohesive and seamless job evaluation exercise would have addressed these disproportionate salary ratios.
The mid-level training of nurses needs urgent review. Birthing surges in the face of facility and infrastructure inadequacies creates adverse maternal and neonatal birth outcomes and midwifery training is absolutely essential. The shocking revelations of the spate of deaths of new-born babies is still fresh on our minds and we expected more prioritisation of our neonatal unit.
This now brings me to the issue of our junior Doctors who are made to work up to 32 hours at a stretch. Surely such stretched hours are a violation of labour standards in a profession where life and death are daily challenges? Is the Ministry actively monitoring these unrealistic and inhumane expectations of new entrants?
When the workload was lighter in the past, it was fairly tenable but the new structure does not even address this.
Madam Speaker – the supply of Pharmaceuticals and Medical Consumables…
The budget announcement made a brief mention of the Free Medicine Scheme, selectively labelling it as “medicine subsidies”..
That is because the scheme is completely dysfunctional. With the stated 140 plus items for release to the public in 2015, the retail pharmacists are still not provided with a list of what is to be dispensed after two years of waiting on this announcement.
Only about 20,000 people are registered for the scheme, when we know full well that 50% of the population are living below or around the poverty line.
If pharmaceutical supplies to our hospitals is inadequate, how is it logically possible for this scheme to still be allocated $10 million and continues to remain largely un-utilized in the last two years with a high wastage rate. Recall that for the past years, except this year “Free Medicine” has been under R (Requisition).
This year’s budget allocation for health addresses the purchase and maintenance of health-related high end equipment. So the question is are these important pieces of health-related equipment still without service contracts after the warranty period comes to an end?
The allocation of $1 million has been put aside for this but it is our understanding that MRI, CAT scanners, radiology, general lab equipment etc. are not in working order as a result of invalid service contract agreements.
In a similar fashion, consumables such as lab reagents and chemical reagents for x-rays are out of stock as well.
It is our hope that the newly announced National Kidney Research and Treatment Centre will also look into renal transplantation with urgency. This will allow some patients to benefit from a one off surgical procedure and not suffer the three/per week dialysis lifelong exercise, at great cost. Appropriate laws will have to be enacted.
There are other important health developments that this budget document has failed to address. What is the progress in the development of the Cancer Unit?
Furthermore, I understand that a senior Health official, had urged MPs of the threat of the oncoming NCD crisis, at a parliamentary workshop a couple of years ago, where even the Consumer Council and other experts made similar pleas. The presenters specifically requested MPs to put in place tax measures to help alleviate the NCD crisis — which has now reared its ugly head on a national scale.
We look forward to the development of a modern Mental Health Clinical, Training and Research Hospital which seems to have fallen off the radar. We are told that support for this establishment was available from a bilateral donor partner with a Memorandum of Agreement again sitting on someone’s desk since 2013.
For our elders for whom we all owe a great measure of indebtedness, the state of the senior citizen’s homes, the development of retirement villages, improved and wider/in-depth training of caregivers including the professional cadre-gerontologists/rehabilitation experts, specialist nurses, enrolled nurses, counsellors, field and community workers, palliative/public health nursing systems needs urgent reviews, as once Mahatma Gandhi had said and I quote
“It is health that is real wealth and not pieces of gold and silver”
Briefly Madam Speaker, let me quickly address the infrastructure needs for Vanua Levu if we are to transform it into a hub as part of the Government’s “Look North” idea’s.
Waiqele Airport (Labasa)
The Labasa Airport needs to be able to cater for night flights with some upgrades with lights installed for night landing.
Upgrades and tarsealing of roads are needed for:
Major trunk road around the island of Vanualevu
a) Coqeloa to Nacavanadi to open up land for resorts and hotels
Cross country roads
Namuavoivoi to Cogea
Nabouwalu to Nabalebale (Wainunu)
Nayarambale Road Junction (Daramu) to Vanuavou.
Labasa By- Pass Road
Labasa needs a by-pass road to alleviate the alrming congestions causing delays to all and affects school children mainly.
For roadworks 15-20 km from Labasa Town
Boubale, Urata, Dreketilailai, Anuve
Flooding at Siberia and Vunimoli, Vunivutu Health Centre
Wainikoro/ Navualevu Crossing
For shipping, there should be freight subsidies and concession for Vanualevu manufacturer’s, spare part dealers, supermarkets. The cost of living is doubled often tripled in the North.
Electrification for rural areas in Vanua Levu, is very slow and neglected, the following areas need urgent power supply:
Seaqaqa interior, Vunivere, Seva,
Nabouwalu, Nasarawaqa, Lekutu, Kolikoso
Nacavanadi towards the Natewa bay costal road side to. Navakaka and from Nagigi towards Matakunea to Buca Bay.
Lagalaga to Namuka-i.e. Naua, Visogo, Laremba
Lagalaga to Nubu, Dogotuki
Interior of Navitia,Wavuwavu, Vunivutu
Uluidau school to Vunikabula. Rural Electrification will enable excess to power and usuage of IT to access internet as per the Govt’s “Knowledge Based Society” push.
For Sporting, it is of some consternation that there is no public swimming pool for northerners – Labasa and Savusavu, and there is nothing specific in the budget for sports in the North. Our children need to be able to learn how to swim properly.
Our tramlines need improvement, portable lines, rail trucks.
JP’s in Rural Areas
I thank you for your indulgence.