Republic of Korea – World Bank Group Partnership on COVID-19 Prepare dness and Response Country Case Study: Fiji Containing, Mitigating, and Responding to COVID-19: Knowledge Generation and Exchange, Preparedness, and Response (March 2020 to June 2022) by Donald Wilson, Avelina Rokoduru, Gade Waqa, and Kaminieli Tawake September 2023 On the cover: Panoramic aerial landscape view of Savusavu town in Vanua Levu island, Fiji © 2023 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW Washington DC 20433 Telephone: 202-473-1000 Internet: www.worldbank.org This work is a product of the staff of The World Bank with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank, its Board of Executive Directors, or the governments they represent. 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Cover design: Amy Chan Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response Country Case Study: Fiji Containing, Mitigating, and Responding to COVID-19: Knowledge Generation and Exchange, Preparedness, and Response (March 2020 to June 2022) September 2023 Authors Donald Wilson Associate Dean Research, College of Medicine, Nursing & Health Sciences, Fjij National University Avelina Rokoduru Former Director–Pacs-Rhrc, Fiji Institute Of Pacific Health Research, College Of Medicine, Nursing & Health Sciences, Fiji National University Gade Waqa Director- C-Pond, Fiji Institute Of Pacific Health Research, College Of Medicine, Nursing & Health Sciences Fiji National University Kaminieli Tawake Former Research Officer–Chipsr, Fiji Institute Of Pacific Health Research, College Of Medicine, Nursing & Health Sciences Fiji National University Acknowledgements This case study was made possible by the support of Korea’s Ministry of Finance and Economy and the World Bank Group Korea office. This report was authored by a team from the Fiji National University, including the lead author, Donald Wilson, Avelina Rokoduru, Gade Waqa, and Kaminieli Tawake. The World Bank task team for this case study included team members from the World Bank’s Health, Nutrition and Population Global Practice, the World Bank Group Korea office, and the World Bank Group Fiji office - Vikram Rajan, Kevin Yunil Kim, Preeti Kudesia, Ahram Han, Akosua O. Dakwa, Maude Ruest A., Dayo Carol Obure, Mesulame Ratu Namedre, Margareta Norris Harrit, and Eka L. Vakacegu Yabaki. Amy Chan provided the overall design for this case study. The team is thankful for the valuable feedback received from the agencies and institutions that contributed to this report. This report would not have been possible without a series of interviews and consultative sessions (face to face and virtual) with different government ministries, technical agencies, and civil society organizations. These included: Organization Name of Representative Dr. Jemesa Tuidravu Dr. Shrish Archarya Dr. Aalisha Sahukhan Dr. Anaseini Maisema Ministry of Health and Medical Services Dr. Marica Mataika Ms. Talica Cabemaiwai Mr. Vimal Deo Mr. Jese Vatuleka Mr. Isoa Talemaibua, Ms. Kelera Kolivuso, Ministry of Economy Ms. Kiman Mala and Ms. Freeda Fremlin Ministry of Education, Heritage, and Arts Ms. Ruth Kuilamu Ministry of Women, Children and Mrs. Selai Korovusere and Ms. Raijieli Mawa Poverty Alleviation The Fiji Police Force Mr. Aporosa Lutunauga The Water Authority of Fiji Mr. Seru Soderberg and Mr. Mosese Nariva The Pacific Community (SPC) Dr. Salanieta Saketa Commonwealth of Australia– Dr. Frances Bingwor, Ms. Paulini Nainima and Department of Foreign Affairs (DFAT) Ms. Margaret Vuiyasawa. Reproductive & Family Health Ms. Tarai Nakolimudu Association of Fiji (RFHAF) Medical Services Pacific (MSP) Ms. Ana Fofole Fiji National University (FNU) Dr. Manueli Kavika and Dr. Timaima Tuiketei The team is grateful for the overall guidance and support received from Jason Allford, Special Representative, World Bank Group Korea Office, Stefano Mocci, Country Manager, World Bank, Fiji, and Aparnaa Somanathan, Practice Manager, World Bank Health, Nutrition and Population, East Asia and Pacific Region.  Preface COVID-19 has ravaged the economy of many countries, and its impact will be felt for many years to come. This World Bank report on COVID-19 preparedness and response documents the impact of COVID-19 in Fiji and presents some lessons learned during the first, second, and third waves of the pandemic, which spanned from March 2020 to June 2022. The study focuses on key areas such as the government/health system/public response to COVID- 19, vaccination, protection of vulnerable people, innovation through leapfrogging, human capital, and the progress of Universal Health Coverage and Sustainability. This report contains six sections, which document the government’s actions in containing, mitigating, and responding to COVID-19. Disclaimer The information has been obtained from published materials deemed reliable and accurate and that were readily accessible for public consumption at the time of data collection, and supplementary data came from key sources who either led or informed specific parts of Fiji’s national response. The authors have no obligation to update any new information, and they will not be liable for any dispute arising in connection to this report.  Magic Waterfall and natural pool in Suva, Fiji Table of Contents TABLE OF CONTENTS Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Key Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.1 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 1.2 Epidemiology of COVID-19 in Fiji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 1.3 Macro-Economic Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 2. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Governance, Policies, and Institutions: 3.  What Existed and What Has Changed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 3.1 Organization and Policy for Disease Surveillance and Response . . . . . . . . . 37 3.2 Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 4. Response to Contain the Outbreak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 4.1 Government Response to COVID-19 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 4.2 Health Systems Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 4.3 Public’s Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 4.4 Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 4.5 Protecting Vulnerable People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 4.6 Innovation Through Leapfrogging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 4.7 Measure to Contain COVID-19 With a Human Capital Perspective . . . . . . . . 72 5. Covid-19 Impact on Uhc and Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 5.1 Service Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 5.2 Impact of COVID-19 on the Use of Health Services . . . . . . . . . . . . . . . . . . . . 81 5.3 Financial Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 5.4 Financing for Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 6. Lessons Learned and Key Takeaways for Other Countries . . . . . . . . . . . . . . . . . 83 7. Preparedness Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Fiji- World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 7 List of Figures LIST OF FIGURES Figure 1: Map of Fiji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Total COVID-19 Cases and Deaths—First, Second, and Third Waves Figure 2:  (per 100,000 Population) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Figure 3: Total Hospital Admissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 First Wave—COVID-19 Status and Government Response Figure 4:  (March 2020 to March 2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Second Wave—COVID-19 Status and Government Response Figure 5:  (April to December 2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Third Wave—COVID-19 Status and Government Response Figure 6:  (December 2021 to June 30, 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Epidemic Curve of Confirmed COVID-19 Cases in Countries or Areas With Figure 7:  the Lowest Number of Cases, as of June 29, 2022, 10:00 (GMT+8) . . . . . . . . . . . . . . . . . 23 Countries or Areas With Reported Laboratory-Confirmed Figure 8:  COVID-19 Cases and Deaths, Covering the Period From June 22 to 28, 2022, as of June 29, 2022 (GMT+8) (n = 63,949,507) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 COVID-19 Deaths per 100,000-—First and Second Waves Figure 9:  (March 2020 to September 16, 2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Proportion of COVID- 19 Deaths by Age Group Figure 10:  (March 2020 to September 16, 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Proportion of COVID-19 Deaths by Age—Third Wave Figure 11:  (December 2021 to June 30, 2022). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Figure 12: Fiji GDP Growth Rate (2013 to March 2021, 2022., and 2023) . . . . . . . . . . . . . . . . . . . . . 28 Figure 13: Percentage GDP Change on Human Health and Social Services . . . . . . . . . . . . . . . . . . 28 Figure 14: Proportion of Budget Allocation—MoHMS (2017 to 2021) . . . . . . . . . . . . . . . . . . . . . . . . . 29 Figure 15: Inflation Rates (June 2018 to June 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 8 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji List of figures LIST OF FIGURES (continued) Figure 16: Total Government Revenue (2017–2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Figure 17: Inward Personal Remittances (2018 to 2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Figure 18: Fiji COVID-19 Management Team Governance Structure . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Figure 19: Fiji—Health Expenditure by Finance Source (2010 to 2020) . . . . . . . . . . . . . . . . . . . . . . . 46 Figure 20: Levels and Types of Health Services Provided in Fiji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Figure 21: COVID-19 Intervention Timeline (2020) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 Figure 22: COVID-19 Intervention Timeline (2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Figure 23: COVID-19 Intervention Timeline (2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Figure 24: Number of COVID-19 Tests per Day . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 Figure 25: COVID-19 Daily Tests per Million . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Fiji—Types of Breaches during COVID-19 outbreak (under the Figure 26:  Failure to Comply with Orders Offence-FTCWO) - (April 19 to July 11, 2021) . . . . . . . . . . 61 Figure 27: Timeline of Key Events—Communication Campaign . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 Figure 28: COVID-19 Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Figure 29: COVID-19 Pacific Vaccination Update (April 19, 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Percentage of Eligible Population Fully Vaccinated in Pacific Island Countries Figure 30:  and Territories (April 19, 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Figure 31: Government Assistance to the Formal Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Figure 32: Government Assistance to the Informal Sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Figure 33: UHC Service Index—Fiji (2000 to 2019) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Figure 34: UHC Services Index—Middle-Income Countries in the PICTs (2019) . . . . . . . . . . . . . . . . 80 Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 9 List of Tables LIST OF TABLES Table 1: Deaths in the Third Wave (December 2021 to March 8, 2022), by Division . . . . . . . . . . . . 27 Table 2: Deaths in the Third Wave (December 2021 to March 8, 2022), by Age Group . . . . . . . . . 27 Table 3: Direct Budget Funding for COVID-19 2020 to 2021 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Table 4: Tourism Earnings 2016–2023. (p) = provisional (f) = forecast . . . . . . . . . . . . . . . . . . . . . . . . 30 Table 5: Fiji Government Debts (July 2017 to July 2021) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Table 6: Fiji Government Debts (July 2018 to July 2022) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 Table 7: Risk Reduction and Risk Management Components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Table 8: Alert Levels for Health Emergency and Disaster Management . . . . . . . . . . . . . . . . . . . . . . 41 Table 9: Alert Levels for COVID-19 Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Table 10: Scenarios and Response Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Table 11: Distribution of Health Care Benefits in Fiji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 Table 12: Public’s Response on Nonpharmaceutical Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Table 13: Sources of Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 Table 14: Financing for COVID-19 Vaccines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Table 15: Software Used During COVID-19 Pandemic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Table 16: Social Welfare Schemes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75 Table 17: Other Government Assistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Table 18: Concessional Loan Funding for Micro, Small, and Medium Enterprises (MSMEs) . . . . . . 76 Table 19: Assistance Provided by Fiji Government During COVID-19 Pandemic . . . . . . . . . . . . . . . 77 10 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji List of Summaries LIST OF SUMMARIES Summary 1: Epidemiology of COVID-19 in Fiji . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Summary 2: Macro-Economic Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Summary 3: Policy and Governance for Disease Surveillance and Preparedness . . . . . . . . . . . . . 42 Summary 4: Legal Framework and Control Mechanism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Summary 5: Health Financing and Health Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Summary 6: Primary Health Care, Physical Infrastructure, and Work Capacity . . . . . . . . . . . . . . . . . 52 Summary 7: Government Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Summary 8: Health System Response . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 Summary 9: Vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Summary 10: Protecting Vulnerable People . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Summary 11: Innovation Through Leapfrogging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Summary 12: Human Capital Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Summary 13: COVID-19 Impact on UHC and Sustainability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82 Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 11 Abbreviations ABBREVIATIONS ABBREVIATION EXPANDED FORM ADB Asian Development Bank AIIB Asian Infrastructure Investment Bank AUSMAT Australia Medial Assistance Team CDC Centre for Disease Control CEPI Coalition of Epidemic Preparedness Innovation CLCF Commonwealth Local Government Forum CRMT COVID-19 Risk Mitigation Taskforce CSN Clinical Service Network CWMH Colonial War Memorial Hospital DFAT Australian Government- Department of Foreign Affairs DISMAC Disaster Management Committee DMO Divisional Medical Officer ESMF Environmental and Social Management Framework EWARS Early Warning Alert and Response System FBOS Fiji Bureau of Statistics FCOSS Fiji Council of Social Services FEMAT Fiji Medical Assistance Team FEMIS Fiji Education Management Information System Fiji CDC Fiji Centre for Disease Control FNPF Fiji National Provident Fund FNU Fiji National University FOID Fijians of Indian Descent FPBS Fiji Pharmaceutical & Biomedical Services FRCS Fiji Revenue and Customs Service FRIEND Foundation for Rural Integrated Enterprises and Development FTCWO Failure to Comply with Orders Offence FWCC Fiji Women’s Crisis Centre GAVI Global Alliance for Vaccines and Immunization GBV Gender Based Violence GDP Gross Domestic Product 12 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Abbreviations ABBREVIATION EXPANDED FORM HCWs Healthcare Workers HEADMAP Health Emergencies & Disaster Management Plan HIES Household Income Expenditure Survey HIU Health Information Unit ICT Information and Communications Technology ICU Intensive Care Unit IMF International Monetary Fund IMT Incident Management Team JICA Japan International Cooperation Agency KAP Knowledge, Attitude, and Practice KOICA Korean International Cooperation Agency LGBTQI Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex LTD Leptospirosis, Typhoid, Dengue MEHA Ministry of Education, Heritage, and Arts MFAT New Zealand Ministry of Foreign Affairs and Trade MLO Media Liaison Officer MoHMS Ministry of Health and Medical Services MSME Micro, Small, and Medium Enterprise NCDs Non-Communicable Diseases NDMC National Disaster Management Council NDMO National Disaster Management Office NFA National Fire Authority NGO Non-governmental Organization NNDSS National Notifiable Disease Surveillance System National NPHL National Public Health Laboratory NPI Non- Pharmaceutical Interventions NZMAT New Zealand Medical Assistance Team PCR Polymerase Chain Reaction PHC Primary Health Care PHECC Pre-Hospital Emergency Care Centre PHEIC Public Health Emergency of International Concern PICTS Pacific Island Countries and Territories Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 13 Abbreviations ABBREVIATION EXPANDED FORM PPE Personal Protective Equipment PPHSN Pacific Public Health Surveillance Network PSIDS Pacific Small Island Developing States RBF Reserve Bank of Fiji RFMF Republic of Fiji Military Forces RISE Revitalizing Informal Settlement Environment RMNCH Reproductive, Maternal, Newborn, and Child Health SCC Suva City Council SDG Sustainable Development Goals SDMO Sub- Divisional Medical Officer SOP Standard Operating Procedure SOPD Surgical Outpatient Department SPC The Pacific Community STC Save the Children Fiji UNDP United Nations Development Programme UNICEF United Nations International Children’s Emergency Fund VRS Vaccination Registration System WAF Water Authority of Fiji WHO World Health Organization 14 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Executive Summary EXECUTIVE SUMMARY The Fiji government responded quickly and moved for high-risk people, teleworking, closure of high- decisively with stringent measures following risk venues, and personal hygiene measures; active the identification of the first COVID-19 case and surveillance and case detection; and appropriate took various effective measures to prevent its case management using various strategies including spread. It has been quick to implement public fever clinics, contact tracing, supervision, and home health emergency measures including lockdowns, quarantine to ensure safe delivery of clinical services. curfews, physical distancing, travel restrictions, and The pandemic has disproportionately impacted the international border closures to prevent imported most vulnerable and marginalized groups, including cases of the virus. While the Fiji government used women, children, older people, young people, its endorsed Health and Emergencies Disaster persons with disabilities, the LGBTQI+ community, Management Plan (HEADMAP) and did not view single and women-headed households, and poor the pandemic as a new concept requiring a new households, with escalating rates of gender-based approach, its application remains one that is violence being reported. Although there are many innovative and potentially transformative, especially challenges faced in adequately containing and for Fiji and the Pacific region. A total of 65,713 cases responding to the COVID-19 pandemic, some of the (7,426 per 100,000 population) and 866 deaths (98 lessons learned could provide valuable insights for per 100,000 population) have been reported up until policy makers and researchers globally. June 30, 2022. The Ministry of Health and Medical Services (MoHMS) in Fiji mobilized its staff to serve at designated fever clinics and isolation facilities in hospitals and communities, and it gradually increased its sentinel sites for polymerase chain reaction (PCR) tests, with additional capacity to undertake GeneXpert COVID-19 testing. Since the first confirmed case of COVID-19 was identified in Fiji on March 19, 2020, the government of Fiji has taken proactive and effective measures, including nonpharmaceutical interventions (NPIs) such as school and workplace closure, community quarantine, limiting size of meetings, restricting travel, stay-at-home guidelines Children playing in the ocean in Savusavu, Fiji Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 15 Abbreviations Key Findings Containment Phase Mitigation • The early formation of the Incident Management • Information and communication technology (ICT) Team (IMT) was important for the coordination of applied to track COVID-19 infections and vaccine the “whole-of-government” response. uptake in real time has been useful to inform decision-making. • Early activation of the Fiji Emergency Medical Assistance Team (FEMAT) was critical to ensure a • The use of incentives has been effective in continuum of health services delivery during the boosting vaccination coverage in Fiji. pandemic. • Retaining the trust of community institutions • Early closure of borders (early February 2020) and leaders (especially religious leaders and and strict implementation of border control health care professionals) was pivotal in the measures helped keep the COVID-19 virus out of government’s success in combating COVID-19. the country during the early phase. • Aggressive risk communication during the • The role of the Fiji Centre for Disease Control second wave was conducted to combat vaccine (CDC) in facilitating good testing capacity led to hesitancy. the early detection of cases, which prevented the direct transmission of the virus to the general community. Mitigation and Containment • Good testing capacity led to the early detection • The development of a remodeled framework of cases, which prevented the direct transmission toward a remodeled health services provision of the virus to the general community. structure was crucial during the pandemic. • The “whole-of-government” approach • Timely and well-coordinated management plans involving stakeholders from the government, are critical during this health crisis. the private sector, and local and international • Continuous capacity developments at the nongovernmental organizations provided institutional, legislative, and individual levels important tools for the fight against COVID. were critical for the overall understanding of the preparedness and mitigation process to ensure trust. 16 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji 1. Introduction INTRODUCTION 1.1 Background Fiji is an island country in the South Pacific Ocean Figure 1:  Map of Fiji consisting of 322 islands, with a total land area of about 18,274 square kilometers (see Figure 1). Close to 100 of the 322 islands are inhabited, with the two major islands of Viti Levu and Vanua Levu having the greatest landmasses and distribution of the population. The latest population census of Fiji (2017) recorded a total population of 884,887; an increase of approximately 5.7 percent from the last census in 2007 (Fiji Government 2018). Approximately half of Fiji’s population is under the age of 27, an estimated 56 percent of the total population resides in urban areas, and the population density is about 49 persons per square kilometer. The country is divided into four administrative divisions (Western, Eastern, Central, and Northern), with 14 provinces, 195 districts, and 1,193 villages.1 The population comprises two major Source: Fiji Map—Turtle Island ethnic groups—the I-Taukei (indigenous Fijians) and the Fijians of Indian Descent (FOID). Other minority ethnic groups include Rotumans, Part-Europeans, Chinese, and other Pacific Islanders. 1 https://bestfijiguide.com/fiji-provinces/ Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 17 Introduction …the social and economic impacts of COVID-19 in Fiji cannot be discussed separately from its experience of climate change impacts, as these costs have also had bearing on the country and its capacity to respond to the pandemic. Economy Economic Impact of Disasters Fiji is an upper middle-income country with a gross The International Monetary Fund’s (IMF) 2020 Article domestic product (GDP) per capita of 4,881 Fiji dollars IV Consultation Report highlights that Fiji is highly (F$) in 2020 (World Bank and IDB/WHO 2021. Fiji’s vulnerable to natural disasters and climate change economy relies heavily on revenues from tourism, (IMF 2020). Therefore, the social and economic sugar and agricultural exports, and remittances as an impacts of COVID-19 in Fiji cannot be discussed important source of household income. Before the separately from its experience of climate change COVID-19 pandemic, tourism contributed to nearly 40 impacts, as these costs have also had bearing on the percent of Fiji’s GDP and directly employed around country and its capacity to respond to the pandemic. 40,000 Fijians and nearly another 100,000 indirectly, The annual economic damages caused by disasters both in the formal and informal sectors. In 2019, between 1980 and 2016 for Fiji have been estimated Fiji’s tourism revenue was F$2065.5 million in total to cost F$35 million, which is approximately US$16.3 (Reserve Bank of Fiji 2021). million (UNDRR 2019). The Category 5 Cyclone Economic growth has been consistent and high Winston which struck Fiji in 2016 resulted in losses for the past decade, with growth averaging over 3 and damages totaling a record US$1.38 billion the percent from 2010 (ADB 2021a). Poverty is much equivalent of 31% of GDP for the country (World Bank higher in rural areas (37 percent) than in urban 2016). areas (20 percent). Basic services reach almost all The disaster had severe impacts on infrastructure, urban and many rural households (Ibid). In the most the agriculture sector, the sugar industry, and public recent Household Income Expenditure Survey (HIES) finances, and the government spent about 4 percent conducted between February 2019 and February of GDP on the reconstruction of schools, roads, 2020 (FBOS [Fiji Bureau of Statistics] 2021a) Fiji’s bridges, and other infrastructure. The World Bank’s poverty rate was recorded at 29.9 percent (258,000) Climate Vulnerability Assessment of 2018 identified with most of the country’s poor living in rural (62 the need for large investments to strengthen Fiji’s percent) rather than in the urban (38 percent) areas resilience to climate change and natural hazards. of the country. The profile of those living below the According to the same source, climate change poverty line in the recent HIES records an almost will create long-term threats to Fiji’s development even distribution of males (52 percent) and females plan as rising sea levels negatively impact coastal (48 percent) who are mostly I-Taukei (75 percent) and populations, agriculture, and food sources for the Fijian of Indian Descent (23 percent). Most of the poor country’s vulnerable populations. This will worsen reside in the Western and Central divisions, rather health issues, as development, climate change, than the Northern and Eastern divisions. and the tourism sector are subjected to multiple 18 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Introduction stressors. The Fiji government has identified five Socio-Economic Impact of a Double potential solutions to address its climate change Tragedy challenges: First, adaptation strategies would be integrated into town planning activities. Second, While the country was in the throes of its first wave partnerships would be developed between the main of COVID-19, Fiji was also hit by Category 4 Cyclone stakeholders (communities, private sector, and the Harold on April 8, 2020. The government declared municipal councils) to facilitate a unified response a state of emergency in the wake of the cyclone, as to address climate change issues. Third, a national well as for the pandemic. As was expected, most platform would be established through which emergency operations and humanitarian responses stakeholders may coordinate their actions. Fourth, targeting cyclone victims were drastically affected awareness would be created on adaptation methods (Cowley 2020). This was mainly due to COVID-19 for communities; and fifth, a national strategic plan for restrictions on movement, social distancing, and other climate change and adaptation would be developed prevention measures, which limited the humanitarian (MOE [Ministry of Economy] 2017). response around the country. A total of 250 evacuation centers were opened around the country’s four divisions, and an estimated History of Epidemics/Disease 10,000 people were further displaced (Du Parc and Outbreaks in Fiji Spieth 2020). Some of the consequences of the double tragedy included an increased demand on Fiji has had multiple epidemics before the well- women’s domestic and caregiving roles, which were known disease outbreaks in 1875 and 1918. In 1875, linked to the COVID-19 restrictions (lockdowns and 40,000 (4,520 per 100,000) people lost their lives school closures). Additionally, the combined impacts due to measles, and in 1918, approximately 9,000 of Cyclone Harold and COVID-19 affected short- and (1017 per 100,000) people died due to the Great long-term socio-economic resilience levels for Fiji’s Influenza Epidemic (Allsopp 2020). However, due to populations, as most people compromised health advancement in science, vaccines were developed and economic security by choosing to reduce food and led to the drop in measles infection in 1982 (the intake, barter of assets (UNAIDS 2020), and out-of- second dose of the vaccine, combined with Rubella, pocket costs for health and education. Sections was developed in 2003). In 2019, following a measles of the population who found themselves jobless outbreak, Fiji’s health authorities responded with resettled in rural areas, and the urban-to-rural drift actions that included banning large gatherings (such is placing undue pressure on existing limited rural as sports), vaccination requirements for inbound and services. Finally, accessing existing but limited outbound travelers, and quarantine for those who assistance available through social protection were believed to be in contact with cases. Nurses schemes for marginalized groups became a conducted vaccination from house to house, and challenge as COVID-19 prevention measures also the 2019 Fiji Measles Check showed that less than restricted movement, especially for people living with 30 cases were identified in the Central division, and disabilities (Cowley 2020). no deaths were recorded. Hence Fiji’s response to measles had been successful. Undoubtedly, the COVID-19 pandemic has had a huge impact on the economy, leading to the Fiji has had an increase in cases of meningococcal closure of 93 percent of Fiji’s tourism industry since disease over recent years. Twenty-nine (29), 48, March 2020. According to a joint research by the and 18 cases were reported in 2016, 2017, and 2018, International Finance Corporation and the Fiji Ministry respectively. All the reported patients were 19 years of Commerce, Trade, Tourism and Transport (2020), old or younger (MoHMS 2018). In 2018, the MoHMS Fiji COVID-19 Business Survey Tourism Focus (2020) conducted a mass vaccination campaign across the report, about 50 percent of tourism businesses were country, with the aim of vaccinating approximately closed due to the pandemic. Tourism revenue went 325,000 children and adults. The government down by 59 percent, hence leaving 27 percent of received support from UNICEF, WHO, and other staff to work on reduced hours per day, 25 percent development partners in sourcing out vaccines and implementation of the vaccination plan, including cold chain (UNICEF 2018). Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 19 Introduction on leave without pay, and 8 percent having been 18 cases in the community—the original Wuhan strain made redundant. The report further stated that large (between March and April of 2020), while other businesses involved in tourism have lost twice as recorded cases were detected from international much income as large businesses in non-tourism travelers undergoing 14 days of quarantine in border sectors, while micro, small, and medium enterprises quarantine facilities (Figure 4). By March 21, 2021, Fiji (MSMEs) have lost seven times more income than had recorded a total of 67 cases, 64 recoveries, and MSMEs in non-tourism sectors. 2 deaths. The second wave began when Fiji recorded the first Delta variant case in the Western division This has directly impacted 37 percent of (Nadi) in April 2021. The disease spread rapidly, and households in urban informal settlement in Fiji, with the number of cases increased exponentially. Three 25 percent having their work hours reduced and days later, cases of the same variant were reported 12 percent having lost their source of income (RISE in the Central division in Suva, and within months, the 2020), resulting in more than 100,000 jobs lost. Apart virus had spread to all the areas within Lami, Suva, from the direct economic impacts, the pandemic and Nausori. The transmission was very fast as the has put significant pressure on the health system in virus almost made its way throughout the whole of Viti Fiji and disrupted education at all levels, affecting Levu. The MoHMS with other government ministries, teaching roles and responsibilities for teachers and civil service organizations (CSOs and other allied learning aspects for students (Gounder and Narayan partners, through tireless efforts, were able to contain 2021). the virus within Viti Levu, sparing Vanua Levu and However, Fiji is gradually moving toward economic most of the Eastern division. However, later in 2021, recovery. The government has successfully the virus was detected in these areas, as borders vaccinated 100 percent of its population with the were opened to allow for domestic travel (Figure 5). first dose and 90 percent with the second dose, as The third wave began when border restrictions were of June 30, 2022 (MoHMS 2022). Following this, loosened in November and December 2021. The the government was able to open containment government opened its borders to its citizens, and zones around the country to enable movement by December 1, 2021, they were fully opened to all in the Western and Central divisions of Viti Levu nationals. A few days later (December 7, 2021), the and allow bus companies to operate. Businesses MoHMS confirmed two new cases of the Omicron began reopening, and people started going to work. variant in Fijians who were returning from Nigeria Private sectors began expanding their trade, and all (Tadulala 2021b). However, the variant had most likely workplaces, tertiary institutions, houses of worship, already made its way into the community based on hotels, restaurants, and so forth started operating positive test reports received by the MoHMS from the at 70 percent capacity (only for fully vaccinated Peter Doherty Institute for Infection and Immunity in individuals). Furthermore, students in Years 12 and 13 Melbourne (MoHMS 2021b) (Figure 6). resumed classes on November 1, 2021, while classes The clinical courses of the disease varied widely. for Years 8 to 11 resumed on January 4, 2022, and Although the MoHMS has no negative pressure classes for Early Child Education to Year 7 resumed isolation rooms, it has facilities available to separate on February 7, 2022 (MEHA [Ministry of Education, patients with infectious disease from others. Because Heritage, and the Arts] 2021d, 2022). fever was one of the most common manifestations of COVID-19, the government of Fiji established fever clinics across the country to identify early 1.2 Epidemiology of COVID-19 in Fiji symptoms and prevent the spread of COVID-19 (see Fiji reported a total of 65,713 (7,426 per 100,000) Figure 3: Total Hospital Admissions). The infection COVID-19 cases from March 2020 to June 30, 2022, can affect people of any age group, with the elderly starting with the first wave, where 65,643 (7,418 per and patients with comorbidities being particularly 100,000) COVID-19 cases were reported since April vulnerable to the high risk of severe infection. 2021 (Figure 2). In the first wave, the MoHMS detected 20 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Figure 2: Total COVID-19 Cases and Deaths- First, Second and Third Wave (per 100,000 population) Introduction Figure 2:  Total COVID-19 Cases and Deaths—First, Second, and Third Waves (per 100,000 Population) Total COVID- Cases & Deaths , Timeline: March - June, Cases Cases and Deaths per Total Cases (n): , Deaths Total Cases per , : Total Deaths: Total Deaths per , : A B C COVID- . . . . . . . . . . . . . . . rch ril y ne Au y t Oc r ve r De ber Ja er Fe ar y ry rch ril y ne Au y t Oc er ve r De ber Ja er Fe ar y ry rch ril y ne Se gus Se us be No be No be Ma l Ma l Ma Ju Ju Ap ua Ap ua Ap mb b mb Ju Ju Ju g nu nu Ma Ma Ma em to m em to m br br ce ce pt pt 2020 2021 2022 A - First Wave B - Second Wave (till Sep) C - Third Wave Timeline: March - March Timeline: April - December, Timeline: December, - Total cases (n): Total cases (n): , June, Total cases per , : Total cases per , : Total cases (n): , Total Deaths: Total Deaths: Totcal cases per , : Total Deaths per , : . Total Deaths per , : Total Deaths: Total Deaths per , : Source: Our World in Data and MoHMS (2020, 2021, and 2022) Figure 3: Total hospitals Admissions Figure 3:  Total Hospital Admissions New hospital admissions Total current hospital admissions 90 200 80 180 Labels indicate the 160 number of hospitals 70 Total lpatients admitted 140 reporting each day 60 Labels indicate the by division New admissions number of hospitals 120 50 reporting each day 100 40 by division 80 30 60 20 40 10 20 0 0 Central Western Eastern Northern Central Western Eastern Northern Source: MoHMS, 2021i Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 21 Introduction COVID-19 Waves in Fiji and later to the Eastern and Northern divisions. Cases plummeted during this period, and more deaths were Fiji experienced three COVID-19 waves after the also recorded. Fiji recorded more than 50,000 cases detection of the SARS-COV-2 virus in Hubei, China. and 699 deaths in the second wave alone. The third The country detected its first case, a flight attendant wave corresponds to the presence of the Omicron returning from San Francisco, on March 18, 2020 (Deo variant in the country. The variant was detected 2020). Following that, the government introduced around late December 2021, and from that period a series of measures to contain the virus (Figure 4). until June 30, 2022, the country recorded more than In the first wave, the country recorded a total of 67 12,000 cases and 165 deaths. Figures 4, 5, and 6 cases and 2 deaths (recorded in July and August of present the distribution of the cases and deaths (by 2020). The second wave started around April 2021, months) and the government responses in each of with the Delta variant spreading rapidly within the Viti the waves. Figure 4: 1st Wave- COVID-19 Status and Government Levu group (mainly the Central and Western divisions) Figure 4:  First Wave—COVID-19 Status and Government Response (March 2020 to March 2021) Travelers from China and Restrictions on movement Fiji received and high-risk countries not Government o cials and social gatherings started deploying the allowed in Fiji not permitted to travel Astra-Zeneca overseas baring vaccine exceptional critical Testing capacity increases COVID-19 Cases and Deaths per 100,000 circumstances as testing was decentralized 1.5 1.6 1.4 1.1 1.2 1 1 0.9 1.0 0.8 0.7 0.8 0.6 0.5 0.6 0.4 0.2 0.2 0.1 0.1 0.2 0 0 0 0 0 0 0 0 0 0 0 0.0 March April May June July August September October November December January February March 2020 2020 Fiji ceased flights Closing of schools and Launch of the CareFiji App non-essential business Cases Deaths Figure Source: 5: 2nd MoHMS Wave- COVID-19 COVID-19 Updates Status and Government Response (April- December, 2021) Figure 5:  Second Wave—COVID-19 Status and Government Response (April to December 2021) Establishment of the Public 3500 Health Infringement Notice COVID-19 Cases and Deaths per 100,000 2866 Government Unemployment 3000 Assistance provided to only vaccinated individuals 2500 Vaccination rate reached 1912 70% coverage (Annex 6) 2000 Increase in testing capacity and the ANZMAT have been Vaccination rate reached 1500 deployed to assist the 80% coverage (Annex 6) MoHMS 1000 Vaccination rate reached 487 90% coverage (Annex 6) 450 500 36 0.2 126 6 39 2 93 6 0 2 25 29 15 0.2 0 April May June July August September October November December 2020 Introduction of the Incentives used to boost vaccination “No Jab, No Job” Policy coverage - Win Together Sweepstakes Cases Deaths Source: MOHMS COVID-19 Updates 22 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Figure 6: 3rd Wave- COVID-19 Status and Government Response Introduction (December, 2021 – 30 June, 2022) Figure 6:  Third Wave—COVID-19 Status and Government Response (December 2021 to June 30, 2022) Suspension of inter- COVID-19 Cases and Deaths per 100,000 1200 1076 island shipping Presence of 1000 the Omicron variant in Fiji Increase in fines - Public 800 Health Infringement Notice 600 400 200 93 121 80 54 0 42 0.2 12 4 26 3 .21 0.2 0 December January February March April May June Months 2020 2020 Enforcement of Exemption of unvaccinated people COVID-19 Safe Measures from enteringpublic places Cases Deaths Source: MoHMS COVID-19 Updates Figure 7: Epidemic curve of confirmed COVID-19 cases in countries or areas with the lowest Figure number 7:  Epidemic ofConfirmed cases, as Curve of of 29Cases COVID-19 Junein 2022 10:00 Countries (GMT+8) or Areas With the Lowest Number of Cases, as of June 29, 2022, 10:00 (GMT+8) 10,000 Brunei Darussalam Cambodia New Caledonia Kiribati Northern Mariana Marshall Islands Island 7,500 Vanuatu Niue Nauru Papua New Guinea Number of cases Palau French Polynesia Lao PDR Solomon Islands 5,000 American Samoa Tonga Cook Islands Tuvalu Fiji Wallis and Futuna 2,500 Micronesia Samoa Guam 0 Ja 30 Fe -27 Ma 24 Ap 23 Ma 20 Ju -18 Ju 15 Au -13 Se 10 Oc 07 No -05 No 2 De 30 Ja -28 Fe 25 Ma -22 Ap 22 Ma -19 Ju 7 Ju 14 Au l-12 Se -09 Oc 06 No -04 No -01 De 9 Ja 27 Fe 24 Ma -21 Ap 21 Ma -18 Ju 6 Ju 3 1 l-1 y-1 1 v-0 v-2 y-1 n- n- r- n- g- c- p- b- n- r- r- n- c- v- r- p- l y r b r v n c t b t g De Date of report Source: WHO 2022a—Pacific COVID-19 Daily Epidemiological Update Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 23 Introduction Figure 8:  Countries or Areas With Reported Laboratory-Confirmed COVID-19 Cases and Deaths, Covering the Period From June 22 to 28, 2022, as of June 29, 2022 (GMT+8) (n = 63,949,507) New cases New deaths Change (7-day Days since last Country or area (cumulative) (cumulative) average of cases) reported case American Samoa 02 (6 414) 0 (31) -10.29 9 Australia 198 493 (8 048 708) 332 (9 777) 678.86 0 Brunei Darussalam 4 528 (163 055) 0 (166) 19.14 0 Cambodia 0 (136 262) 0 (3 056) 0.00 52 China 304 411 (4 686 285) 971 (21 073) -11 867.00 0 Cook Islands 6 (5 768) 0 (1) -5.14 0 Fiji 197 (65 558) 0 (865) 7.57 0 French Polynesia 82 (73 268) 0 (649) 2.86 0 Guam 376 (43 073) 0 (371) -41.71 0 Japan 109 145 (9 283 083) 189 (31 246) 1 596.14 0 Kiribati 21 (3 236) 0 (13) 3.00 0 Korea, Republic of 51 460 (18 349 746) 63 (24 537) 233.86 0 Lao PDR 44 (210 258) 0 (757) -0.86 0 Malaysia 15 957 (4 560 583) 21 (35 758) 234.71 0 Marshall Islands 0 (18) 0 (0) 0.00 26 Micronesia (Federated States of) 0 (38) 0 (0) 0.00 24 Mongolia 02 (928 586) 2 (2 118) -81.86 24 Nauru 2 491 (3 174) 0 (0) 258.71 0 New Caledonia 822 (64 337) 0 (313) 44.14 0 New Zealand 41 245 (1 323 528) 81 (1 449) 1 039.14 0 Niue 5 (15) 0 (0) 0.57 0 Northern Mariana Islands 190 (11 759) 1 (35) 14.71 0 Palau 27 (5 220) 0 (6) -0.14 0 Papua New Guinea 26 (44 717) 0 (662) 1.43 0 The Philippines 5 119 (3 702 319) 55 (60 531) 254.86 0 Pitcairn Islands 0 (0) - - - Samoa 94 (14 906) 1 (29) -31.57 0 Singapore 47 081 (1 425 171) 5 (1 410) 2 538.00 0 Solomon Islands 02 (21 544) 0 (153) 0.00 18 Tokelau 0 (0) -- - - Tonga 222 (12 301) 0 (12) 31.71 0 Tuvalu 0 (3) 0 (0) 0.00 37 Vanuatu 253 (11 266) 0 (14) -8.29 0 Viet Nam 5 945 (10 744 854) 3 (43 087) 45.86 0 Wallis and Futuna 0 (454) 0 (7) 0.00 77 Total 788 240 (63 949 507) 1 724 (238 126) -5 041.57 Source: WHO 2022a—Pacific COVID-19 Daily Epidemiological Update 24 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Introduction Mortality of COVID-19 Cases more deaths were reported from the Central division (69 percent) compared to the Western and Eastern Fiji has recorded 866 deaths (which is 98 deaths divisions (Figure 9). Case fatalities were among per 100,000 population) since the beginning of the those aged 50 years and above (Figure 10). These pandemic until June 30, 2022, with most deaths may be related to non- or partial vaccination, as well reported in the second wave (Figures 2 and 9). Other as existing comorbidities. Fewer deaths have been Pacific Islands such as Samoa, Vanuatu, and the recorded for age cohorts under 40 years old and Solomon Islands reported low counts of COVID-19 more than 90 years old. cases and deaths. As of June 29, 2022, Samoa recorded 14,906 cases with 29 deaths, Vanuatu During this period, the country reported high 11,266 cases and 14 deaths, and the Solomon Islands rates of deaths on arrival (DoA) and deaths at home 21,544 cases and 153 deaths (WHO [World Health (DaH). These may be attributed to local health- Organization] 2022b) (Figures 7 and 8). seeking behaviors as well as the fear of being isolated from family members and dying alone if they presented at health facilities. At the peak of the Analysis of COVID-19 Deaths in the wave, administration of life-saving treatment proved First and Second Waves futile as the symptoms and complications of the virus appeared to escalate in a matter of hours. Reports [Note: Data provided in Figures 8 and 9 is from March of deaths at homes or on the way to the hospital 2020 to September 17, 2021. Data from September 18, increased exponentially for the country, and severe 2021, and onwards was not obtained due to limited respiratory distress was the common complication information on deceased cases]. (RNZ 2021b). Tran et al. (2020) discussed health- Fiji’s youngest COVID-19 death was a four- seeking behaviors as one of the factors related to month-old baby boy, and the oldest case was a deaths on arrival at hospitals. Generally, there was 102-year-old female—both deaths reported from the a fear of visiting hospitals or health centers and a Central division. Fiji recorded the highest number of higher preference for seeking over-the-counter COVID-19 deaths in July and August of 2021. Fewer remedies at local pharmacies for self-treatment or females (47 percent) were reported as dying from for accessing alternative herbal medicine through Figure 9: COVID-19 Deaths per 100,000- COVID-19 compared to males (53 percent), and First and Second traditional Wave healers. (March 2020 to 16 September 2021) Figure 9:  COVID-19 Deaths per 100,000-—First and Second Waves (March 2020 to September 16, 2021) Deaths A - First Wave B - Second Wave (till Sep) , Timeline: March - March Timeline: April - September, Total Deaths: Total Deaths: Deaths per Total Deaths per , : A B COVID- . . . ry rch ril y ne ly st r rch ril y ne ly st r r er er y be be be Ma Ma ar Ju Ju gu gu Ap Ap ua mb mb Ju Ju nu Ma Ma em em to Au Au br ve ce Oc Ja Fe pt pt De No Se Se 2020 2021 Months Total COVID- Deaths Proportion and total number of Proportion and total number of Timeline: COVID- Deaths by Patient Sex COVID- Deaths by Division March - September, Male Females Central Western Eastern Total Deaths: % % % % % % % Total Deaths per , : n n Source: World in Data and MoHMS—2020 and 2021 Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 25 Introduction Analysis of COVID-19 Deaths in the Third Wave The third COVID-19 wave started around mid- to number of deaths (n = 67), while the Northern division late December 2021 (since the reporting of the had the highest rate of death when adjusted for Omicron variant in Fiji). Deaths started peaking population—20.7/ 100,000 population (Table 1). When by mid-January 2022, contributing to a total of analyzing deaths by age group, the age group 50 165 deaths in the third wave alone (Figure 11). The years and older has the highest death rate adjusted Western division recorded the highest absolute per 100,000 population (Table 2). Figure 10: Proportion of COVID- 19 Deaths by Age Group (March 2020 to 16 September, 2022) Figure 10:  Proportion of COVID- 19 Deaths by Age Group (March 2020 to September 16, 2022) More deaths reported from - years % ( - %), - ( - %), - ( - %) and - ( - %) % Less deaths reported from - years ( - . %), - ( - . %) and - ( - %) Proportion of Death (%) % Males: more deaths reported from - ( - %), - ( - %) and - ( - %) % Females: more deaths reported from - ( - %), - ( - %) and - ( - %). % % % - - - - - - - - - - - months Age Category (years) More deaths reported from the Central ( - %) and Western ( - %) division. Six ( %) deaths reported from the Eastern division. Total Count (deaths) Males Females Central division: highest number of deaths received from Central Western Eastern - ( - %) and - ( %) age category. Western division: highest number of deaths received from - ( - %) and - ( - %). Source: World in Data and MoHMS—2020 and 2021 Figure 11: Proportion of COVID-19 Deaths by Age- Third Wave- December 2021 to 30 June 2022. Figure 11:  Proportion of COVID-19 Deaths by Age—Third Wave (December 2021 to June 30, 2022). 14 – 165 deaths (19 deaths per 100,000) reported 12 – Western division has the highest number 12 COVID-19 Deaths per 100,000 of deaths (67 - 40.6%), followed by Central divison (64 - 38.8%), Northern division 10 (29 - 17.6%), and Eastern division (5 - 3%). 8 – Most deaths reported from 70-79 years, 80-89 years, and 60-69 years categories. 6 – Less deaths reported from 10-19 years, 4 20-29, and 30-39 years categories. 4 3 2 0.2 0 0.2 0.2 0 December January February March April May June Months 2021 2022 Deaths Source: MoHMS 2022b 26 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Introduction Table 1:  Deaths in the Third Wave (December 2021 to March 8, 2022), by Division Summary 1:  Epidemiology of COVID-19 in Fiji • Fiji’s first case was reported on March 19, 2020. Total COVID Deaths per In the first wave, the MoHMS detected 18 Division Deaths 100,000 confirmed cases in the community, from March to April 2020, while other cases were reported Central 64 15.9 from border quarantine facilities. A total of Western 67 18.8 67 cases and 2 deaths were reported during this period. In the second wave, the MoHMS Northern 29 20.7 detected 52,748 cases and 699 deaths from Eastern 5 13.0 April to December of 2021. In the third wave, Fiji recorded 165 deaths and 12,898 cases—as of Source: MoHMS 2022b June 30, 2022. • The original COVID-19 Wuhan strain reached the Fiji shores in March 2020. The Delta and Table 2:  Deaths in the Third Wave (December 2021 to Omicron variants were detected in April and March 8, 2022), by Age Group December of 2021, respectively. Deaths per • COVID-19 cases and deaths peaked between Age Group Total Deaths 100,000 June and August of 2021, and they gradually population decreased in September 2021. 0-9 6 3.3 • Fiji’s youngest death was a four-month-old baby, and the oldest was a 102-year-old female. 10 - 19 2 1.3 • Most deaths reported were from the Central 20 - 29 3 2.1 division with a fair distribution of deaths by 30 - 39 4 2.9 patient gender. High-risks groups were those ages 60 years and above. 40 - 49 7 6.7 • In the first and second waves, most deaths 50 - 59 21 23.1 reported were from the Central division, with a fair distribution of deaths by patient gender 60 - 69 34 65.4 (Figures 9 and 10). In the third wave, most 70 - 79 50 223.2 reported deaths were from the Northern division—rate adjusted for population (Table 1). 80 - 89 30 533.2 90 - 99 6 1153.8 Source: MoHMS 2022b Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 27 Introduction Figure 12: Fiji GDP Growth Rate (2013- March 2021, 20 1.3 Macro-Economic Indicators Figure 12:  Fiji GDP Growth Rate (2013 to March 2021, 2022., and 2023) Prior to COVID-19 in Fiji, the country had the % strongest period of economic growth from 2010 to 15 12.4 2018. For instance, per capita income levels rose to 9.2 10 over F$13,000, and the unemployment rate fell to a 5.0 5.4 20-year low of 4.5 percent. This economic stability 5 4.5 3.8 2.4 was due to increased productivity and investment, 0 improved private sector confidence, political stability, -0.6 and implementation of critical reforms by the Fijian -5 -4.1 government. However, COVID-19 and a series of -10 natural disasters devastated the country’s economy -15 in terms of local business activities and the global -17.2 supply chains, impacting trade flows, employment, -20 2015 2017 2019 2021(e) 2023(f) remittance inflow, and government tax collections. Source: Republic of the Fiji 2022a Fiji’s data on the percentage change GDP on Gross Domestic Product (GDP) human health and social services was 6.1 percent in per Capita 2018 (actual) and 25.5 percent in 2019 (provisional). According to the International Monetary Fund (2021), The years 2020 and 2021 (estimated) showed an the global economy was projected to increase by 5.9 estimated percentage of 20.8 and 27.4, respectively. percent in 2021 and 4.9 percent in 2022. However, However, projections of 2022 to 2024 (forecasted) beyond 2022 it was expected to grow moderately, are forecasted to be -4 percent, 4.8 percent, and 4.8 by 3.3 percent. Fiji’s GDP contracted by 17.2 percent respectively percent, 13: Figure Percentage(Figure 13). change on Human Health a GDP in 2020 with a further 4.1 percent contraction in 2021 Figure 13:  Percentage GDP Change on Human Health (Figure 12). Projections showed that Fiji’s real GDP and Social Services is expected to increase by 11.3 percent in 2022, 8.5 percent in 2023, and 7.7 percent in 2024. The 30 27.4 25.2 Gross Domestic Product (% Change) COVID-19 pandemic and consecutive natural disasters 25 have contributed to these drops, as jobs, public 20.8 20 finance, and socioeconomic conditions were altered. However, Fiji’s economy is gradually recovering as 15 the government was able to vaccinate more than 10 6.1 100 percent and 95 percent of its population with the 4.8 4.8 5 first and second doses, respectively, and 45 percent 0 with the booster doses (n = 141,572 or 15,999 per 100,000 population). Borders were also opened to -5 -4 international, regional, and domestic travelers, as a 2018 2019 2020 2021 2022 2023 2024 response to economic recovery (MoHMS 2022). Year GDP (% Change) Source: Republic of Fiji 2022a Budget Increase for the MoHMS (2017 to 2021) COVID-19 has increased fund allocation toward the MoHMS in the total government budget. As depicted in Figure 14, budget allocations have increased in the years 2019, 2020, and 2021. A comparison of the budget estimates for the years 2018–2019 and 2019–2020, 2020–2021, and 2021–2022 shows it Fishing fleet at anchor, Suva harbour, Fiji increased by 2.3 percent, 3.1 percent, and 3.7 percent, respectively. Budget allocation details are provided in Annex 21. 28 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Introduction Figure 14: Proportion of Budget Allocation- MoHMS (2017- 2021) Figure 14:  Proportion of Budget Allocation—MoHMS redirection of funds to “relevant front-line agencies (2017 to 2021) that required additional resources for the prevention and containment activities, ensuring food security and . % . % . % maintaining support for the disadvantaged” through a series of measures in its 2020/2021 budget (MOE . % . % 2020). These included support to all employers in Fiji through a reduction of the mandatory Fiji National Provident Fund (FNPF—social security scheme) employer contribution from 10 percent to 5 percent, - - - - - thereby providing approximately F$103 million (US$49.6 million) relief to employers from April to % Budget allocation (MoHMS) December 2020. Employee deductions to the same scheme were also reduced from 8 percent to 5 Source: Republic of Fiji 2017, 2018a, 2019a, 2020a. percent, allowing F$80 million (US$38.5 million) worth of spending back into the pockets of employees for The economy is projected to recover in 2022 and the same period. The government provided further 2023 with a broad-based growth forecast of 8.7 relief to employers through direct reimbursement percent, based on the assumption that tourism activity payment for 21 days of leave for employees who will normalize, leading to a pickup for tourism-related were certified by the MoHMS as having COVID-19 sectors and a rebound in domestic demand toward infections. Additionally, employers who continued the end of 2021 (Reserve Bank of Fiji 2021). to pay their employees during self-quarantine, as required by the MoHMS, were eligible for a 300 In response to the pandemic, the Ministry of percent tax reduction. Table 3 presents a summary of Economy introduced a COVID-19 Response Package the direct budget funding for the COVID-19 response valued at F$1.0 billion (US$470 million) in parliament for fiscal year 2020. in 2020, and announced a strategy focusing on Table 3:  Direct Budget Funding for COVID-19 2020 to 2021 Details` (FJD) $ Million (US) $ Million % Ministry of Health 40.00 18.800 4.000 Fiji Police Force 0.70 0.329 .070 Rep of Fiji Military Forces 0.15 0.070 0.015 Min. of Agriculture 1.00 0.400 0.100 Fiji Competition & Consumer Commission 0.01 0.047 0.001 Unemployment Benefits - Tourism Sector 5.60 2.600 0.560 Unemployment Benefits - Lockdown Areas (Formal Sector) 7.00 3.290 0.700 Unemployment Benefits - Lockdown Areas (Informal Sector) 3.00 1.400 0.300 Unemployment Benefits - General 5.00 2.350 0.500 Assistance to SMEs 5.00 2.350 0.500 Contingency Funds (Unemployment) 5.00 2.350 0.500 Contingency Funds (General) 27.50 12.900 2.750 Total Budget Allocation FJD $1 Billion (USD $470 million) 100.00 47.000 Source: Fiji MOE—Supplement to the COVID-19 Budget Address Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 29 Introduction A total budget of F$3,536.4 million (US$1,698.68 industry was favorable from 2016 until 2019, with an million) was allocated to the COVID-19 response average earning of F$1,955.9 million, with 849,976 in 2020, of which F$2,507.6 million (US$1,204.5 visitors (Republic of Fiji 2020c.). However, it was million) was to be funded through projected total not consistent in 2020 and 2021, as visitors’ arrivals revenue, and the remaining deficit of F$1,028.7 million declined from more than 890,000 in 2019 to 146,905 (US$494.12 million)—9.0 percent of GDP—funded from in 2020, then further to 31,618 in 2021 (Republic of Fiji the Asian Development Bank and World Bank 2021b) (Table 4). (MOE 2020). In a COVID-19 business impact survey taken The government allocated 10.6 percent of its total between January and February 2021 of the country’s budget (2021–2022) toward the MoHMS (F$403.3 1,569 branches and outlets of 236 enterprises that million). The MoHMS’s major focus has been on earned F$8 million or more per annum (and comprise communicable diseases, including the response to 70 percent of total gross output), 94 percent reported COVID-19 and the vaccination initiative. The budget being adversely affected by the pandemic. About also ensures that various components of the health 87 percent of the businesses reported reduced system are supported, which includes strengthening income of between F$ 1–5 million (33 percent) and and decentralizing selected clinical services. Annex more than F$5 million (32 percent (FBOS 2021b). 23 presents a distribution of funds that has been They embarked on a series of measures including allocated toward the COVID-19 National Deployment renegotiation of building rentals, deferment of loan and Vaccination Plan (Republic of Fiji 2021a). repayments, and reducing wages and salaries. Additionally, 59 percent of the businesses (6 out of every 10) placed their staff on reduced hours. Overall, Tourism Industry performance by businesses in Fiji was impacted negatively by local demand (74 percent), international The tourism industry has been identified as an demand (44 percent), staff reduction (38 percent), important economic activity in Fiji as it contributes high cost of raw materials (33 percent), and shortage to 40 percent of Fiji’s GDP, both indirectly and of materials (31 percent) (FBOS 2021b). indirectly. The Fijian 2021 development plan stipulated that by the end of 2021, Fiji’s tourism During the same period, 57 percent of the industry will be worth F$2.2 billion with 930,000 businesses were directly affected by lockdown visitors (Republic of Fiji 2021c). However, this plan measures, resulting in shortened business hours, was affected when COVID-19 emerged in late 2019. temporary reduction of staff working hours, and The Fiji Tourism Statistics showed that the tourism therein reduced local demand (FBOS 2021b). Table 4:  Tourism Earnings 2016–2023. (p) = provisional (f) = forecast 2016 2017 2018 2019 (p) 2020 (p) 2021 (f) 2022 (f) 2023 (f) Visitors 792,320 824,884 870,309 894,389 146,905 16,892 268,317 715,511 Average length of 11.2 11.2 11.2 11.1 11.0 11.0 11.0 11.0 stay (days) Visitors days 7.0 7.2 7.6 7.6 1.5 1.5 2.7 5.3 (millions) Earnings 1,823.3 1,924.3 2,010.3 2,065.5 314.9 14.3 486.6 1,035.0 (F$M) Source: FBOS (Fiji Bureau of Statistics) 30 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Introduction About 76 percent of the businesses retained their employees and granted their employees were granted paid/unpaid leave or reduced working hours. However, employees of the remaining 26 percent of the businesses lost their jobs and 24 percent of the businesses placed their staff on work-from- home initiatives (FBOS 2021b). Capital investment performance of the businesses has also been affected by the pandemic. While only 4 percent reported increased investment, 23 percent deferred capital plans and expenditure and another 4 percent canceled investments. This has ramifications not only for businesses, but also workers and the government. Multi-colored fabrics in a local Fiji market Inflation Government Debt Since September 2019, Fiji had experienced negative The government debt was estimated to reach inflation with inflation rates dropping to -2.8 percent F$8.3 billion (83.4 percent of GDP) by the end at the beginning of the pandemic. However, there of July 2021. However, the budget forecast was was a significant turnaround from August 2021 to much lower, at around F$7.6 billion (79.2 percent June 2022, after figures had remained in the negative of GDP) in the same year (Table 5). For fiscal year territory for nearly two years. The low inflation rates 2022, debt was forecasted to reach F$9.1 billion, were influenced by the pandemic as movement was equivalent to 88.4 percent of GDP, by the end of restricted, and there was a continued labor shortage, July 2022, with 64 percent in domestic debt and an increase in prices of food and fuels, higher freight 36 percent in external debt (Table 6). In the fiscal costs, and discrepancies between demand and supply. years 2021 and 2022the government accessed Figure 15 shows the country’s annual inflation rate over F$900 million concessional loans from at 5.1 percent in June 2022. This was attributed to the development partners. The external debt financing war in Ukraine, which has led to the increase in prices and budget support grants were made available of food and fuels. It is estimated that by the end of through the government’s multilateral and bilateral Figure 15: Inflation Rates(June 2018- June 2022) partnerships with development partners including 2022, Fiji’s annual inflation rate will be 5 percent. the Asian Development Bank (ADB), World Bank, Figure 15:  Inflation Rates (June 2018 to June 2022) Japan International Cooperation Agency (JICA), Asian Infrastructure Investment Bank (AIIB), and the % governments of Australia and New Zealand. The . COVID-19 pandemic contributed to Fiji’s increased debt levels amounting to over 80 percent of GDP. Prior to the pandemic, Fiji’s debt-to-GDP ratio remained within the accepted benchmark of 50 percent. However, the prolonged and continuous impact of the pandemic led the government - to support the economy as business revenue - plummeted, and tax revenues declined by almost - 50 percent, with the largest foreign earner (tourism) - at near zero for almost 20 months. Hence, the government implemented a countercyclical fiscal Jun- Sep- Dec- Mar- Jun- Sep- Dec- Mar- Jun- Sep- Dec- Mar- Jun- Sep- Dec- Mar- Jun- response through increased borrowings from external and domestic sources. This response was critical to Source: Republic of Fiji 2022b prevent severe economic contractions and severe socio-economic challenges and to help increased liquidity levels in the domestic market. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 31 Introduction The Ministry of Economy reported that the of the vulnerable population. Hence, the government government finances had been under strain during ramped up borrowings from development partners the pandemic. The pandemic has contributed to and was able sustain expenditure at all levels. the decrease in tax revenue collected in the fiscal Figure 16 depicts the total revenue collected in the years 2020/2021 and 2021/2022. During this period, years 2017–2022, with (a) signifying actual amount expenditure demands increased to support Fiji’s and (b) signifying budgeted amount. delicate economic situation and to meet the needs Table 5:  Fiji Government Debts (July 2017 to July 2021) Particulars Jul-17 Jul-18 Jul-19 Jul-20 Jul-21 (f) Domestic Debt 3,300.8 3,763.0 4,278.5 4,976.5 5,240.8 External Debt 1,370.9 1,457.5 1,456.8 1,709.5 2,365.2 Total Debt 4,671.7 5,220.5 5,735.2 6,686.0 7,606.0 % growth 3.6% 11.7% 9.9% 16.6% 13.8% Debt (as a % of GDP) 43.5% 46.0% 49.3% 65.5% 79.2% Domestic Debts to 71% 72% 75% 74% 69% Total Debt (%) External Debts to 29% 28% 25% 26% 31% Total Debt (%) Source: Ministry of Economy Table 6:  Fiji Government Debts (July 2018 to July 2022) Jul-22 Revised Particulars Jul-18 Jul-19 Jul-20 Jul-21 Forecast Domestic Debt 3,763.0 4,278.5 4,976.5 5,241.2 5,825.7 External Debt 1,457.5 1,456.8 1,709.5 2,422.5 3,300.0 Total Debt 5,220.5 5,735.2 6,686.0 7,663.7 9,125.7 Debt (as a % of GDP) 46.0% 49.3% 65.5% 79.8 88.6 Domestic Debts to 72% 75% 74% 68% 64% Total Debt (%) External Debts to 28% 25% 26% 32% 36% Total Debt (%) Source: Ministry of EconomyTax Revenue 32 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Figure 16: Total Government Revenue (2017 – 2022) Introduction Figure 16:  Total Government Revenue (2017–2022) Summary 2:  Macro-Economic Indicators • Fiji’s GDP contracted by 15.2 percent in 2020 . and contracted by another 4.1 percent in 2021. It . . is expected to increase by 11.3 percent in 2022. Total Revenue (million) . • Fiji’s main source of revenue, the tourism . industry, has been severely affected in the years 2020 and 2021. • In 2020, the government established the COVID-19 Response Package, valued at F$1 billion dollars, with most allocations directed toward the MoHMS. • COVID-19 has resulted in 87 percent of - - - - - businesses having reduced income, with (a) (a) (a) (a) (b) 59 percent of businesses placing their staff Fiscal Year on reduced hours. About 26 percent of the Total Tax Revenue employees lost their jobs, while 24 percent of the businesses placed their staff on work-from- Source: Republic of Fiji 2020c, 2021d, 2022b. home status. • Capital investments have also been affected in Remittances the same businesses, with 4 percent reported to have increased investment, 23 percent to Remittances continued to increase from 2018 to 2021. have deferred capital plans, and 4 percent As depicted in Figure 17, actual remittance amount having canceled their investments. surpassed estimated remittance amount and there was a significant increase in 2021. Inward remittance • Fiji’s inflation rate drops were influenced by noted a substantial growth of 14.6 percent in 2021. the pandemic due to movement restrictions, This was influenced by increase of remittances from continued labor shortages, increase in prices Fijians living abroad. Cash assistance was sent to of food and fuels, higher freight costs, and support family members, relatives, or friends during discrepancies between demand and supply. the pandemic in Fiji. Additionally, people opted for Continued conflict between Russia and Ukraine or preferred cheaper and more convenient mobile led to the increase in prices of foods and fuel. money Figure transfer platforms. 17: Inward Personal Remittances (2018 – 2021) • The pandemic contributed to the decrease Figure 17:  Inward Personal Remittances in tax collected in fiscal years 2020/2021 (2018 to 2021) and 2021/2022. To meet the needs of Fiji’s vulnerable population, the government ramped Inward Remittances (FJD$ million) up borrowings from development partners. . • Remittances increased from 2018 to 2021 by . . . 14.6 percent. This was influenced by Fijians living abroad who sent in cash assistance . . . to support family members/ relatives/friends . during the pandemic. Year Estimated amount Actual amount Source: Republic of Fiji 2018b, 2019b, 2020b, 2021b Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 33 Parliament Building in Suva, Fiji Methodology 2. METHODOLOGY This case study adopted a mixed-methods such as the WHO, ADB, WBG (World Bank Group), study-based design involving archival records UNICEF (United Nations Children’s Fund) , and UNDP search, administration of online semi-structured (United Nations Development Programme), from their questionnaires, and key informant interviews. corresponding websites and databases. Apart from observing COVID-19 social restriction measures, prior approvals were sought from those institutions for Research Tools access, storage, and use of information and data prior to data collection. Archival Records Search This involved the search and retrieval of institutional governance documents including relevant institutional Key Informant Interviews (Annex 24) policies, annual reports, work plans, evaluation Due to their extensive technical knowledge of reports, program reports, and relevant statistics from relevant law and bylaws, policies, and programs websites and databases held by the institutions, of action in their own fields of expertise, select among others. Information such as Fiji’s COVID-19 individuals in technical agencies, government, and epidemiology has been disaggregated by gender, civil society were approached for interviews to geographic location, and age, while macroeconomic provide insight for this study. The one-hour interviews indicators such GDP per capita, poverty levels and have yielded responses to questions concerning risk inequity, budget decreases, and other factors were communication and information disclosure, primary used to measure economic impact. Records of care and hospital response, and human resources public responses to policies and measures were for health, among other issues. Again, apart from obtained from the Fiji Police Force, nongovernmental the observation of COVID-19 restriction measures, organizations (NGOs) including the Fiji Women’s consent and willingness to voluntarily participate were Crisis Centre and the Kidney Foundation, and the Fiji first obtained from participants prior to interviews. National Provident Fund, and included performance reports and forecasts from technical institutions Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 35 Methodology Data and Sources of Fiji FY2021–FY2024 (WBG 2020), and IMF data on different countries’ GDP have been used in this Given the time limitations of this study, most of the study. The ADB’s annual status reports and economic data used was sourced from updated secondary plans concerning Fiji before and now during COVID- available information in the public domain. Data 19, the WHO Dashboard (WHO 2022b), the Pacific included relevant organizational structures, annual Community’s regional COVID-19 updates, other reports, policies and laws of those institutions, and relevant reports from UN agencies, the media (radio, databases holding programmatic information such print, and TV), and social media (research blogs) have as types and uptake of services by age, location, also been used and appropriately acknowledged in and sex, among other factors. Government ministry the report. Data was triangulated from the different websites such as that of the MoHMS’s annual reports, sources for accuracy and synergy. annual work plans, strategic plans, evaluation and performance reports, and daily updated information relating to COVID-19 were reviewed. Data from Limitations other statutory bodies such as the Fiji Police Force, the Fiji National Provident Fund Ministry of Women, This study also had its own limitations. Firstly, due to Poverty Alleviation & Social Welfare, and the Ministry COVID-19, a few of our participants were sick and of Education, Heritage, and Arts (MEHA) was also thus inaccessible for interviews. There were others gathered, either as physical or e-reports. All data who were heavily involved in the response and were accessed from these sources has been appropriately not able to accept our interview request. Secondly, referenced within the report and links provided. there was a low response rate for the online survey. Hence the team had to adapt the knowledge, attitude, Other information relating to the effectiveness of and practice (KAP)survey conducted by the MoHMS response or changes in the same and preparedness and AusAID (Australian Agency for International of the country going forward was mostly accessed Development) titled “Understanding Knowledge, through primary data collection— online semi Attitudes and Practices in the Context of COVID-19 structured surveys, Key Informants Interviews (KII), in Fiji.” and Focus Group Discussions (FGDs). Key thematic responses were gleaned from analysis of the qualitative tools and used to describe phenomena Ethics in the field. Primary sources of data have been acknowledged in the report, with relevant quotations The Fiji National University (FNU Team followed used within it highlighting significant findings. ethical research processes by submitting its research proposal and ethics application for this study to the Other independent sources of data such as relevant College of Medicine, Nursing & Health Sciences published assessments and research on Fiji and (CMNHS) through its College Human Health Research COVID-19 (UNP 2020) published technical agency & Ethics Committee (CHHREC). This work has been reports and forecasts, such as the World Bank’s approved by the CHHREC Committee of the CMNHS, Country Partnership Framework for the Republic FNU (CHHREC 030.21). 36 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed 3. GOVERNANCE, POLICIES, AND INSTITUTIONS: WHAT EXISTED AND WHAT HAS CHANGED 3.1 Organization and Policy for Disease Surveillance and Response 3.1.1 Organizational Structure The country’s first-ever Fiji National Pandemic Plan was developed along with a National Health Emergencies and Disaster Management Plan (HEADMAP) in 2002 (MoHMS 2013b), almost two decades ago. HEADMAP was developed in response to the first (and current) Fiji Natural Disaster Act (1998), as well as the first National Disaster Management Plan (1995) and directs actions for the health sector at the national, divisional, and subdivisional levels Savusavu marina and Nawi islet, Vanua Levu island, Fiji for all health programs and activities linked to health divisional, or district level (MoHMS 202a).2 Another emergencies and disaster management. Consequent is the establishment of a COVID-19 Taskforce (as Fiji reviews over the years have informed a more went into high alert in January 2020 (MoHMS 2020a) targeted and coordinated approach toward health and later, with WHO assistance, a COVID-19 Incident emergencies (HEADMAP 2013–2017) (MoHMS 2013a), Management Team (IMT) headed by the Ministry’s whose primary purpose is to inform and guide actions Permanent Secretary on March 1, 2020. Similarly, for the heath sector during public health emergencies during the preparation phase from February to April and their phases (mitigation, preparedness, 2020, the Fiji government made at least 51 requests emergency responses, relief, and rehabilitation) in to the WHO for technical assistance, training, and conjunction with other ministries, as well as national support for Case Management, Incident Management, and international agencies. Examples of HEADMAP Infection Prevention and Control, Laboratory, Points being activated in response to preparedness for of Entry, Risk Communications, Surveillance, Supplies, COVID-19 in line with the Natural Disaster Act (1998) and other areas (Merianos 2020). include the ministry’s activation of its Emergency Operations Centre—a suitably equipped and It must not be forgotten that Fiji did not have staffed area or room from within which emergency legislation specifically targeting health pandemics. operations are conducted at either the national, The Fiji parliament led by the government added 2 Fiji Natural Disaster Act (1998): Interpretation—Part 1(2). Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 37 Governance, Policies, and Institutions: What Existed and What Has Changed Figure 18: Fiji COVID-19 Management Team Governanc the COVID-19 pandemic into the Employment and Figure 18:  Fiji COVID-19 Management Team Relations legislation (Amendment 2020), to facilitate Governance Structure the government’s national response to the pandemic. Hon Prime Minister Therefore, the national response to the pandemic (Sub-Commttee of Cabinet) was crippled initially because of this and later remedied to facilitate actions based on the existing Minister of Health & structure described below. Medical Services At the national level, the MoHMS is the lead agency for the Health and Nutrition Cluster for Fiji’s National Permanent Secretary of Permanent Health & Medical Services Secretaries Forum Disaster Management Office (NDMO). The actions of this cluster and seven others in the national response are determined by a National Disaster Management Council (NDMC). The composition of the NDMC COVID- Taskforce Incident Management includes a Council Chairperson (usually the minister (Policy) Team (IMT) responsible for disaster management activities) and all the permanent secretaries of the other ministries, Lead by General Chaired by CMA the Commissioner of Police; Controller of Government Manager - IMT Supplies; Director of Meteorology; Managing Director, Source: MOHMS 2020a Telecom Fiji Limited (TFL); Chief Executive, Energy Fiji Limited (EFL); Director-General, Fiji Red Cross Society; The COVID-19 Taskforce is chaired by the Chief Director, Fiji Council of Social Services (FCOSS); and Medical Advisor and is in place to provide advice the Chief Executive, National Fire Authority (NFA).3 to the Permanent Secretary for MOHMS on policy Therefore, the Council is an intergovernmental body matters (MoHMS 2020a). The Incident Management responsible for disaster management, development Team (IMT) is led by the General Manager IMT and is of strategies and policies for disaster mitigation and responsible for the implementation of the COVID-19 preparedness and training, management, and public Preparedness and Response Plan (COVID PRP). education in disaster management. It also oversees The Permanent Secretary for MoHMS is responsible the preparation and implementation of adequate for the COVID-19 Taskforce and the IMT, with the rehabilitation programs after disasters; recommends Hon. Prime Minister as the Chair of the Fiji MoHMS policies, strategies, and alternatives to the Cabinet; COVID-19 Response team (MoHMS 2020a) (see and is responsible for the formation of subcommittees Figure 18). to execute specific tasks within their specific fields of competence (Ibid). Furthermore, there are three For Fiji’s economic recovery, the government subcommittees within this national framework, with established the COVID-19 Risk Mitigation Taskforce the Permanent Secretary of the MoHMS being a (CRMT). The team was jointly chaired by the member of all three—the Emergency Committee, Permanent Secretary for Economy and included the the Preparedness Committee, and the Mitigation Permanent Secretary for Health and the Permanent and Prevention Committee—working in tandem Secretary for Commerce, Trade, Tourism and with other ministries and statuary institutions. In the Transport. It worked closely with the Permanent national organizational structure described above, the Secretary for Immigration, the Health Protection Unit, linkages between the MoHMS and other ministries the Incident Management Team (IMT), and the Fiji were demonstrated during the COVID-19 pandemic, Military Forces. CRMT roles included the review of the while ensuring that the whole-of-government Fijian COVID-Safe Economic Recovery Framework, approach was maintained during all phases of the to ensure that the country evolved alongside pandemic. Those links are illustrated by instances of the changing global and local environments (Fiji budgetary allocations and procurement processes Government 2020a). during the pandemic. Although the Ministry of Through the leadership of the government and Economy allocated specific COVID-19 budget lines support from development partners, Fiji successfully in the 2020/21 National Budget, processes dictated controlled the transmission of the COVID-19 that the MoHMS access those lines through internal virus during the first wave of the pandemic. The processes between the ministries. government imposed travel bans on highly affected countries such as China, Republic of South Korea, Italy, Iran, and Spain, and as the pandemic worsened all borders and ports were closed to nonresidents. To 3 Natural Disaster Management Act, 1998:19. 38 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed limit the spread of the virus, nonessential businesses One of the challenges faced during the pandemic and schools were closed and Fiji Airways flights were was the slow dissemination of information from suspended until the end of June 2021. Frontline the administration level to the clinicians and health workers such as health professionals, immigration personnel in primary, secondary, and tertiary level of and customs officials, and uniformed personnel care regarding such things as new SOP’s (standard including military, police, and prison officers were operating procedures), Gazetted directives, and trained on COVID-19 protocols and adherence to so forth. strict guidelines including the proper donning and Vaccination continues to play an important role in discard of personal protective equipment (PPE). the reduction of COVID-19 cases and deaths in Fiji. Furthermore, the public was required to adhere to The government introduced the “No Jab, No Job” the curfew hours imposed by the government from 10 policy, which was mandatory for all employers and pm to 5 am daily. Fiji’s success in the first wave (when employees in the public and private sectors. At the the majority of infections were detected and treated peak of the pandemic, customers were required by at border quarantine facilities) was attributed to the management to show their vaccination cards when early investment in testing capacity done locally at entering supermarkets, stores, and restaurants, and a the Fiji Centre for Disease Control (Fiji CDC). This series of incentives and assistance were developed enabled the MoHMS to test, trace, and isolate cases, to boost vaccination coverage among the general and to quickly limit local transmission. Additionally, population. These policies have contributed to the active awareness campaigns in the media about the success of vaccination coverage in the country, virus, its origins, modes of transmission, prevention leading to the ease of COVID-19 restrictions (around through regular handwashing (20 seconds each time), September, October, November, and December two meters of social distancing, and using masks of 2021) such as the lifting of border closures and became routine for people. Simultaneously, about re-opening of containment areas, extension of curfew 37 fever clinics were set up around the country for hours from 6 pm–4 am to 11 pm–4am, re-opening of temperature checks as well as to receive patients businesses, and the school re-openings for years suspected of having contracted COVID-19. 12 and 13. The country started opening its borders From July 2020 to April 2021, fewer cases were to regional and international travelers in December recorded from managed border quarantine facilities 2021. This has led to the development of the “No Jab, and the government eased COVD-19 restrictions No Flight” policy, published around October 2021 (Fiji to boost its economic recovery. This led to the Airways 2021). transmission between travelers under border quarantine and staff of a border quarantine facility. This further resulted in community transmissions and 3.1.1.1 Role of Local and Central the beginning of the second wave. The township of Governments Nadi and the city of Lautoka went into a lockdown, the national curfew hours were re-instigated, and schools The Ministry of Local Government, together with were suspended until further notice upon receipt of the MoHMS, municipal councils, and the National information that a case had participated at a super- Fire Authority (NFA), provided a preparedness plan spreader event—a funeral with 500 attendees in for COVID-19. Councils worked collaboratively with Lautoka city. As the transmission of the Delta variant the MoHMS to ensure open spaces for temporary soared through the Central and Western divisions of health services, and members of the public were Viti Levu, the government sealed off the main island informed that normal council services, such as grass and established the Suva, Lautoka, Nadi, Nausori, cutting, street cleaning, garbage collection, and so Rakiraki, and Lami containment areas. The MoHMS on would not cease. Part of the preparedness plan also deployed its WHO-accredited Fiji Emergency was to ensure disinfection and hygienic practices in Medical Assistance Team (FEMAT) to Lautoka and all councils in Fiji. Councils worked with the NFA to later to Suva to assist in the increasing number of provide water blasting services during the disinfecting cases in the two divisions. The ministry also worked and cleaning stage/period. Market vendors were with the Fiji Police Force in developing and enforcing made aware of any changes in market operations, the Public Health Infringement notice for COVID-19 and NPIs such as spacing of tables were emphasized infection prevention (focusing on nonpharmaceutical (Fiji Government 2020b). interventions). However, there were a few gaps Challenges were also faced by municipalities identified during this period. during the COVID-19 outbreak. This was due to several reasons: (i) lack of manpower to assist in the Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 39 Governance, Policies, and Institutions: What Existed and What Has Changed deployment of their preparedness plans because the pandemic was declared a natural disaster. The staff were being sent home due to testing positive amendment therefore facilitated the government for COVID-19 or for being primary or secondary response to the COVID-19 pandemic as a natural contacts for COVID-19, and/or allocation of workers disaster. This further meant that COVID-19 was into working bubbles, which was difficult for staff to also a national health emergency and obligated a comprehend; (ii) staff not being paid for overtime whole-of-government response through the legal work, with this time being converted instead into framework of the Fiji National Disaster Act (1998). time off in lieu; (iii) people not being available at The amendment also provided an avenue through home during awareness drives, although this was which employers and employees would negotiate addressed to some extent by the government sharing employment contracts as the pandemic began to COVID-19 -related information via social media take its devastating social and economic toll on the and other national news coverage; and (iv) lack of country during the second wave of COVID-19, from equipment to assist workers on the ground.4 March to August 2021. Therefore, for this section, any reference to disaster refers to the COVID-19 On August 8, 2021, the Local Government Act 1972 pandemic as a health emergency and natural disaster. was amended so as to align the Council’s financial year with that of the government’s. This was to ensure that budget planning and financial reporting Fiji National Disaster Management Clusters by the Council matched the government’s timeline of implementation. Some of the changes made Disaster management clusters were established to included: incentives given to ratepayers in the form of improve coordination in Fiji (MoHMS 2013b). The discount to encourage timely payment of their arears, clusters consist of groups of organizations responding stall fee waivers provided to market vendors (F$2.6 to humanitarian events and the needs of affected million), and base fees for Public Service Vehicles communities. These clusters allow partnerships (PSV) provided by the government (F$2.5 million) (Fiji between international humanitarian actors, national Government 2021a). and local authorities, and civil society. The Fiji National Clusters model has closely followed that of global and regional clusters so that there is standardization 3.1.1.2 Disaster Management System and better understanding by everyone of the role of each cluster, its terms of reference, and standard Background operating procedures. It also enhances the potential In accordance with Fiji’s National Disaster for assistance, partnerships, training, and funding. Fiji Management Act (1998), “a disaster means a natural has nine National Clusters5, as follows. disaster and includes the occurrence of a major 1. Health & Nutrition (Lead: MoHMS; Co-Lead: WHO), misfortune which disrupts the basic fabric and normal functioning of the society or community, or an event 2. Shelter (Lead: Ministry of Housing and Community or series of events which give rise to casualties, Development; Co-Lead: Habitat for Humanity Fiji and/or damage or loss of property, infrastructure, and Country Cluster Delegation for the Pacific), essential services or means of livelihood on a scale 3. Education (Lead: Ministry of Education, which is beyond the normal capacity of the affected Heritage, and Arts; Co-Leads: UNICEF, communities to cope with unaided, but does not Save The Children Fiji), include man-made disasters.” 4. Food Security (Lead: Ministry of Agriculture; Thus, in May 2020, the Fiji parliament declared the Co-Lead: Ministry of Fisheries) COVID-19 pandemic as an “act of God” to facilitate government response. The following key change 5. Safety & Protection (Lead: Ministry of Women, was inserted into the Employment Relations Act Children and Poverty Alleviation; Co-Lead: (2007) as an Amendment (2020): “’act of God’” UN Women), includes a pandemic declared by the World Health 6. WASH (Lead: MoHMS—Environmental Health Unit; Organization.” Based on the legal amendment to the Co-Lead: UNICEF), Employment Relations Amendment Act (2020), 4 Rep-Min. Local Government, “COVID-19 Preparedness and Response (Interview),” interview via Zoom with Kaminieli Tawake, November 8, 2021. 5 https://www.ndmo.gov.fj/cluster-system/ 40 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed 7. Logistics (Lead: National Disaster Management and Protection and WASH have played active Office; Co-Lead: Fiji Procurement Office and World supporting roles in the national response (Annex 5). Food Programme). Fiji Emergency and Disaster Management 8. Infrastructure (Lead: Ministry of Infrastructure and There are four (4) phases of risk reduction and risk Meteorological Services) management during emergencies (Table 7 and 9. Communication (Lead: Communications; Co-Lead: Annex 27). Fiji Council of Social Services, UNICEF) Table 7:  Risk Reduction and Risk Management In the wake of COVID-19, the National Disaster Components Management Council (NDMC) for Fiji is currently in the process of remodeling its national crisis framework Phase 1: Mitigation and Wellness (Prevention) in terms of preparedness for future disasters such as cyclones and pandemics (Fiji Government 2021b). Phase 2: Preparedness On July 8, 2021, the Fiji Council of Social Services Phase 3: Response (FCOSS) called on the Fiji government to activate its Disaster Management Committee (DISMAC). to Phase 4: Recovery address the COVID-19 crisis that the country was facing (RNZ 2021a). This was in response to the Source: MoHMS—Health Emergency and Disaster Management 2013b increasing number of COVID-19 deaths and cases recorded in July. Additionally, the health system was directly impacting access to essential services Alert Levels (RNZ 2021a).6 7 The MOHMS, through its IMT in collaboration with the WHO and the support of the Additionally, the MoHMS has established an internal Health and Nutrition Cluster, adopted the lead role emergency management system that applies specific in addressing the pandemic, while the other clusters actions based on alert levels during disasters and such as Education, Food Security, Safety humanitarian events (Table 8). Table 8:  Alert Levels for Health Emergency and Disaster Management Level Alert Level MOH EOC Meeting Actions to be taken by MOH EOC members Meeting is only necessary when coming down from yellow, orange or red level. 1 WHITE White meeting Otherwise, activities will be MOH awareness campaigns. MOH planning for evacuation and execution of simulation exercises. Increase MOH staff awareness measures and advisories through the media announcing the immediate need for preparations when approaching a disaster. Revision and updating of emergency plans and preparations for evacuation. 2 YELLOW Yellow meeting Execution of a simulation exercise if possible. When coming down from Orange or Red levels, analyses the possibility of letting the MOH services go back to almost normal depending on the situation. MOH EOC activated. Immediate assessment on all the division and inform the 3 RED Red meeting DMO’s (Divisional Medical Officers) and MS’s (Medical Superintendents). The activation of the Divisional EOC will be under the responsibility of the DMO. MOH EOC activated. Analysis of the situation. Response/recovery. Activities 4 GREEN Green meeting depending on the magnitude and duration of the disaster. Source: MoHMS—Health Emergency and Disaster Management 2013b 6 Note: DISMAC operates in three levels: national, divisional, and district levels. It is an acronym that collates and encompasses the National Disaster Management Council (NDMC), the National Disaster Management Office (NDMO), and the National Emergency Operations Center (NEOC) at the national level. 7 http://www.ndmo.gov.fj/images/Fiji_National_Disaster_Management_Plan.pdf Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 41 Governance, Policies, and Institutions: What Existed and What Has Changed increase the fines and corresponding prison terms for Summary 3:  Policy and Governance for Disease those who are not in compliance. The 2019 training Surveillance and Preparedness for FEMAT and consequently their snap field hospitals • In response to the pandemic, the government in Suva, and earlier training in Lautoka in 2020 due to established the COVID-19 Response Team COVID-19 lay well within the ambit of the law. consisting of the Incident Management Team (IMT) and the COVID-19 Taskforce. The Quarantine Act of Fiji (1964, Cap. 112), while dated, stipulates relevant actions related to the arrival • The government also established the COVID-19 of suspected or infected persons, vessels, aircrafts, Risk Mitigation Team to ensure the country’s or goods into Fiji (MoHMS 2016a). The sections safe economic recovery. of the law that are relevant to outbreak response • The Ministry of Local Government worked include procedures for infected or suspected vessel with the MoHMS, municipal councils, and the or aircraft, compulsory disease notifications by National Fire Authority (NFA) in preparing masters of vessels, measures to be undertaken in the preparedness plan for COVID-19. The case of a case fatality, measures for dealing with deployed preparedness plan included cleaning, vessels arriving from malaria-endemic and infected disinfecting, and doing hygienic work in all areas, provisions relating to quarantinable diseases, councils in Fiji. measures applied to persons/vessels arriving from infected places, and measures for preventing the transmission of quarantinable or other infectious diseases (also necessary to refer to protocols, if 3.1.2 Legal Framework available, from the environment health unit). Legal Framework dealing with infectious disease The Quarantine Act Part VIII provided a list of brief and health emergencies actions that may be taken for persons arriving from Fijian and international laws and policies have an infected place; those in contact with an infected governed and facilitated preparedness and response vessel; and those arriving from an area infected with to COVID-19. Apart from the Public Health Act (1935) acute anterior poliomyelitis, measles, influenza, or and its Amendment (2020), there are other policies whooping cough. related to infectious diseases, other related acts Persons arriving from an infected place: “The such as the Quarantine Act (1965) and the Health Authority may take, after disembarkation, the and Safety at Work Act (1998) (Annex 11). Others measures which he considers appropriate to ensure include outputs from international mechanisms the surveillance or observation of persons arriving on such as the International Health Regulations (IHR) a vessel or aircraft coming from, or touching at, any 2005 Emergency Regulation Committee Decision, place infected with a quarantinable disease, and who UN Emergency Council Decision to support Fiji’s are not protected, to the satisfaction of the Authority, COVID-19 Preparedness and Response Plan, 2020 by vaccination against such disease.” (MoHMS 2020a, p. 20). Person in contact with an infected vessel: “Any Section 7 of the Fiji Public Health Act (1935) person who without the permission of the Authority contains clauses related to infectious diseases as boards any infected or suspected vessel or aircraft subsections 67 through 83. There are four divisions or any vessel or aircraft which has come from, in this section that cover Administration, Powers, or touched at, any infected local area where a General Provisions, and Expenses of Isolation. These quarantinable or other infectious disease exists, sections stipulate the powers of the health minister, or enters or lands at any quarantine station, may the Board, and the permanent secretary for health be detained under observation or subjected to relating to isolation and quarantine, and mobilization surveillance for such a period as the Authority may of resources including human, funding, technical, deem necessary.” and logistical ones, among others. The current preparedness and response actions are well covered Persons arriving from an area infected with within the law through a few key amendments such acute anterior poliomyelitis, measles, influenza, as including COVID-19 in the list of infectious diseases or whooping cough: “All persons arriving in Fiji (amendment made in March 2020 to the Public by air from an area infected with acute anterior Health Act 1935), as well as with the Infringement poliomyelitis, influenza, measles or whooping cough Notices amended in 2020 to the same Act, to may at the discretion of the Authority be placed under surveillance or observation.” 42 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed Government convened cabinet at the MoHMS headquarters in early 2020 at the beginning of the first wave (March 2020). The Honorable Prime Minister and all government ministers were present at the sitting. Cabinet papers were approved in these sittings, and senior managers at the MoHMS continued to discuss the best way forward with the health permanent secretary and the cabinet on ways to reduce the transmission of COVID-19. With that in place, notices, restrictions, policies, and new regulations were developed to curb the spread of the virus. One of the milestones was the introduction of the Government building in Suva, Fiji Public Health (Infectious Diseases) (Infringement Notices) Regulation.8 The regulation was developed, publicized, and enforced on July 8, 2021. The restrictions. However, the legal system was not government mandated that people follow the able to keep track of those who failed to pay the COVID-19 protocols to prevent the transmission of infringement notice penalty; nor was it able to trace the virus to the wider community. This facilitated the the reported few violators, as they had given incorrect enforcement of COVID-19 interventions, and those personal information.10 who opposed or failed to oblige were penalized The Immigration Act needs to be amended to (Annex 12). include protocols for travelers who have been living in high-risk countries (such as China, where the initial COVID-19 outbreak occurred). The Act should also Current Gaps in Legal System list the endemic diseases that can cause severe The legal system played an important role in the social, health, and economic impact to the country establishment of laws that governed people during (Annex 13). Furthermore, COVID-19 led to the closure the pandemic. However, there are a few flaws within of schools for more than six months; hence the the system that need improvement. Currently, there Education Ministry should establish processes (in the are no specific policies or protocols for quarantining Education Act) and protocols that coordinate school people who refuse treatment for infectious diseases activities and curriculum during future pandemics such as tuberculosis. It is recommended that policies (Annex 14). and protocols be developed for managing people who refuse treatment if their refusal poses a health risk to the public. The same recommendation and 3.1.3 Control Mechanism a few others have been echoed by the HEADMAP Levels of alerts from highest to lowest, focusing on (2013) for the MoHMS. Other recommendations what response activities need to be conducted at include ensuring that medical indemnity issues are each level of alerts addressed; reviewing sections of the Public Health Act to strengthen powers to address important The MoHMS has adopted three levels of alert in disaster responses such as quarantine; ensuring relation to the expected progression of the COVID-19 legislation for disaster management (such as for outbreak. These alert levels are predicated upon curfews) is drafted, reviewed, and passed; and the nature of the COVID-19 outbreak in Fiji—from the ensuring guidelines and criteria are drawn up to initial situation of no cases, through the first cases, to address mass disposal or burial of the dead.9 the potential worst case of widespread community transmission (Table 9). The newly introduced Public Health (Infectious Diseases) (Infringement Notices) Regulation, under section 83 of the Public Health Act, has effectively controlled people’s conduct in terms of COVID-19 8 https://www.fijivillage.com/documents/gazette-fines.pdf 9 HEADMAP 2013–2017:26 10 Rep-MoHMS 2021, “COVID-19 Preparedness and Response.” Interview via Zoom with Kaminieli Tawake, November 10, 2021 Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 43 Governance, Policies, and Institutions: What Existed and What Has Changed Table 9:  Alert Levels for COVID-19 Actions LEVEL & PERIOD OF ALERT LEVELS ACTION TAKEN BY GOVERNMENT GOVERNMENT RESPONSE (REALITY) COMMENCE- FOR COVID-19 MENT Government appointed a Corona Virus Taskforce in Command and Coordinate: Formation 30 January January 2020 to oversee the Health Ministry response to and Development of the Fiji COVID-19 2020 the global COVID-19 outbreak. Taskforce, Development of Terms of Reference, Appointment od Chair The MoHMS formed the Incident Management Team (IMT) 1 March 2020 and Secretariat and Appointment of Members. A Joint Incident Management Team (JIMT) consisting of 21 February WHO and MoHMS was formed. 2020 The MoHMS developed the COVID-19 preparedness and 31 December Surveillance, Risk Assessment and response plan. 2019 Level 1 Actions Response: Develop protocols and (No potential or tools for enhanced surveillance and The UN team and the JIMT worked together to develop a confirmed cases train providers. multisectorial plan for COVID-19 response. The plan is for August 2020 of COVID-19 10 countries in the Pacific. in Fiji) First case was confirmed- March 2020. Command and Coordinate: Monitor alert triggers for activation of Closing of borders protocols for level 2 of the COVID-19 preparedness and response plan and Opening of fever clinics around the country coordinate with divisional Response March – Team (DORT) and Rapid Contact Opening of isolation facilities December Tracing Teams 2020 Suspension of schools and national events Implement extended hours (evenings/ weekends) operation of national Closing of non-essential businesses health EOC. Creation of toll free for COVID-19 response Level 2 Actions • Surveillance, Risk Assessment Launching of the CareFiji App (Case/cases and Response. Inform IHR (2005) of imported Activation of the Contact Tracing and Swabbing team. through the Fiji national Focal Point March 2020 potential or and seek international assistance Different Government and Technical Agencies made – December confirmed expertise as required FCDC / IMT. donations to the Fiji Government to aid its response to 2021 COVID-19 in Fiji – no local • Activate enhanced contact COVID-19. Donations include medical equipment and transmission) tracing teams for rapid investigation monetary values. First community transmission was recorded- April 25, 2021. Activation of the FEMAT. Command and Coordination: Monitor alert triggers for activation of Testing capacity was increased and the MoHMS received Level 3 Actions protocols for level 3 of the COVID-19 assistance from the ANZMAT. March – (Case/cases preparedness and response plan and December Government approved and deployed the usage of Astra of potential coordinate with divisional Response 2021 Zeneca vaccine. or confirmed Team (DORT) and Rapid Contact COVID-19 Tracing Teams. Containment zones were deployed in Fiji’s Central and associated Western division with local transmission House to house screening programs were conducted in in Fiji) the Western division. Surveillance, Risk Assessment and Response ramped up as cases of COVID-19 (mainly Delta Response: Revise case definition March – variant) spread vastly across communities in Fiji. The for Identification of cases and December country also recorded cases of Omicron variant (known as referral based on wide spread local 2021 variant of concern) around December of 2021. transmission. Source: M0HMS 2020a—COVID-19 Fiji Preparedness and Response Plan These alert levels are used to guide when and how described in this plan. The actions to be implemented to take the preparedness and response actions at each alert level are further described in Annex 1. 44 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed 3.1.3.1 Response Strategies Decision-making was vital during the pandemic; phases that explain how the outbreak developed hence the MoHMS developed a model to anticipate over time and the anticipated preparedness and how outbreak escalates in Fiji, particularly on severity, response actions in the containment and mitigating speed, and distribution. Table 10 discusses the three phases of the outbreak (Annex 15). Table 10:  Scenarios and Response Strategies CONTAINMENT PHASE Development of COVID-19 governance structure including the COVID-19 Taskforce, COVID-19 Risk Mitigation Taskforce, and the Joint Mitigation Taskforce Activation of FEMAT team and FEMAT hospitals Closure of borders and suspension of international and domestic travel Designation of COVID-19 hospitals Containment phase began as soon as Fiji Enforcement of 2m social distancing, wearing of masks, and restriction of social confirmed its first COVID-19 case in March distancing 2020. As cases increased, MoHMS had to re-strategize and focus on hospitalization and Establishment of laboratories (testing of COVID-19 virus) around the country reducing COVID-19 mortality. Closure of schools and nonessential businesses Establishment of containment areas, curfew hours, and nationwide lockdown Work-from-home initiative and emphasis on e-learning for students Non-health ministries and CSOs assisting the MoHMS Development of toll-free helplines (158 and 165) MITIGATION PHASE Establishment of the Pre-Hospital Coordination Care Centre (PHECCC) and the MoHMS Oxygen Unit were critical during the pandemic Mitigation phase began around June 2021, Development and enforcement of the Public Health (Infectious Diseases) with most reported cases and deaths from Infringement Notice Regulations 2021 the Central division of Fiji. Fijians around Enforcement of the “No Jab, No Job” policy the country continued with containment measures to limit the transmission. Deployment of the NZMAT and AUSMAT to the Central and Western divisions of Viti Levu Relapsed Back to CONTAINMENT PHASE Border restrictions lifted and containment areas reopened. Curfew hours extended from 11 pm to 4 am, and as time progressed curfew was Vaccination played an important role in increased (based on vaccination status), then removed. the easing of COVID-19 restrictions. As Businesses started operating and schools re-opened Fiji reached 70 to 90 percent vaccination coverage, the government eased Country’s border opened to regional and international travelers. Local citizens nonpharmaceutical intervention measures. allowed to travel to Viti Levu, Vanua Levu, and maritime islands under risk reduction strategies Source: MoHMS 2020a, COVID-19 Fiji Preparedness and Response Plan Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 45 Governance, Policies, and Institutions: What Existed and What Has Changed Summary 4:  Legal Framework and Control Mechanism • The Public Health Act and its Amendment is the enforcement of COVID-19 restrictions among law that governs and facilitates actions to deal the public. with different diseases in the country. However, in • Gaps within the legal system include the lack addition, during the pandemic, other related acts of policies or protocols for people refusing such as the Quarantine Act, the Health and Safety to be vaccinated, review of the Public Health at Work Act, and other inputs from international Act, follow-up and enforcing people to pay the guidelines have supported Fiji’s COVID-19 penalization fees, and the inclusion of a pandemic Preparedness and Response Plan. response in the Immigration and Education Act. • Presence of the cabinet at the MoHMS • The MoHMS adopted three levels of alerts to headquarters allowed timely approvals of the new guide the overall framework for the preparedness laws and regulations, which are expected to curb and response actions to COVID-19. It also the transmission of the COVID-19 virus. established two phases of control mechanisms • The newly established Regulation, Public during the COVID-19 pandemic: the containment Health (Infectious Diseases) (Infringement and mitigation phases (Figure 17). Notices) Regulation, has positively impacted the 3.2 Health Systems Although global databases are yet to be updated for more recent years, we know that significant 3.2.1 Health Financing additional DP support was provided across all Pacific The WHO Global Health Expenditure Database Island Countries (PICs) including Fiji, for COVID-19 noted the primary source of financing for the Fiji preparedness and response. Most of it has been health sector originated from the central government off-system (and largely off-budget), meaning that it domestic budget (WHO 2022c); this source is is not funneled through a government budgetary or followed by household out-of-pocket costs, private financial system, making it difficult to track. expenditure (largely contributions to voluntary health insurance), and external development partners’ (DP) financing. Figure 19: Fiji- Health Expenditure by Finance Source- 2010 - 2020 Figure 19:  Fiji—Health Expenditure by Finance Source (2010 to 2020) % % % % % % Domestic Government Health Expenditure Out of Pocket Payment External Aid Other Private Health Expenditure Others Source: WHO 2022c, Global Health Expenditure Database 46 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed Health The pandemic has impacted Fiji’s economy in the years 2020 and 2021. In terms of UHC in Fiji, all The medium- to long-term impact of COVID-19 on the health services provided are subsidized and all costs health of the general population in Fiji will be manifold are covered by the Fiji Government.12 and varied. Noncommunicable diseases (NCDs) have continued to be Fiji’s main cause of morbidity and “During this crisis, people who have insurance can mortality over the last decade and account for more visit private hospitals, and General Practitioners than 80 percent of deaths annually. COVID-19 has the (GPs) looked at cases which were mild/moderate. If potential to further adversely affect the general health the disease was severe, patients were transferred prognosis of the country. to hospitals. Hence, Government is responsible for the high-end cost of the care. In responding to Fiji’s national 5- and 20-years’ development plans access, the Fiji citizens are provided with actually are aligned with the Sustainable Development Goals no-cost by the Government” (Chief Medical (SDGs), with its key performance indicators being Advisor, Key Informants Interview, August 20, 2021). measured against SDG 3 (Good Health & Wellbeing). However, the pandemic has limited access to The majority of Fiji’s health system services are various health services. During the pandemic, most funded by the Fiji government through tax.11 Access public transport has been suspended and people to health services is not limited to Fiji citizens; hence have not been able to visit nearby health centers everyone is able to access doctors, medicines, and and hospitals, and surgical outpatient departments high-level hospital care (Ibid). Health services in Fiji (SOPDs) and clinics have been closed, with only are free and at no cost to patients. emergency services operating. Important health programs such as vaccination in schools and mass drug administration campaigns have also 3.2.2 Extent to Which Universal Health been suspended. Coverage Is achieved The poor are the main recipients of services Like other developing countries, Universal Health from nursing stations, as these were the first points Coverage (UHC) remains an elusive quest for Fiji. of contact for rural residents in Fiji. However, the Many low- and middle-income countries are reforming government allocated a significant amount of health their health financing systems to align themselves expenditure to hospital-based services, even though with the UHC goals. Asante et al. (2017) revealed that nursing stations were the first points of contact more than 70 percent of government expenditure was for most rural residents. In 2009 and 2010, the allocated to hospital services, where 47 percent of government increased the health expenditure for the total health spending was for hospital outpatient nursing stations from 1.4 million to 1.9 million dollars. care, less than 1 percent was allocated to nursing With around 47 percent of Fiji’s population living in stations, and less than 7 percent went to private rural areas, a well-resourced and well-functioning hospitals and clinics. Health care benefits in Fiji nursing station network could contribute to the slightly favor the poor, who receive 61 percent of the national goal of achieving health equity and UHC. benefits from nursing stations, with only 2.4 percent going to the richest groups. A study showed that 37 Health centers and hospital outpatient services are percent and 41 percent of the benefits, respectively, used by all Fiji citizens. Benefits are relatively evenly for private GP clinics and private outpatient hospitals distributed among the rich and poor groups in Fiji. are directed toward the rich. Only 0.7 percent and 2.2 About 70 to 80 percent of the population has access percent of the benefits, respectively, for the GP clinics to health services (Table 11). and private outpatient hospitals are directed toward the poor (Asante et al. 2017). 11 J. Tudravu, Chief Medical Officer, Key Informant Interview, August 30, 2021, Suva, Fiji 12 J. Tudravu, Chief Medical Officer, Key Informant Interview, August 30, 2021, Suva, Fiji. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 47 Governance, Policies, and Institutions: What Existed and What Has Changed Table 11:  Distribution of Health Care Benefits in Fiji CI = concentration index; GP = general practitioner Public sector Private sector Income quintile Nursing Health Hospital Hospital Hospital Hospital Total GP/clinic station centre outpatient inpatient outpatient inpatient benefit Share of 0.7 16.2 46.5 30.1 1.8 4.3 0.5 100.0 government subsidy Q1-poorest 61.2 17.6 15.9 25.5 0.7 2.2 0.0 18.5 Q2 24.7 23.8 26.9 21.3 7.1 30.9 16.9 24.5 Q3 7.2 26.9 23.3 27.3 20.0 9.8 10.4 24.3 Q4 4.6 15.2 16.2 12.2 35.3 15.6 14.0 15.1 Q5-richest 2.4 16.5 17.7 13.8 36.9 41.4 58.6 17.8 CI -0.563 -0.033 -0.011 -0.128 0.436 0.278 0.524 -0.030 Source: Asante et al. 2017 Although the MoHMS has resources from various service (the government is the biggest employer) and sources (Figure 19), it is primarily financed through sections of the private sector that have successfully general taxation revenue. However, due to the impact weathered the pandemic’s second wave. Health of COVID-19, the government’s budget (including service delivery in Fiji is structured along three tiers MoHMS resources) was mostly financed through (Figure 20). The country has more than 200 health loans from a wide range of development financial facilities with different roles and scopes of services. institutions including the Asian Development Bank, In addition, there are more than 300 GPs who World Bank, International Monetary Fund, European complement the provision of health services. Primary Infrastructure Bank, and Asian Infrastructure health care comprises of nursing stations as the first Investment Bank (Fiji Government 2020c). Section 1.3 level of contact with the public, health centers, and gives details on the macro- economic factors subdivisional hospitals. Services provided include basic health care; health promotion; domiciliary care; WASH; and maternal and child health, which includes 3.2.3 Health Service Delivery immunization. The MoHMS uses a strong referral system to escalate the care of the patient, not only Presently, health services in Fiji are free and at no by consulting, but also by moving the patient to cost to patients. When cases peaked in the Central the next level of care when the situation is beyond and Western divisions, the government responded their capability. by developing a scheme known as the COVID-19 Engagement of Private Medical Practitioner Scheme (mid-September 2021) (Deo 2021). Through this the Figure 20: Levels and types of health services provided Figure 20:  Levels and Types of Health Services public can also access services provided by private Provided in Fiji practitioners, and health insurance is common as part of employment contracts. A total of 17 General Village health workers Medical Practitioners (GPs) have been appointed by Nursing stations Primary Care the government: seven (41 percent) in the Central Health Centres division (four in the Nasinu area and three in Suva), Sub-divisional hospitals and 10 (59 percent) in the Western division (five in Divisional hospitals Nadi, one in Lautoka, and four in Ba). Emergency transportation services Since COVID-19, insurance companies have banned Specialist national hospital Secondary and together and used various media platforms to create General Practitioners (GP) Tertiary Care awareness on the potential financial benefits of Aged care services owning health insurance, given the uncertainties Private hospitals surrounding COVID-19. Other Specialist Services (NGO funded) However, this benefit will only be available to those Traditional Medicine who have been able to keep their jobs during the pandemic. This will mainly be employees in the civil Source: WHO and Fiji MoHMS 2012 48 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed Lessons learned after the first wave of COVID-19 protection is Fiji’s International Health Regulations in Fiji provided impetus for the MoHMS to review (2005) National Focal Point. its health service delivery for effectiveness and 3. Family Health Department. The key aim of this efficiency. The review has prompted a remodeling department is to manage, implement, monitor, exercise of the ministry’s framework of health and evaluate programs pertaining to Child Health, service delivery. The new remodeled framework Maternal Health, HIV/STIs, and Reproductive focuses on: (i) decentralizing health care services, Health and Gender. (ii) integrating public health and clinical services during the pandemic; (iii) increasing outreach support 4. Health System Strengthening. This department and communication between and within the three aims to strengthen health system standards different tiers of health services within a division across the key health system building blocks— and standardizing services offered to communities, leadership/governance, health care financing, and (iv) ensuring the inclusion of Community Health health workforce, medical products, technologies, Workers in the model. Decentralization allowed health health information, and research. services to be operational during the COVID-19 5. Human Resource Department. This department pandemic. During the lockdown of the Western oversees the effective management of all divisional hospital (Lautoka Hospital), the facility and HR-related activities, programs, and issues and trained personnel were inaccessible to the public and provides advice on recruitment, posting, leave their families. In response, the ministry constructed administration, learning and development, a 150-bed field hospital for non-COVID-19 patients. strategic workforce planning process, and Hence, all health personnel (public health and industrial relations matters. clinical) were advised to learn, share, and integrate to be able to reach out to the community during the 6. Finance, Asset Management, and Digital pandemic. Positive changes include the increased Health. This department is responsible for health presence in the communities, reaching the the implementation of service-wide policies most vulnerable populations, and strengthened and procedures in relation to finance, budget, communication and referrals between public health accounts, and asset management within the and clinical staff at all tiers of the health services MoHMS. delivery. The ministry acknowledges the need to 7. Fiji Pharmaceutical and Biomedical Services strengthen its health information systems within this (FPBS). The FPBS is the supply chain management remodeling as there is potential to continue with this of medical supplies and health commodities. It model beyond COVID-19 and into the future. also focuses on improving access to essential medicinal products of assured quality, safety, efficacy, and cost-effectiveness. Prevention and Promotive Health 8. Planning and Policy Development Division (PPDD). Fiji’s MoHMS aims to ensure that people remain PPDD is responsible for policy development, healthy by making right lifestyle choices and analysis, and coordination of policy-related decisions. For this to be in place, there is a shift in activities, as well as evidence-based health focus from a disease or illness-based approach planning, including the development of medium- to to a wellness-centered approach. The different long-term strategies and annual operational plans departments (MoHMS 2020g) that fall under this and facilitation of health services planning. category are: 9. The Research, Innovation, Data Analysis, and 1. Wellness Division. This was established with Management Unit. This unit supports and the focus on enhancing the usage of quality, strengthens research and innovation in the accessible, and valuable information for supporting MoHMS. The unit aims to ensure that good quality behavioral wellness choices at all levels. There evidence is used to guide decisions about health is an overall shift from being disease focused sector strategy, functioning, and oversight. to addressing the social determinants of health through a multisectoral approach. The Nursing and Midwifery Division. This division 10. is responsible for the planning, coordination, and 2. Health Protection Division. This division focuses evaluation of the delivery of nursing services on prevention, preparedness, and response including the development, coordination, and with respect to acute threats to public health, monitoring of nursing standards, policies, particularly communicable diseases. Health guidelines, and protocols designed to direct and Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 49 Governance, Policies, and Institutions: What Existed and What Has Changed inform patient care, community health services, clinical services for various disciplines in private and specialist nursing care, and nursing management. general hospitals. 11. The Executive Support Unit. This unit is The health centers are staffed by either a doctor responsible for high-level executive support and or a nurse practitioner (staff ranges from two to 20). administrative services for the ministry’s Executive. Health centers provide the first level of referrals for The unit maintains awareness, identifies and nursing stations and are situated to serve a catchment investigates emerging corporate issues that may population of between 3,500 in a rural area to 10,000 require the direct intervention of the Executive, and in urban settings. Subdivisional hospitals provide ensures they are properly briefed and advised. secondary care for the population of Fiji. During the pandemic, nursing stations and health centers were used as screening facilities for COVID- Summary 5:  Health Financing and Health Service 19, while suspected cases were referred to secondary Delivery and tertiary facilities. FEMAT units were set up in • Health financing in Fiji is largely public; the main divisions and subdivisions, which recorded increasing source of financing is provided through the incidence of COVID-19-like symptoms. These domestic government budget and some limited included setups in the subdivisions of Lautoka, Rewa, external financing. Out-of-pocket payments and and Suva. The public was requested to report their voluntary health insurance provide the balance. symptoms at any of these FEMAT sites. Each FEMAT unit consisted of teams of trained and qualified • Publicly provided services in Fiji are largely medical emergency health care workers. The FEMAT free at the point of care for patients (although Field Hospital is open 24 hours a day. The three patients may incur private travel costs to access divisional hospitals and two specialized hospitals care). Government also started a scheme where managed complex cases, while providing secondary the public can access private GPs without any and tertiary care to the general population. Fiji has a charges. total of 130 private general practitioners who provide • The COVID-19 pandemic enabled the MoHMS services to complement health services provided in to decentralize its health care services, the public sector. integrate public health and clinical services, increase outreach support and communication between and within the three different tiers of 3.2.3.2 The Role of Telemedicine in health services, and include Community Health Health Emergencies Workers in the health team. The pandemic pushed the telehealth agenda, and it has accelerated the need for the MoHMS to engage in digital technology since 2020.13 The MoHMS’s 3.2.3.1 Primary Health Care and Referral remodeled framework approaches health information in Fiji and communication as a pillar within it. Thus, there Primary health care (PHC) is mostly delivered through is now an amplified need to set up telehealth and nursing stations and health centers in Fiji. Fiji has a telemedicine capacity within the MoHMS. As part total of 98 nursing stations, 84 health centers, and of the mitigation phase response, teams regularly 19 subdivisional hospitals (Asante et al. 2017). The exchanged information using virtual platforms through nursing stations are considered the lowest health Zoom, Viber messaging/calling, and many other facility, and they are mainly situated in rural areas to platforms. In terms of virtual care, doctors and nurses serve as a first point of contact with the health system accessed patients (who were at home) through for many rural Fijians. telephone calls, and the availability of information networks allowed them to track patient health status The MoHMS is focusing on improving access, virtually—the ministry’s strongest component of the coverage, and quality of primary health care through mitigation response, so far. an integrated approach: curative and rehabilitation health and prevention and promotive health. Curative Another development is the establishment and use and rehabilitation health services include those of toll-free lines (dial 165) that direct a patient to a provided to people with disabilities, and the wider doctor (who will advise on the medication and other Clinical Services Network (CNS), which provides matters). It is currently being deployed in the Western 13 J.Tudravu, Chief Medical Officer, Key Informant Interview, August 30, 2021, Suva, Fiji. 50 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Governance, Policies, and Institutions: What Existed and What Has Changed and Central divisions in Fiji and is slowly reaching the The turnaround time for getting test results is very other divisions. Patients now have virtual access to important, as this helps in the COVID-19 response. different specialists within the hospitals such as those The Fiji CDC laboratory can test around 2,000 in oncology, palliative care, gynecology, and mental samples within a 24-hour period, whereas the other health. As the public has responded positively to the laboratories can test 1,000 samples in the same use of digital technology within the hospitals during period. As the country reached the containment this pandemic, the ministry envisages expanded and and mitigation phases, the laboratory manager and further use within the other disciplines. heads of the Fiji CDC ensured that these daily targets were being met and that health care workers were provided with mental and psychosocial support, as 3.2.4 Physical Infrastructure and Work stress and burnout were encountered by many. Capacity In terms of availability and use of personal Facilities available for infectious disease protective equipment (PPE), the MoHMS ensured that there was abundant supply of PPE in all the testing A total of eight COVID-19 isolation facilities were facilities and that staff followed the standard operating initially set up across Fiji in April 2020, with five procedures (SOP) provided by the Fiji CDC in terms of hospitals (two in the Central and three in the Western wearing PPE. division) and three community isolation facilities (one in the Central and two in the Western division). With the abundance of testing equipment, the However, the use of the community isolation unit was Centre faced a shortage of human resources to later reviewed by the COVID-19 Incident Management conduct testing. Hence, the MoHMS received support Team in the wake of community transmission as from the Australian government, as it funded 15 there were too many cases to handle. The MoHMS Australian nationals to assist the Fiji CDC. As the has established different departments to manage pandemic progressed, a few members of the facility infectious disease (Annex 28). had to be isolated; and the manager had to strategize to ensure workflow (Ibid.). Capacity of laboratory testing and supplying medicines and PPE Supply of medicines and PPE Laboratory testing The Fiji Pharmaceutical and Biomedical Services (FPBS) Centre is responsible for coordinating, With the start of the pandemic, COVID-19 testing was procuring, warehousing, and distributing supplies established at the Fiji CDC in March 2020. In January required for outbreak response (MoHMS 2016a). 2021, more testing sites were established in Fiji; two Supplies have included medicines, medical in the Central division (Twomey clinic and the main consumables, and medical laboratory reagents CWM [Colonial War Memorial] hospital), two in the and consumables. The ministry believes that the Western division, and one in the Northern division. undisrupted supply of materials critical to a successful The Fiji CDC conducts two methods of testing: response to an outbreak is dependent on effective OpenPCR and GeneXpert molecular testing. As the planning and management with stakeholders at the demand on testing increases, private laboratories preparedness phase. moved in to assist the MoHMS, and the ministry expanded testing through the use of rapid antigen To improve the efficiency of the supply chain kits by health facilities across Fiji. The government management during the COVID-19 pandemic, the Fiji received support from donor agencies such as the COVID-19 IMT, through the FPBS and development WHO, DFAT (Australian Government—Department partners, has developed a system to manage of Foreign Affairs, the European Union, SPC (Pacific forecast, procurement, and distribution of PPEs and Community), and many others, which allowed for other medical supplies (Parliament of the Republic widespread testing capacity of COVID-19 around the of Fiji 2020). Other ministries have also provided country. Initially, testing of COVID-19 was only done support in delivering PPEs and medical supplies at the Fiji CDC, but when there was an abundance of to primary and tertiary facilities, fever clinics, and testing kits, testing was decentralized.14 isolation facilities. 14 T. Cabemaiwai, “COVID-19 Preparedness and Response,” interview, November 26, 2021, Fiji CDC, Tamavua, Fiji. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 51 Governance, Policies, and Institutions: What Existed and What Has Changed PPE is an essential medical device used to protect concerning the new SOP and guidelines for the health care workers (HCWs) during the COVID-19 remodeled framework through weekly scheduled pandemic. It is important, therefore, that HCWs be webinar sessions with groups of health workers. The trained on the correct use, wear, doffing, and disposal MoHMS hopes to be able to standardize practice of PPE. Fiji faced a shortage of supply of PPE during in each division this way, using virtual and physical the first wave of the pandemic (Turaga 2020). PPE platforms. such as face masks (N95) and hand sanitizers were Health workers are one of the high-risk groups out of stock due to the high demand and use by the during this crisis. Hence, SOPs were in place to population. The government resorted to using locally ensure the safety of staff and patients. PPEs were produced face shields to protect HCWs (MoHMS made accessible to staff, and the MoHMS continued 2020b), and it managed with support from different to educate its staff on use and safe practices. Senior countries and agencies (note: the Fiji CDC did not managers and executive-level personnel in the ministry face any shortage of PPE, as its use is vital tool in a were able to visit and counsel/motivate health workers laboratory). Additionally, the MoHMS in partnership on the ground. with the World Bank Group (WBG) developed a framework—the Environmental and Social Management Framework (ESMF)—to provide a guide Summary 6:  Primary Health Care, Physical Infra- during the containment and mitigation phase of the structure, and Work Capacity pandemic (MoHMS 2020c). Part of the framework was • Fiji’s PHC is mostly delivered through nursing to look at strategies to optimize the availability of PPE stations and health centers, which are the first during the pandemic (Annex 19). point of contact for most patients, whereas subdivisional hospitals provide secondary care and divisional hospitals/specialized hospitals Workforce capacity specialized in infectious provide secondary and tertiary level care to diseases the population. Fiji has made significant improvements in the • FEMAT hospitals were established to handle capability of its health systems to deal with infectious patients who were normally seen/treated at diseases based on major outbreaks of dengue (2013), hospitals. COVID-19 patients were transferred meningococcal C (2018), and measles (2019). The to CWM Hospital (those in Suva) and government of Fiji through the MoHMS supported the Lautoka Hospital. training of a few doctors specializing in this field and in internal medicine, who provided guidance in terms • Telehealth has been well used during the of specialty care in hospitals. Apart from domestic containment and mitigation phase of the support, Fiji also received technical assistance/ pandemic. Health teams have been using expertise from several development partners virtual platforms through webinars, Zoom including the WHO, CDC, DFAT, NZ-MFAT, and SPC calls, and Viber to converse daily. Doctors in supporting the COVID-19 regional response. and nurses access patients through the Through these networks, COVID-19-relevant standard toll-free line 165. operating procedures, guidelines, and pathways • The MoHMS established six testing sites were developed to assist the MoHMS in the future. and was conducting three methods of testing: The MoHMS also worked with the Fiji military forces rapid COVID-19 antigen testing, polymerase in setting up an intensive care unit (ICU) in the chain reaction (PCR), and GeneXpert military hospital at the Nabua barracks to serve as molecular testing. an isolation facility for frontline workers who contract • The Fiji COVID-19 IMT worked with the FPBS COVID-19. The delivery of health care is challenging, and development partners to develop a and the SOP sets out the standards for undertaking system to manage forecast, procurement, and COVID-19 community awareness and communication distribution of PPEs and other medical supplies. to increase knowledge and understanding among the general population about the risk and potential impact of the pandemic. Numerous training sessions have been conducted for health professionals in the field. The ministry has been able to raise awareness 52 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji 4. Response to Contain the Outbreak RESPONSE TO CONTAIN THE OUTBREAK 4.1 Government Response to individuals were required to undertake two COVID COVID-19 PCR tests while in quarantine before release after the 14th day. Quarantine and COVID test costs for Fijian Like many other countries and territories, the citizens were initially covered by the government, government of Fiji mandated several NPIs to address whereas costs for resident noncitizens were covered COVID-19, including lockdowns, curfews, and travel by the individual (Figure 21). restrictions. Domestically, the government of Fiji responded According to the Permanent Secretary for Health, a by imposing a national curfew, restricting large lockdown in Fiji constitutes the following: gatherings, closing schools and nonessential “A lockdown—in the Fijian context—means a services, and imposing strict lockdowns in two of its 24-hour curfew; It means no movement for any largest cities in the Central and Western divisions. purposes except for medical emergencies; No A national curfew was imposed in March 2020 at shopping. No going out to get food. No going for the onset of the pandemic, from 10 pm to 5 am, and a walk; No, nothing—it means total lockdown” (Dr. varying curfew hours have since been implemented James Fong, Permanent Secretary, MoHMS, Fiji across the country. The government’s strategy then Times, June 27, 2021 [Chaudary 2021]). was to revise the curfew hours with each successive increase in the percentage of fully vaccinated individuals. Curfew hours were revised to 11 pm to 4.1.1 Travel Restriction, Quarantine, and 4 am once 60 percent of the population was fully Lockdown vaccinated. Since the second wave of COVID-19 in April 2021, the government has also implemented The government established its border control unit lockdowns on several occasions that entailed a in response to the quarantine, isolation, and border 24-hour curfew, where movement outside the home control measures. International travel restrictions were was restricted to medical emergencies only. For imposed, placing a ban on inbound passenger flights, instance, on May 4, 2021, the Suva-Nausori area was and allowing entry only for returning Fiji nationals and on a four-day lockdown. This was a stringent measure residents. All travelers were required to quarantine for put in place to boost contact tracing by the MoHMS 14 days upon arrival at a government facility located team, and to map out a mitigation plan. in Nadi in the Western division and were supervised by the MoHMS and the military. All quarantined Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 53 Response to Contain the Outbreak At the beginning of the second wave, the To maintain the country’s economic activity and MoHMS mandated containment zones within the considering the movement of citizens of other Central division to control the rapid spread of countries, Fiji did not fully close its borders to the Delta variant. Check points were set up in travelers. Airports were not closed, as Fijian citizens strategic locations at the borders of lockdown zones.were able to return to Fiji, as were repatriation flights for foreign nationals to their countries. Seaports The Fiji Police Force (FPF) enforces laws and remained opened to allow import and export orders in compliance with MoHMS guidelines on between countries. Opening of the country’s borders containment zones, as and when announced by depended on top-level approval, negotiations, and way of legal notice(s) issued by the Permanent assessments by the border health protection unit. The Secretary for the MoHMS. The operations team unit consisted of health and military personnel and cordoned off the zones and the entry and exit points other agencies/organizations. Through tremendous of containment areas. Police patrolled towns and efforts, the country was able to prevent the presence cities, settlements, and villages to ensure that of the Alpha and Beta variants, but the Delta variant curfews were followed, social gatherings banned, made its way into the country in April 2021 and border restrictions upheld. Figure 21: COVID-19 Intervention Timeline- 2020 (Figures 22 and 23). Figure 21:  COVID-19 Intervention Timeline (2020) TIMELINE March • Fiji confirmed first COVID- cases • Schools and non-essential businesses closed in Lautoka • Establishment of border control unit • -hour nation-wide curfew introduced and enforced • International travel restrictions were imposed • Free helpline provided for COVID- response • fever clinics opened around the country • -days quarantine for travelers in-country April May to July August to December • Schools remained closed • Extension of flights suspension • Fiji recorded its second COVID- death • Fever clinics increased to • Schools anticipated to start on July , • Total of cases and deaths • Isolation facilities provided confirmed (Western division- , • Launch of the CareFiji App Central division- ) • Flights scheduled on • Fiji recorded its first December - were ceased, • Quarantine period extended COVID- death due to a new variant spreading to days in the United Kingdom – • Suspension of sporting Delta variant activities Source: MoHMS COVID-19 Updates. 54 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak Figure 22: COVID-19 Intervention Timeline- 2021 Figure 22:  COVID-19 Intervention Timeline (2021) TIMELINE January February March • Fiji confirmed new cases of • Fiji approved access to the • Fiji received the first batch of COVID- at border Oxford Astra-Zeneca vaccine Astra-Zeneca vaccine quarantine facilities • new cases were detected • new cases were detected at border quarantine facilities at border quarantine facilities April • -hour curfew lockdowns were initiated for people at • Containment zones established in the Central division, i.e., Nadi and Lautoka. Only essential services resumed Suva, Nausori and Lami. operation such as banks, hospitals, pharmacies, etc. • People living in Suva and Nausori not allowed to move out • Schools nation-wide were closed for weeks of their homes for hours (e ective on April , and ended on May , ) • MoHMS launched a house-to-house screening program in the Island State’s Western town. • Fiji confirmed new cases May June to July • Lautoka hospital closed to the general public to • Enforcement of the No Jab, No Job policy prevent the hospital from becming ground-zero • Curfew hours enforced from pm to am for a wider outbreak. • Development and enforcement of the Public • Third and fourth death confirmed Health Infringement Notice • FEMAT activated and dispatched its medical carrier vessel MV Veivueti to Lautoka August September October • Movement restrictions and • Deployment of Moderna and • Easing of COVID- curfew hours were initiated Pfizer vaccine restrictions in villages at Vanua Levu • Curfew hours renewed from • Announcement of the re- and Kadavu am to am opening of schools by November , , and • Containment areas have been borders by November , removed/lifted Figure Source: 23: COVID-19 MoHMS Intervention COVID-19 Updates. Timeline- 2022 Figure 23:  COVID-19 Intervention Timeline (2022) TIMELINE February March • PCR testing was no longer required to travelers • Government avoided -hour curfew lockdown as entering Fiji. owever, travelers aged years and a measure to combat COVID- (third wave), but above from entering Fiji from a “Travel Partner enforcement continued for vaccination, masking, Country” were required to produce a negative physical distancing, overcrowding and hand rapid antigen test within hours of their flight’s hygiene. scheduled departure. • Isolation and quarantine requirements were • Unvaccinated individuals were exempted from revised by Government, which included the entering public spaces, which included places self-isolation of HCS (who tested positive) for of worship, sporting avenues and high-risk seven days. businesses. • Informal gatherings were limited to people who • Wearing of masks was mandatory for all Fijians. refused to wear masks, and businesses were penalized if they failed to record or have QR codes installed at the entrace of their shops. Source: MoHMS COVID-19 Updates. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 55 Response to Contain the Outbreak One of the interventions instituted at this time, for a period of approximately three weeks, was the conversion of the CWM Hospital (Fiji’s main referral hospital) to a COVID facility. 4.1.2 Screening, Testing, Contact patients would wait at the fever clinics while the tests Tracing, and Isolation were being processed at the appropriate laboratory. All these clinics had patient beds set up, like field At the onset of the pandemic, the MoHMS established hospitals, to accommodate patients who required and operationalized 32 fever clinics around Fiji on prolonged observation and those who needed to wait March 2020 (MoHMS 2020d). This number was for laboratory results. increased to 37 on April 2020, as Government ramped up its response to COVID-19 (Fiji Government COVID-19 laboratory testing began in Fiji on 2020e). In the first wave, fever clinics were not fully January 28, 2020, with samples taken to the WHO utilized as fewer cases and deaths were recorded- collaborating center reference laboratory at the March 2020 to March 2021 as infections were mostly Peter Doherty Institute for Infection and Immunity reported from quarantine facilities with no community in Melbourne, Australia, for confirmation. On March transmission. However, the MOHMS reactivated and 11, 2020, using the real-time reverse transcription alerted these fever clinics on April 2021 (Tadulala polymerase chain reaction (RT-PCR) test, the country 2021a) as cases and deaths started peaking- was able to test COVID-19 locally through the Fiji presence of delta variant Centre for Disease Control (Fiji Government 2020d). These clinics became critical additions to the health Samples were sent from health facilities around system structure, forming another layer of screening the country to the Fiji CDC for testing, and as the or triaging of patients who were presenting with pandemic progressed, the MoHMS increased its COVID-like symptoms, at a time when the Central testing capacity by placing several GeneXpert division (particularly) was inundated with extensive machines across the country. From March 2020 until community transmission of COVID. One of the June 30, 2022, Fiji conducted 567,192 tests, with 24: Number Figure tests 524,331 conductedof April 2021Tests COVID-19 from to Juneper 30,day interventions instituted at this time, for a period of approximately three weeks, was the conversion of 2022 (Figure 24). the CWM Hospital (Fiji’s main referral hospital) to a Figure 24:  Number of COVID-19 Tests per Day COVID facility. This was when Fiji experienced the greatest number of severe COVID-19 cases needing ICU admission and the highest case fatalities. The presence of fever clinics in strategic locations extending radially from the CWM Hospital and Lautoka Hospital (on the western side) ensured that only cases who met specific clinical criteria were referred to these tertiary care hospitals for further management. The COVID-19 screening protocols were applied Fiji to all patients who presented to the fever clinics, and Mar , Nov , Jun , Dec , Jun , COVID tests (nasopharyngeal swabs [NPS]) were to be taken when indicated by the protocol. Such Source: Johns Hopkins University CSSE COVID-19 Data 56 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak Figure 25: COVID-19 Daily Tests per Million Figure 25:  COVID-19 Daily Tests per Million , , , , Daily Tests per Million , , , , , , / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / / Dates Australia New Zealand Fiji Source: https://ourworldindata.org/coronavirus/country/fiji#the-positive-rate As depicted in Figure 25, the MoHMS conducted of COVID-19 transmission. The Fijian government more than 3,000 to 4,000 tests per million population introduced the CareFIJI App under the Digital FIJI per day in the months of June and July, with tests initiative to assist the MoHMS in streamlining and starting to decline from August to December 2021, speeding up their manual contact tracing efforts. in line with the change in the testing policy. Australia The CareFIJI App, adapted from applications used in had been conducting more than 4,000 tests per Singapore and Australia, uses Bluetooth technology million population per day during these periods, to make contact tracing much faster and accurate, while New Zealand conducted less than 1,400 tests and it does not require people to recharge their per million population per day in the same period. phone for internet purposes. During this period, Fiji was conducting more tests Fiji established eight COVID-19 isolation centers than New Zealand and almost the same amount as in June 2020, in five hospitals and three community Australia. This testing feat illustrates the capacity of isolation facilities across Fiji (three facilities were in the MoHMS and the Fiji CDCS to efficiently coordinate the Central division—CWM Hospital, Navua Hospital, and implement testing at a very high level. With six and Forestry Training Centre; and five in the Western laboratories around the country, testing has been division—Nadi Hospital, Lautoka Hospital, Nadi decentralized, and the MoHMS has been able to Special School, Natabua High School, and Ba Mission meet the daily requirement, which is 3,000 per day. School) (MoHMS 2020d These isolation wards were At the beginning of the second wave in Fiji, contact used to separate the sick individuals from uninfected tracing was a critical component of Fiji’s success people. However, as the number of cases increased, in the early detection and breaking of the chains villagers would locate a separate building (such as a hall or school) to isolate or quarantine those infected. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 57 Response to Contain the Outbreak 4.2 Health Systems Response Summary 7:  Government Response • The government established its border control 4.2.1 Primary Care and Hospital unit to limit the transmission of the virus. Fiji’s Response first response was the restriction of international Fiji’s health care system consists of primary, travel and the quarantining of visitors for secondary, and tertiary care. The first level of 14 days. Domestic restriction includes the care (primary) has been instrumental during this imposing of curfew hours and suspension pandemic, as health care workers continue to of schools, nonessential business, national conduct health promotion, health prevention, and events, and gatherings. The government also identification of cases through the agreed case established containment zones in the Central definition. Additionally, primary care teams provided and Western divisions of Viti Levu, with the aim home-base cared and ensured that health facilities of controlling the spread of the virus. remained open, prioritizing health services such as • Contact tracing and testing was a critical immunization, and maternal and child health clinics component of Fiji’s success in the early and outpatient services continued to operate.15 detection and breaking the chains of COVID-19 Secondary and tertiary facilities focused on providing transmission. Contact tracing was conducted the best care to patients who needed admission into mainly through traditional outbreak response health facilities. Additional work includes going out methods, but Fiji also used the CareFIJI contact into the community and supporting primary health tracing app to trace people who have been in care teams in conducting awareness and outreach close contact with COVID-19 cases. and running health programs. • A total of 32 fever clinics were established Community capacity supported the MoHMS in around the country. However, as the number of establishing community isolation and quarantine cases increased, the main divisional hospital— facilities. In addition, the commissioner’s office in CWM Hospital—was designated as a COVID-19 each division facilitated the availability of schools facility. The MoHMS also established eight and community halls for isolation and quarantine. isolation facilities in June 2020; however, According to the MoHMS, the designation of hospitals the number of facilities was increased as as COVID-19 facilities was determined by the number support was received from the community of COVID-19 cases in each division. However, the in establishing community isolation and designations may change with the number of cases quarantine facilities. diagnosed in different settings. • The MoHMS implemented lockdown as a In mobilizing beds for treating confirmed cases, measure to speed up contact tracing efforts. the MoHMS has a good storage capacity for beds available for COVID-19 patients, as support was • Fiji’s border (airport and seaport) was not fully received from communities and technical agencies; closed to Fijian citizens. The government for example, communities around Fiji supported the continues to open its seaport for export and MoHMS by purchasing beds for community isolation import of goods. facilities. The WHO also assisted by providing beds in • During the peak of COVID-19 cases in the the Vodafone arena. second wave, Fiji was conducting more The private sector has also been very supportive in than 3,000 tests in the months of June and mobilizing resources such as linen, food rations, beds, July 2021. and so forth. Fiji Emergency Medical Assistance Team (FEMAT) FEMAT is the first team in the Pacific Islands established to respond to health emergencies domestically and across the Pacific. It provides a range of medical and emergency services to more than 100 patients a day (Reliefweb 2019). During the COVID-19 pandemic, FEMAT moved in to treat cases 15 J. Tudravu, Chief Medical Officer, “COVID-19 Preparedness and Response,” interview with Gade Waqa, August 8, 2021. 58 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak that hospitals would normally treat. Services ranged 4.2.2 Human Resources for Health from acute cases, childbirth, accidents, and other nonelective surgeries. This was done to avoid the Services by frontline health professionals have spread of infection between infected and noninfected increased during the pandemic. To address the patients in hospitals (Fiji Government 2021c). In increasing number of people accessing health the Central division, the MoHMS established the services, retired health personnel, volunteers, and Vodafone Arena as a FEMAT hospital. CWM Hospital civil servants outside the Ministry of Health were was designated a COVID-19 hospital, at the same temporarily recruited to assist with MoHMS services time also treating complex cases for non-COVID-19 and operations. Standard operating procedures patients. Emergency surgeries and deliveries for were developed and implemented to guide services non-COVID patients were done onboard the MV provision, as well as the use of PPEs. The government Veivueti Ship, while maternity care was provided at mobilized 867 civil servants (including municipal staff) the FEMAT hospital (MoHMS 2021a). In the Western to be part of the COVID-19 Divisional Emergency division, the MoHMS established the Old Government Response Team (Boila 2021a). Additionally, the Supplies building in Natokowaqa and Nadovu Australia and New Zealand Medical Assistance Teams Park, Lautoka, as a FEMAT field hospital. COVID-19 (NZMAT and AUSMAT) deployed 17 HCWs to help patients were cared for at Lautoka Hospital (COVID-19 the Fiji MoHMS strengthen its COVID-19 prevention hospital), while deliveries were done at the Viseisei and control activities (Chaoke 2021). For example, the Health Center, and care for mothers and babies was NZMAT and AUSMAT used their technical expertise provided at the Ba Hospital (MoHMS 2020c). and knowledge to convert non-COVID-19 facilities into COVID-19 facilities around the country. To respond to the crisis, the MoHMS identified COVID-19 Facility and established the response level and determined With cases peaking in the Central and Western the skill set in each division. It also developed and divisions of Viti Levu (especially during the second mobilized the Fiji Emergency Medical Assistance wave), the MoHMS designated the CWM and Lautoka Team (FEMAT) to support the COVID-19 response. hospitals as the main COVID-19 care facilities. The For areas that were deemed high risk (because of ministry established the Pre-Hospital Emergency increasing cases), the FEMAT identified staff with Coordination Care Centre (PHECCC), an ambulance relevant skills and deployed them accordingly. transfer and retrieval service. As oxygen demand Because cases were peaking at different periods increased during this time, the MoHMS established an of time in Fiji’s four divisions, teams were trained oxygen body that looks at restocking oxygen tanks and deployed to respond to and tackle issues on in the mornings and evenings. Naval officers worked the ground. with the MoHMS to ensure the timely availability To ensure that health services were not disrupted, of stocks. health workers were grouped into work bubbles The whole-of-government approach has been accommodated in hotels for months and discouraged a key factor in the daily operations at Fiji’s health from seeing their families for fear of infection spread. care facilities. Retired health personnel, volunteers, FEMAT members were accommodated on the and civil servants assisted in the MoHMS services Captain Cruise ship. Staff members were paid on a and operations. The Republic of Fiji Military Forces salary basis and provided with meals and subsistence (RFMF) assisted the MoHMS in COVID-19 patient allowances if relocated for COVID-19 duties. The transfers and home retrievals (PHECCC), conducting government also recognized the need for coping examinations and medical assessments for COVID-19 mechanisms for workers during the pandemic. As patients at their individual homes, looking after an example, it has placed emphasis on professional quarantine facilities, and manning the Call Centre on development of its staff during this time, and training a 24/7 hourly basis (toll-free line—165). The Fiji Police was offered to staff as personal development/gain. Force; Fiji Correction Services; National Fire Authority; The ministry was also mindful of potential fatigue St John Ambulance; Volunteer First Responders; and and burnout of its workers and through its human civil society organizations such as Medical Services resources and planning division has encouraged Pacific, Empower Pacific, Red Cross Society, and workers to take leave when they can. Similarly, the many others were part of the team (Boila 2021b). ministry supports mental health and psychosocial services for its workers and has made those services readily available for them. It has also made special Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 59 Response to Contain the Outbreak arrangements with officials of the military hospital to 4.3 Public’s Response provide dedicated ICU services for health workers should any fall sick on duty during the pandemic. 4.3.1 Social Distancing, Personal Health workers have been informed about this Hygiene, and Social Normal provision and have been assured that the same The government escalated its COVID-19 containment specialists and the necessary equipment would be measures in the second wave after the country offered to them while in isolation at that other hospital. confirmed its first case of community transmission Furthermore, visiting health teams from Australia and (April 2021) in the capital of Suva. The government New Zealand have been assigned specific duties— introduced the following restrictions to prevent the specifically to focus on infection control among health transmission of the virus (Fiji Government 2021f) workers and to provide training and monitoring of COVID-19 safe measures within the workforce. • Closing of bars, gyms, restaurants, movie theatres, video gaming shops, cyber cafes, taverns, billiard shops, and amusement centers; Summary 8:  Health System Response • Suspension/closure of schools around • Fiji has a three-tier primary health care system: the country; primary, secondary, and tertiary care. Primary • Funerals (deemed “super spreaders”): restricted care is focused on improving the health to 10 people only; status of people in communities through health promotion, health prevention, and case • No other gatherings or contact sports allowed; identification. Secondary and tertiary care • Suspension of community engagement is focused on providing the best services to activities (the government initiated other ways patients admitted into hospitals. of awareness through use of speakers and police media platforms); • Establishment of the FEMAT has boosted Fiji’s health system response during the pandemic. • All protective equipment and any vehicle used for the conveyance of bodies to mortuaries • Engagement of the NZMAT and AUSMAT or burial sites are sanitized before and after boosted the MoHMS’s response during the each use; pandemic. • The Fiji Police Force conducted vigorous • CWM Hospital and Lautoka Hospital were awareness campaigns through community designated as COVID-19 facilities. However, policing initiatives to safeguard people in complex cases were still referred to adhering to the two meters social distancing, CWM Hospital, making it a COVID-19 and restricted social gatherings, and basic hygiene; non-COVID-19 facility. • Avoiding unnecessary contact with documents, • The whole-of-government approach was key using gloves if possible, or washing hands during the containment and mitigation phase immediately after handling a document; of the pandemic. The Military Force, Police • Regular disinfection of office space, exposed Force, Education Ministry, CSOs, and other office surfaces, and office equipment after use; government ministries assisted in the MoHMS • Wearing PPE such as masks, gloves, and eye operations. protection while interacting with other people; • Community involvement has been shown • Awareness about not touching the face, eyes, to be of great value during the containment nose, or mouth with unwashed hands; and and mitigation phases of the pandemic. The • Maintaining physical distance of at least two community has supported the MoHMS through meters away from other people during social the purchase of beds and the establishment of interactions or while working in police stations community isolation and quarantine facilities. and offices. • The MoHMS provided mental health and psychosocial services and has also been mindful of fatigue and burnout. 60 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak According to the Fiji Police Force, the biggest The Fiji Police Force has ensured that the public challenge that the Fiji government is facing in terms of observes the laws issued by the government NPI is social distancing because of cultural factors. regarding COVID-19 restrictions. However, there has been resistance, recorded from various sections “Gathering is an important part of life making it of society, to abiding by these laws, and as a result a behavioral, traditional and of cultural importance these individuals faced penalties mandated by the in the Fiji community. Fijian people gather to law or regulation relating to COVID-19. celebrate, drink kava, help one another and many people practice communal living. Hence making A total of 1,458 cases were registered during the it a biggest challenge for the government, reporting period (April 19 to July 11, 2021), with a total and unfortunately this saw families, couples, of 3,359 accused persons. The Southern division villagers, being brought in for such breaches.” recorded the highest number, with 645 cases, (Police Officer. 16) followed by the Western division (458 cases), Eastern division (232 cases), Central division (81 cases), and The guidelines used by the Fiji Police to ensure that Northern division (42 cases). people follow these practices are: The types of breaches of the total 3,359 offenders 1. Public Health (Infectious Diseases) (Infringement were (Figure 26): Notices) Regulations 2021 • 58 percent—social gatherings; 2. Legal Notices • 28—curfew breaches; 3. Fiji Police Force Plan for Infectious Disease • 12 percent—failure to wear mask, maintain 4. Public Health Advisories distance/restrictions; and • 2 percent—lockdown and containment areas. Figure 26: Fiji- Types of Breaches in the FTCWO cases- April 19 – July 11, 2021 Figure 26:  Fiji—Types of Breaches during COVID-19 outbreak (under the Failure to Comply with Orders Offence- FTCWO) - (April 19 to July 11, 2021) Central Southern Western Eastern Northern COVID- Restrictions Lockdown/ Social Curfew (Mask/ Containment Isolation Gathering Maintain Areas Distance) Central Southern Western Eastern Northern Source: Fiji Police Force Data 2021 16 Fiji Police Force, “COVID-19 Preparedness and Response,” interview with Gade Waqa and Avelina Rokoduru, August 13, 2021. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 61 Response to Contain the Outbreak The survey was conducted to help understand the effectiveness of risk communication in phase 1 of the COVID-19 response. 4.3.2 Trust in Government and Social Institutions Survey sample size understand the effectiveness of risk communication in phase 1 of the COVID-19 response (Annex 26). Two This section of the case study was adopted from a groups of respondents were assessed in this survey: KAP survey study conducted by the MoHMS (IMT) (i) face to face and (ii) online respondents. with the AusAID (Annex 26). A total of 804 individuals took part in the survey: 466 responded online and The activities and corresponding timelines are 338 face27: Figure to face. The survey Timeline wasevents- of Key conducted to help illustrated Communication in Figure 27 below. Campaign Figure 27:  Timeline of Key Events—Communication Campaign st case of COVID- in Fiji Fiji s video reaches Fiji declared and st press conference Suva lockdown , , people COVID- contained SMS messaging Digital billboards Non-digital First fever clinics campaign starts go out billboards th established - launched Nabua media public informed and release hotline Soasoa Vunkagii issued by launched lockdown lockdown starts MHMS Mar Mar Mar Mar Mar Mar Apr Apr Apr Apr Apr Apr Apr Apr Apr Apr May May Jun Jun Jun Lautoka National Mobile Risk reduction th MHMS updated lockdown curfew screening animation video posted on Facebook starts starts starts - launched - MHMS public informed COVID- posters Frontline health worker calls received printed for health facilities story series starts on hotline , COVID- posters printed - three languages Source: MoHMS and AusAID, 2021 62 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Figure 28: COVID-19 Interventions Response to Contain the Outbreak Public Response to Government Intervention and Figure 28:  COVID-19 Interventions COVID-19 Interventions In assessing the public’s response to NPIs, the survey results showed that respondents were practicing washing of hands with soap and water and maintaining two meters of social distance. Low scores were identified for two protective behaviors: avoiding touching eyes, nose, and mouth; and avoiding close I... contact with people who are coughing or have fever. . ... .. .. ... s. . ce g n. g. ap on in er n he rin fa er he so et g w du In the analysis of knowledge about pathways of g th lin w m n ith e ga hi ve e th m o w uc m tw ou tra ho infection, most of the respondents agreed that people al ho g to ci n m w at d so hi id at llo oi y as contracted COVID-19 by contacting someone who y o rm Av d Fo y a Av dw a oi St St ve Av an has tested positive or shaking hands and sitting next Co H to someone who is coughing (Table 12). Percentage of face to face respondents Respondents preferred to stay at home during Percentage of online respondents curfew hours when experiencing flu-like symptoms Source: MoHMS and AusAID, 2021 and to avoid social gatherings of more than 20 people (Figure 20). Public Trust in Government and Social Institution Table 12:  Public’s Response on Nonpharmaceutical Interventions Getting the right information from reliable sources is critical during the pandemic. Results showed that Face-to- Online television, radio, Facebook, and online news sources Protective Behaviours were the prominent sources of information that Face (N-447) people have been using during this period. It was Wash hands with soap 87% 96% also noted that online respondents use a wider range Maintain two metre distance 81% 92% of information sources, such as the MoHMS website, internet sources, and word of mouth from friends and Cover nose and mouth when families (Table 13). 60% 92% sneezing or coughing Avoid touching eyes, nose 37% 84% Table 13:  Sources of Information and mouth Avoid close contact with Source Face to face Online anyone who has a fever 42% 84% or a cough Television 87% 85% Avoid large gatherings Radio 72% 74% 60% 87% of people Facebook 54% 76% Clean hands with an alcohol- 62% 89% based hand rub Online news sources 76% Source: MoHMS and AusAID, 2021. Newspaper 65% Internet search 62% Not Fiji MHMS Website applicable 60% Text/SMS messages 56% Word of mouth – 56% family, friends Source: MoHMS and AusAID, 2021. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 63 Response to Contain the Outbreak Public’s response if they develop symptoms of the vaccine rollout campaign. The easy access to of COVID-19 all forms of online information (and misinformation) gradually triggered increasing vaccination hesitancy The most common responses from online responders among the population, resulting in a slump in uptake were self-isolation (81 percent) and calling the 158 of vaccination. This trend was of serious concern to hotline (84 percent). Other actions included visiting the government as it recognized that a considerable fever clinics and health facilities. Similar responses number of public servants from various ministries were elicited from people with disabilities. Face-to- were also choosing to not get vaccinated. In response face responders preferred calling the 158 hotline (32 and following various stakeholder consultations that percent) and visiting the nearest fever clinic or health were unanimous about the critical need to protect facility (76 percent). Both groups of respondents people from the ongoing Delta wave and reach (face to face and online respondents) understood herd immunity through vaccination, Prime Minister the importance of contacting/connecting with health Voreqe Bainimarama introduced a “No Jab, No Job personnel when asymptomatic. Policy” on July 9, 2021. This policy mandated that all civil servants and private employers and employees must have received their first dose by August 15 and 4.4 Vaccination their second dose by November 1, 2021. Those who 4.4.1 Status of Vaccination in Fiji refused were asked to take their outstanding leaves and decide before August 15. By September 18, Fiji has made tremendous progress in vaccinating 2021, the Ministry of Health had terminated the work its population against COVID-19. The Oxford contracts of 54 medical personnel, and the Ministry AstraZeneca and Moderna vaccines have been the of Education had terminated 122 teachers. Individuals predominant vaccines used in Fiji. Vaccination efforts with medical conditions that are contraindications to began on March 2021 with the arrival of the first batch vaccination were issued exemption letters endorsed of Oxford AstraZeneca vaccines, obtained from the by the Permanent Secretary for MoHMS. This COVAX facility, a partnership between CEPI (Coalition included those who suffered adverse side effects for Epidemic Preparedness Innovations), GAVI (Global following vaccination. The introduction of the “No Alliance for Vaccines and Immunisation), UNICEF, Jab No Job” Policy boosted the vaccination rollout and the WHO. The first batch of 12,000 doses of in Fiji, and by October 20, 2021, 592,904 individuals the Oxford AstraZeneca vaccines was administered (95.9 percent of the eligible adult population) had to individuals most vulnerable to COVID-19. These received their first dose and 524,475 (84.4 percent included frontline workers in border control, seaports, of the eligible adult population) had received their and quarantine facilities; hoteliers; defense forces; second dose. However, in late December, the variant health workers; and the elderly population ages 60 of concern, Omicron, made its way into the country, years and older. and people were advised to receive the booster The MoHMS conducted nationwide COVID-19 shot. By June 30, 2022, the government managed to vaccination campaigns around the country using vaccinate 642,154 (100.3 percent) individuals with the several strategies. Health centers, community halls, first dose, 587,556 (95 percent) with the second dose, and school sites were used for vaccination drives. and 141,572 (45 percent) with the booster dose. Some teams had to traverse rivers, seas, or steep The Moderna vaccine has been used for children, mountains to access and provide vaccination services pregnant women, and populations above the age of to remote populations. In addition, the government 60. Since September 24, 2021, the Moderna vaccine was able to establish drive-through vaccination sites has been administered to children ages 15 to 17 years. in towns and cities, where people were vaccinated in Children ages 12 to 14 years started receiving the the comfort of their vehicles. Pfizer vaccine on November 15, 2021, and onwards As COVID-19 vaccination programs rolled out all (Kate 2021). By June 30, 2022, 38,726 children (ages around the world, mainstream and social media 15 to 17 years) had received the first dose and 32,061 began to report on the growing “antivaxxer” the second dose. Among those ages 12 to 14 years, sentiments. In addition, there were questions about 25,738 received the first dose and 15,702 the second the safety of vaccines, particularly AstraZeneca, which dose (MoHMS 2022). was the only vaccine available in Fiji at the beginning 64 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak In the Pacific Island Countries (PICs), 62 percent Tonga, and Guam. With respect to the third dose, (n = 13) out of the 21 island countries have vaccinated only one country has reached the 90 to 100 percent more than 90 percent of their population—as of April vaccination coverage (Palau), three countries have 19, 2022. These include American Samoa, Cook reached the 80 to 90 percent vaccination coverage, Islands, Guam, Fiji, Kiribati, and others. With respect five have reached the 70 to 80 percent coverage, to the second dose, 38 percent (n = 8) of the island and 48 percent (n = 10) have attained less than countries have vaccinated more than 90 percent 70 percent vaccination coverage (WHO 2022f) Figure of 29: COVID-19- the population; Pacific these include Vaccination American Samoa, Update (April (see 19,29 Figures 2022) and 30). Cook Islands, Nauru, Palau, Pitcairn Island, Tokelau, Figure 29:  COVID-19 Pacific Vaccination Update (April 19, 2022) st dose (eligible population) Fully vaccinated (eligible population) Fully vaccinated (total population) % % % % Vaccine coverage % % % % % % % * ds i sia * Isl lic ti M* u ia * M* u* ds a ds lau a ** u a Fij (R he ue oa am mo ng un a ur at lu* on la an an an all pu rib ) FS CN ne ke ds f t nu Na MI Ni am ut To Pa Gu led Sa va Isl Isl Isl an o Ki ly To Va dF nS Tu Po Ca ok irn on an b ica Co ch lom ca w llis Ne er en Pit rsh Re So Am Wa Fr Ma Source: WHO 2022f Figure 30: Percentage of eligible population fully vaccinated in Pacific Island Countries and Territories (April 19, 2022) Figure 30:  Percentage of Eligible Population Fully Vaccinated in Pacific Island Countries and Territories (April 19, 2022) Cook Islands Fiji Kiribati Nauru* Pitcairn Islands Samoa Solomon Islands Tonga Tuvalu Vanuatu % % % % Vaccine Coverage % % % % % % % % -May -Jun -Jul -Aug -Sep -Oct -Nov -Dec -Jan -Feb -Mar -Apr Date Source: WHO 2022f Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 65 Response to Contain the Outbreak Vaccine wastage and shelf life of vaccines were two of the key issues that the MoHMS has had to deal with during the vaccination drives. 4.4.2 Financing and Distribution the vaccines, the bilateral partners, Australia and New Zealand, have also provided funding for vaccine Fiji was the one of the first countries in the Pacific deployment. Islands to receive the COVID-19 vaccine doses on March 6, 2021, through the COVAX facility. An initial Vaccine wastage and shelf life of vaccines were shipment of 12,000 doses of the AstraZeneca vaccine two of the key issues that the MoHMS has had to was received, followed by subsequent shipments deal with during the vaccination drives. There were of the AstraZeneca vaccine from the COVAX facility instances where fewer people were turning up to and various bilateral partners. Table 14 presents a vaccination drives, and one vial should be used by 10 summary of the COVID vaccines received in Fiji from people (Uluwai 2021). This issue is concerning as it March to November 2, 2022. In addition to providing could hinder the government’s opportunity to secure more vaccines from donors. Table 14:  Financing for COVID-19 Vaccines Source Vaccine Type Date of Arrival Number of Doses 1st batch—March 6, 2021 COVAX Facility Oxford AstraZeneca 36,000 2nd batch—April 19, 2021 COVISHIELD India March 30, 2021 100,000 AstraZeneca Australia AstraZeneca November 2, 2021 Over 1 million doses New Zealand AstraZeneca August 4, 2021 100,000 USA Moderna July 16, 2021 150,080 Japan AstraZeneca August 24, 2021 56,000 New Zealand, Australia, and UNICEF Pfizer February 2, 2022 175,000 Australia Pfizer February 24, 2022 175,000 New Zealand Pfizer Pediatric vaccine March 31, 2022 50,000 66 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak 4.4.3 Information, Communication, nonadherence, the MoHMS and the MEHA terminated Compliance the contracts of 54 medical personnel (30 nursing and midwifery staff, 15 support staff, 4 medical officers, Although Fiji has managed to achieve a high 2 oral health staff, 1 dietitian, 1 physiotherapist, and vaccination rate, initial vaccine hesitancy was a 1 health inspector) and 122 teachers (33 teachers in challenge. Hesitancy has been attributed to a the Central division, 7 in the Eastern division, 20 in general lack of confidence in the safety and efficacy the Northern, and 62 in the Western) (Rabonu and of the vaccine; long queues at the vaccination sites Talebula-Nuku 2021). According to the Fiji Minister of (long hours of standing); people’s constitutional Economy Hon. Aiyaz Sayed Khaiyum, the policy has right to refuse vaccination; negative comments had positive effect, as the country reached high rates and information on social media; distrust in the of vaccination, schools are being re-opened, and the government, triggered by the inconsistent and economy is gradually picking up steam (RNZ 2022). unreliable information shared by the government; religious beliefs; and employment concerns, as reasons for non-vaccination (FWRM 2021). Vaccine Hesitancy Fiji’s vaccination teams conducted awareness Vaccine hesitancy is a growing challenge to campaigns in different communities and villages, achieving herd immunity in Fiji and thus a prominent emphasizing the importance of the COVID-19 vaccine. public health concern. It is defined as the delay The MoHMS has established a COVID-19 vaccine in acceptance, or refusal, of vaccination despite information hub on the MoHMS website that can be availability of vaccines (MacDonald 2015). Two accessed by the public. The development partners, important studies done by Kumar (2021a and 2021b), private sector, and civil society groups have also been (i) “Determinants of COVID-19 Vaccine Hesitancy providing their support to create awareness, as well in Fiji” and (ii) “Parents’ Intentions and Perceptions as technical support with medical and other essential About COVID-19 Vaccination for Their Children,” items. have quantified the levels of vaccine acceptance Some of the actions instituted by the government and vaccine hesitancy in Fiji. The first study found to encourage vaccination include the “No Jab, No that age, ethnicity, gender, religion, and geographical Job” policy, which requires all civil servants to be location significantly influence vaccine acceptance. vaccinated by October 2021, and a “No Jab, No The Western division had high levels of vaccine Government” initiative that provides F$120 per month acceptance compared to other divisions. People for the next six months to eligible Fijians who receive more than 24 years old were more likely to be their first dose of the vaccine by August 7, 2021, and a vaccine hesitant, whereas people more than 65 second dose by October 31, 2021.17 The government years old showed high levels of vaccine acceptance. also established a lottery draw (known as “Let’s Females have high levels of vaccine acceptance (74.9 Win Together Sweepstakes”), where 10 people won percent) compared to males. In terms of ethnicity, F$5,100 (vaccinated adults are eligible to apply). vaccine acceptance was high among Fijians of Indian descent (84.1 percent) and was lowest among the I-Taukei (52 percent). With respect to religious No Jab, No Job Policy affiliation, Muslims and Hindus (88.6 percent and 83.4 percent, respectively) were more likely to be The “No Jab, No Job” policy was developed and vaccinated, compared to Christians. Kant et al. (2021), established around July 2021. The policy was in stated that Christian influencers, including religious place to encourage Fijians to get vaccinated and be leaders, shared conspiracy theories that the vaccine immune to the COVID-19 virus (MoHMS 2021g). The was associated with demons and the “mark of the policy mandated that all civil servants and employees beast,” which contributed to the low acceptance and employers in the private sectors receive their rates among Christians. Other reasons for vaccine first dose by August 1, 2021, and their second dose hesitancy include fear of the vaccine’s side effects; by November 1, 2021. The government even granted beliefs that the vaccines have metal chips connected leave for civil servants to get booster shots before to a 5G network or that they are magnetic; religious these tentative dates or face contract termination reasons; lack of trust in the health care system, (Panapasa 2021). Employers and employees at private government and public health agencies; conspiracy firms were advised to comply or either face fines or theories; and online misinformation. allow their businesses to stop operations. Due to 17 Ministry of Economy, 2021, “COVID-19 Preparedness and Response,” interview with Gade Waqa and Avelina Rokoduru, August 12, 2021. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 67 Response to Contain the Outbreak The second study found that ethnicity, religion, directly linked to the Births, Deaths, and Marriages geographical location, and parental education level Portal, so the user’s personal details automatically get were significantly associated with vaccine hesitancy. populated once the user enters the birth registration A total of 1,056 parents’ survey data was analyzed number. The user is required to choose the closest and showed that 70.3 percent would get their child health facility from a drop-down menu, name any vaccinated with the COVID-19 vaccine, 13.5 percent existing medical conditions, provide contact details, were unsure, and 16.2 percent indicated that they and upload a copy of a valid identification card. Upon would not get their child vaccinated. Fijians of Indian successful registration, the user is given a reference descent had the highest vaccine acceptance level, number, which he/she presents to the health worker while I-Taukei parents were the most hesitant. In at the vaccination station, on the day of vaccination terms of age, parents above the age of 40 years (Fiji Government 2021d) have high levels of vaccine hesitancy, and degree In terms of administration, all information entered is of acceptance decreased with lower age groups. verified by data managers to ensure all relevant fields The Western division reported high levels of vaccine have been populated. The system will not complete acceptance compared to other divisions. Muslims and a registration successfully unless all fields have been Hindus reported high levels of vaccine acceptance filled appropriately. On the day of vaccination, the compared to Christians. Further, parents who had individual will need to be verified against the details university postgraduate degrees had the lowest in the VRS system before receiving the jab, and the levels of vaccine hesitancy, were fully vaccinated, vaccination nurse enters the details of the jab in the and were most likely to allow their children to get a system including the date, the type of vaccine, and COVID-19 vaccine. the batch number. All vaccinated individuals are issued a vaccination card as proof of vaccination (MoHMS 2021f). 4.4.4 Vaccination Registration System/ GIS Vaccination Dashboard On September 18, 2021, the MoHMS began the registration of students in the 15-to-17-year age group In the past, vaccination programs rolled out by (Fiji Government 2021e), while registration and rollout the MoHMS were always conducted manually, of COVID-19 vaccination for children aged 12 to 14 with “patient” information recorded on printed years began on November 15, 2022 (Turaga 2021). forms and large registers used for storage of Students are required to register with their parents/ population data. With technological advancement, guardians for consent, and vaccination is offered in the government introduced a digital system to the schools through collaboration with the MEHA. support the vaccination program. In collaboration As of September 25, 2021, although vaccination for with the Ministry of Communication through Digital students was not mandatory, they were not allowed Fiji, the Vaccination Registration System (VRS) was to enter school compounds unless fully vaccinated. launched on March 8, 2021. This “first-of-its-kind” They were encouraged to get vaccinated for the system marked a new era, aligning with the Digital safety of their peers, and indoor masking was Transformation Pillar of the 5–20-year National mandatory in schools. Development Plan of the Fijian Government (MOE 2017). The launching on the VRS coincided with the Furthermore, for vivid visualization of the progress arrival of the first batch of the Oxford AstraZeneca of the vaccination program, a geospatial component vaccines, which became an incentive to get was incorporated to support the VRS. This includes registered, even though the vaccines were initially the launching of a geographic information systems prioritized for vulnerable populations only. (GIS) dashboard that transforms the data from VRS to a geographic visual. The dashboard is open source The VRS is a user-friendly platform that can be and can be accessed by anyone on any device. accessed through any electronic device that can Users are also encouraged to register to make full connect to the internet. Users are not required to use of the portal, but most of the details are also create an account but need to provide a copy of displayed on the viewing interface. Users can view their identification card for verification purposes and vaccination details by division and subdivisions and their birth or permit number for registration (MoHMS see a percentage representation of the vaccination 2021g). Vaccination in Fiji is open to citizens who rates. Users can also download the raw data for were either born and live in Fiji full time, attained personal or research purposes (MoHMS 2021e) citizenship through the Fijian Immigration Office, or hold a valid permit to reside in Fiji. This system is 68 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak A thematic brief developed through the support Summary 9:  Vaccination of the Pacific Women Shaping Pacific Development • The AstraZeneca and Moderna vaccines were (Pacific Women, DFAT) and in partnership with the the predominant vaccines used in Fiji. Pfizer Pacific Girl program (Cowley 2020) looks at the vaccines were deployed to children 12 to 14 issues adolescent girls (14 to 19 years old) are facing years old. because of COVID-19. Twenty-one Pacific girls offered • The No Jab, No Job policy has been effective their insights in the survey (including in Fiji, Papua in reducing the antivaxxers, and the use of New Guinea, Solomon Islands, and Vanuatu). The incentives has contributed to the increase in survey concluded that COVID 19 results in: vaccination coverage in Fiji. 1. Disrupted education • The government introduced a digital system The closure of schools has disrupted girls’ learning known as Vaccination Registration System, and they are less able to access online learning which has made work efficient for the options. This has led to increased pressure to vaccination team, and is a milestone for the undertake domestic labor and care responsibilities MoHMS—as previously patient information was for their families. recorded on printed forms and large registers. 2. Increased anxiety and loneliness Impacts related to adolescent girls’ age and developmental stage include: a loss of peer 4.5 Protecting Vulnerable People support, leading to depression and anxiety; an increased propensity to boredom and risk-taking 4.5.1 Women and Children behaviors; and for those with online access, The COVID-19 pandemic has exacerbated the an increased exposure to predators, online already very high rates of violence against women harassment, exploitation, and bullying. and girls. A survey conducted by the COVID-19 3. Feeling isolated and unsafe at home and online Response Gender Working Group in 2020 reported Prolonged school closures and economic that 64 percent of women who have ever been in an recession due to the COVID-19 pandemic have intimate relationship have experienced physical and/ the potential to significantly increase the risk of or sexual violence by a husband or intimate partner gender-based violence, early and forced marriage, in their lifetime (COVID-19 Response Gender Working sexual exploitation, and child labor. Group 2020). A rise in violence has been one of the COVID-19 impacts, with a significant increase in calls 4. Increased care burden at home received by the National Domestic Violence helpline The COVID-19 pandemic has increased the burden in April 2020, and 50 percent of them related to of care on women and girls. Caring for siblings and COVID-19. COVID-19 exponentially increased gender- children in the community, especially during school based violence due to the deepening of economic closures, and additional household work often and social stress coupled with restricted movement fall on adolescent girls. This is because they are and social isolation measures (UN 2020). Many traditionally expected to assist their mothers and women were forced into lockdown at home with their female relatives to undertake most of the unpaid abusers while services to support survivors were domestic labor and childcare. disrupted or inaccessible. 5. Disrupted access to menstrual hygiene and COVID-19 has also doubled the burden of workload sexual health services for many women, particularly for those with paid jobs Restricted movement decreases access to sexual who are working from home while schools are closed; and reproductive health information and services, this has become a triple burden as many women are while increasingly crowded living conditions also expected to be responsible for their children’s impinge on girls’ access to water, sanitation, education (Cowley 2020). Women are responsible for and hygiene (WASH) and menstrual hygiene caregiving (of children, ill or elderly family members, management. and people with disabilities) and household work. Additional unpaid work for women at home has been brought about by the closure of schools and workplaces and bans on social gathering have meant that everyone has had to stay home. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 69 Response to Contain the Outbreak Government intervention for women and girls 4.6 Innovation Through Leapfrogging during COVID-19 pandemic 4.6.1 Communication and Information 1. Multisector COVID-19, Gender and Protection SOPs have been developed to ensure that Technologies frontline service providers can adapt quickly to COVID-19 has triggered an unprecedented reliance this interagency coordination and to support girls, on ICT in Fiji, as people were isolated in their women, and families affected by gender-based individual homes, workers were mandated to work violence. from home, students needed to use online learning 2. Helpline services for girls and women were platforms, and so forth. The Fiji MoHMS has been established, which include the Fiji Domestic using ICTs in establishing internet connections, Violence Helpline, Child Helpline, and Mental networks, apps, databases, phones, and other Health Helpline. important developments that were pivotal during the pandemic (see Table 15). Below are some of the 3. Centers or shelters for girls or women who faced developments that have evolved around ICTs: domestic violence or other types of gender-based violence were also provided. These centers/ shelters are in Lautoka, Labasa, and Sigatoka. Risk Communication 4. Counseling sessions for men were established. Effective communication is an important tool in This is done to provide support for emotional the COVID-19 daily operations in Fiji. The MoHMS health and relationship concerns of men affected executive members conduct daily meetings via by or considering using violence. Zoom to update strategies and consult on technical 5. Gender Based Violence primary prevention issues. The Fiji COVID-19 Taskforce and Development approaches have been established. Partners conducted webinars to reach more than 400 health workers to update them on the current protocols and mechanisms. Furthermore, use of social media platforms such as Viber, Facebook, and Gmail Summary 10:  Protecting Vulnerable People were critical in notifying/reminding workers about • COVID-19 has exacerbated the very high the daily operations. The Medical Superintendent rates of violence against women and girls in and Divisional Medical Officers were able to develop Fiji, according to a report from the COVID-19 different groups on these social media platforms with Response Gender Working Group in 2020. the aim of transmitting information to health workers It has also doubled/tripled the burden of on the ground. workload for many women as some are required to work from home and look after the children and the elders—keeping in mind that Contact Tracing schools were also closed. The practice of contact tracing has been a critical • Some of the circumstances faced by component of Fiji’s success in the early detection adolescent girls during this crisis were and breaking of the chains of COVID-19 transmission. disrupted education, increased anxiety and Apart from physical contact tracing teams and loneliness, feeling isolated and unsafe at home processes, the Fijian government introduced an app and online, having an increased care burden called the CareFiji App under the DigitalFIJI initiative at home, and disrupted education access to to assist the MoHMS in streamlining and speeding up menstrual hygiene and gynecological services. its manual contact tracing efforts (initially, much of the effort of contact tracing relied on people’s memories of the places they went to and people they met) (Annex 6). The app has eased the work of the contact tracing team, as civil servants, private sectors, and the 70 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak Vaccination and tracking of activities in medical facilities Vaccination plays an important role in Fiji. The MoHMS used the Vaccination Registry System (VRS) to register people who have decided to get the COVID-19 vaccine. Tupaia MediTrak is an official site used by the MoHMS to update and track activities in different medical facilities in Fiji (Annex 8). 4.6.2 Public and Private Partnership Hindu temple Sri Siva Subramaniya temple in Nadi, Fiji Local Support/Partnership The government has been receiving support public have been advised to download and use the through collaboration with private companies in Fiji. app. Also, bar codes have been placed in different Support has been received for improving the health locations such as supermarkets, stores, pharmacies, information system that allows the health team to and other locations. The app had positively assisted collect and analyze data electronically instead of the MoHMS by generating mobile numbers that have manually. Further support was from the Digital FIJI come in proximity with suspected/confirmed cases of Company, which developed the contact tracing app COVID-19. It also saves time as people were able to that was used in the initial contact tracing work in the avoid filling out personal details via paper. The main Central division. challenge faced by CareFiji users was the failure of the QR scanner, as the QR scanner feature requires Telecommunication partners (such as Digicel) an internet connection to work. Although the app has have also provided support by establishing toll-free been used nationwide in Fiji during the pandemic, lines that connect patients with doctors, and the there has been no formal assessment or evaluation government has been engaging general practitioners of its effectiveness in supporting contact tracing (GP) in the Western and Central divisions (through the processes in the whole national response. COVID-19 Engagement of Private Medical Practitioner Scheme) to manage COVID-19 patients for free. Approved medical services include consultation, Swabbing review, referrals, injections, dressings, and other minor procedures. The Tamanu system has been used to track and record test results of people who have successfully been swabbed. Tamanu is a patient-level electronic Intergovernmental and International Support medical record (EMR) designed to provide support and ensure consistent management through the The government has received support from different continuum of care. countries and agencies. This includes the purchase of medical supplies (PPEs, GeneXpert machines, It is used by practitioners in Fiji to insert details of and so forth) and the release of funds (grants) to aid an individual prior to a swabbing test. The Tamanu the government in its response to the pandemic dashboard is accessed by command centers, the IMT, (Annex 29). and laboratories. Once details have been submitted, a code is generated, and this will be sent to the The Ministry of Economy received budget support individual’s code for follow-ups on their test results. of around F$430 million dollars, and, in addition to The use of this technology has prevented delays, and that, development partners such as the World Bank, it allows individuals to know their test result, rather JICA, and ADB provided concessional loans to the than going to hospitals/health centers/laboratories to government (Kumar 2022). obtain it. It has also allowed the MoHMS rapid access to timely data for analysis and decision-making. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 71 Response to Contain the Outbreak Table 15:  Software Used During COVID-19 Pandemic Response App/Software used Detail Contact Tracing CareFiji app Streamline and speed up manual contact tracing efforts. Swabbing Tamanu system Track and analyze people who have successfully been swabbed. Vaccination Registry System Vaccination Register people who have decided to get COVID-19 vaccine. (VRS) Track and monitor health status of incoming travelers who were Surveillance of incoming Surveillance Outbreak quarantined. Software is used by Border Health Unit, subdivisional travelers—if they display Response Management and medical officers (SDMOs), subdivisional health inspectors (SDHIs), symptoms of COVID-19. Analysis System (SORMAS) and HCWs who are stationed at quarantine facilities. Tracking activities in Tupaia MediTrak To update and track activities in different medical facilities. medical facilities Summary 11:  Innovation Through Leapfrogging 4.7 Measure to Contain COVID-19 With a Human Capital Perspective • ICTs have been well used during the COVID-19 pandemic, in establishing internet connection/ 4.7.1 Education networks, apps, databases, phones, and other The COVID-19 pandemic has disrupted the teaching important devices/software that were pivotal roles and responsibilities of teachers and learning during the containment and mitigation phases aspects for students. of the pandemic. In April 2020, teachers were required to report and • The MoHMS has been using Zoom calls, liaise with their heads of schools to prepare for home- webinars, other social media platforms (such as based educational activities, so that professional Viber), and email to communicate. The use of advancement and development of supportive software and apps has increased the efficiency learning resources for children were available at of health staff in terms of collating, analyzing, their home. As of May 4, 2020, parents who could and presentation of data/results (Table 15). not access online supplementary resources were advised to access resources from respective schools. The MEHA provided supplementary resources on the MEHA website, Google Shared drive, the Fiji Education Management Information System (FEMIS), and the ongoing radio programs on Radio Fiji One and Radio Fiji Two (Cowley 2020). The MEHA removed all English, Vernacular, and Test Subject project work that formed the basis of internal assessment in the school curriculum in Fiji. However, Internal Examination was to be conducted for years 1 to 8., Literacy and Numeracy Assessment for years 5 to 7, Standard Examination for years 9 to 11, and External Examination for years 12 and 13, when school resumed classes As of April 27, 2020, the 72 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak ministry has also established the WALESI Free to Air to be vaccinated to be protected and to save the Educational Channel, for children to tune into while at lives of others (MEHA 2021b). As of June 30, 2022, home (Cowley 2020, Gounder and Narayan 2021). 38,726 students (ages 15 to 17 years) have received the first dose of the Moderna vaccine, while 32,061 In 2021, the MEHA developed a digital platform to have received the second dose. For children ages 12 provide learning resources for students, and many to 14, 25,738 have received the first dose, and 15,702 schools and teachers have started using social received the second dose (MoHMS 2022a). media as a platform to provide learning resources to students (Gounder and Narayan 2021). The ministry has also launched a digital hub where parents can access work sheets for their children, and a charitable 4.7.2 Social Protection and Jobs organization that owns 21 primary and five secondary Government assistance was prioritized to assist schools, known as TISI Sangam, has established vulnerable groups of people during the COVID-19 a digital portal that pools learning resources from pandemic in Fiji. Several initiatives were established across its 26 schools to make these available to to provide income support to people who lost students on one platform (Gounder and Narayan their jobs or were on reduced hours in both formal 2021, MEHA 2021c, TISI SANGAM 2021). For students and informal sectors. The government developed who were not able to access online materials, and continued this support through social welfare teachers were able to provide hard copies of lessons payments and other social protection initiatives. and distribute these to villagers with the assistance of the village headman (known as Turaga ni Koro). Social Protection Initiatives In getting students back to school, the MEHA developed a Safe Re-Opening of Schools Guidelines. Under the social protection initiatives, the government The ministry worked with the MoHMS, WHO, and allocated funds to two groups or people: the formal UNICEF to develop standard operating procedures sector and informal sector. People in the formal sector and assessment of schools in line with COVID-19-safe included those who were unemployed and those measures. Consequently, all schools were assessed on reduced hours. The unemployed were eligible to before November 2021. In addition to that, vaccination withdraw F$220 per fortnight from their Fiji National plays a significant role in the gradual return of Provident Fund (FNPF) General Account (GA), while normality and recovery of the Fiji economy. Increase those on reduced hours were eligible for a pro rata in vaccine uptake led to the easing of COVID-19 payment based on the number of days they were not restrictions such as the lifting of border closures in working. Those who did not have enough money in containment areas, easing of curfew hours, and the their GA were accommodated by the government. increasing number of people at social gatherings A total of F$432.3 million was paid out to more than and has allowed the opening of schools around Fiji. 400,000 Fijians since the start of the pandemic Classes resumed for years 12 and 13 on November 1, (March 2020) to July 2022, of which F$205 million 2021, and the MEHA realigned school curriculum to was topped up by the government on the members’ ensure that students who sat for external exams were FNPF General Account (GA)—under the COVID-19 able to proceed further to tertiary studies. Unemployment Scheme18 (Figure 31), and F$227.3 million was paid directly by the government in direct Classes for Early Child Education (ECE) to year 7 cash assistance through M-PAiSA and MyCASH started on February 7, 2022, and classes for years 8 mobile wallets (one round of F$90, two rounds to 11 began on January 4, 2022. For ECE, the MEHA of F$50, two rounds of F$360, and one round of established a technical working group to assist in the F$100)19 (Figure 32). development and implementation of the ECE program in Fiji (MEHA 2021a). Vaccination is not mandatory for students; however, the MEHA encourages students 18 https://www.economy.gov.fj/images/Budget/budgetdocuments/supplements/2022-2023_Budget_Supplement_final.pdf 19 https://www.economy.gov.fj/images/Budget/budgetdocuments/supplements/Budget_Supplement_2021-2022_Web.pdf Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 73 Response to Contain the Outbreak In the FY2021/2022 budget, the government increased the unemployment support by increasing the funding allocation by F$200 million. In the FY2021/2022 budget, the government of F$360 occurred in August 2021 to cater for three increased the unemployment support by increasing months until October 2021. However, this assistance the funding allocation by F$200 million. People was only available to people who received the first with sufficient GA balances in their FNPF continued dose of the COVID-19 vaccine. The second payout with the monthly withdrawal of F$220 and pro rata of F$360 was done in November 2021, to cater for assistance for those on reduced hours. People with the three months ending January 2022; and those insufficient GA balance and those affected in the who had received the first and second doses before informal sector were assisted by the government in October 31, 2021, were eligible to apply for further the initiative, where the payout of F$120 per month government assistance. This strategy boosted was made for a period of six months. The first payout vaccine uptake around the country. Figure Figure 31: 31:  Government Government Assistance Assistance to the to the Formal Formal Sector Sector. 25,000 21,457 Number of People Assisted (n) 20,000 15,000 13,548 13,491 11,513 10,000 8,855 5,000 0 Less than $500 $501 - $2,000 $2,001 - $3,500 $3,501 - $5,000 More than $5,000 Range of Assistance ($) Number of people assisted Government top on Members GA: Disaggregation by Sex FJD $205 million Males 38% Females 62% Source: Republic of Fiji 2021b 74 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak Figure 32: Government Assistance to the Informal Sector Figure 32:  Government Assistance to the Informal Sector 350,000 300,000 294,924 Number of People Assisted (n) 250,000 241,347 224,000 205,000 200,000 150,000 118,000 100,000 50,000 19,526 2,501 0 Round 1 Round 2 Round 3 Round 4 Round 5 Round 6 Round 7 ($90) ($50) ($50) ($360) ($360) ($100 - ($100 - Vanua Levu Taveuni, Qamea Assistance) and Rabi Assistance) Range of Assistance ($) Number of people assisted Round 1 - FJD $10.6 million (May, 2021) TOTAL - Round 2 - FJD $11.2 million (Jun, 2021) Direct Cash Assistance: Detail of Government Round 3 - FJD $10.2 million (Jul, 2021) Assistance Round 4 - FJD $106 million (Aug - Oct, 2021 FJD $227.3 million Round 5 - FJD $87 million (Nov, 2021 - Jan, 2022) Round 6 and 7 - FJD $2 and $0.26 million (Jun - Jul, 2022) Source: Republic of Fiji 2022. Social Welfare Support The government continued to support more than 130,000 Fijians through the social welfare scheme of F$145.5 million. Table 16 presents the details of the subsidy: Table 16:  Social Welfare Schemes Support FJD ($) Million Detail Supported more than 40,000 elderly Fijians above the age of 65. Receive Social Pension Scheme 55.3 monthly payment of F$100. Supported more than 20,000 people who are poor and vulnerable. Consists of Poverty Benefit Scheme 36 a monthly cash transfer ranging from F$35 to F$127, and F$50 food voucher. Disability allowance 10.8 Given to people with disability. Monthly payout of F$90. Child Protection Allowance 11.3 Supported vulnerable children. Bus Fare Support 5 Bus fare support for the elderly and disabled persons. Monthly top- up of F$10. Food Voucher 1 Food voucher for rural pregnant mothers. Source: Republic of Fiji 2021d Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 75 Response to Contain the Outbreak Other government Initiatives that were provided during COVID-19 are described in Table 17. Table 17:  Other Government Assistance Support FJD ($) million Detail Family households with income less than F$30,000 were assisted through this subsidy. Government provided a subsidy of 16.34 cents per unit for the first 100 kwh of Electricity and electricity. The subsidy has assisted more than 50,000 households. 11 Water Subsidy Government also assisted people earning less than F$30,000 by establishing the Free Water Initiative. More than 30,000 households were assisted under this initiative. Stronger Together Scheme was provided to assist and create jobs for people in the informal sector and Job Support 12 those who have lost their jobs. Around 48 employers have been engaged and 831 new Scheme and Jobs jobs have been created. for Nature Supply of food to Government provided household food packs to Fijians who have been isolated/ those in quarantine 12 quarantined after being suspected of having COVID-19 or have tested positive. or Isolation Access to Established to lighten patient load and risk at public hospitals and at the same time Private General 5 ensures that Fijians are not deprived of essential medical care. Seventeen GPs were Practitioners (GPSs) involved in the initiative. Government paid out F$2.6 million (full market stall fees) to cater for permanent and Stall Fees/ Fishing temporary market vendors. F$200,000 was allocated to pay the full fishing license 2.9 Fees fees for two years, and an additional F$100,000 went to pay the fees for training and certification of seafarers. Government allocated F$11 million to waive accidents levy charge for 12 months. This includes buses, taxis, minibuses, rentals, carriers, and private vehicles. F$2.5 million Support for allocated to assist public transportation providers to pay the base fee or entry fee paid 13.7 Transportation to the municipal councils by taxis, minibuses, carriers, and omnibuses for one year. An additional F$0.2 million was allocated to pay Public Service Vehicle (PSV) drivers’ license fee and defensive driving course fee for all those needing renewal. Provision of sanitary Government provided sanitary pads to female students in year 7 to year 13 (Forms 1.5 pads 1–7). Over 55,000 females were expected to be assisted. Source: Republic of Fiji 2021d Self-employed/small-to-medium and microfinance Table 18:  Concessional Loan Funding for Micro, Small, enterprises and Medium Enterprises (MSMEs) To support businesses during the challenging Maximum % of Loan times, the Fiji government was able to provide Category Annual Turnover Loan Limit Guarantee unemployment support with concessional loan Micro Less than 50,000 $10,000 90 funding for micro, small, and medium enterprises (MSMEs) (Republic of Fiji 2021d). MSMEs are defined $50,001 to Small $20,000 85 according to their concessional loan eligibility as $300,000 described in Table 18 below: $300,001 to Medium $50,000 80 $1,250,000 Above Large $100,000 75 $1,250,000 Total Available Funding $200 million Interest rate 3.99 percent Source: Republic of Fiji 2021d. 76 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Response to Contain the Outbreak Apart from this, loan repayment holidays were interest rate financing through the Reserve Bank of provided to both businesses and personal customers. Fiji (RBF) were made available to businesses (see Other forms of cash flow relief including deferment Table 19). of tax payments, targeted wage support, and low Table 19:  Assistance Provided by Fiji Government During COVID-19 Pandemic Scheme Total Budget Explanation FJ$200 million facility was available to meet people’s operational COVID-19 recovery credit FJ$200 million needs, including payment of wages and salaries, rental costs, utility guarantee facility bills, purchase of stocks and other working capital requirement, Under this scheme, employers were guaranteed a wage subsidy Stronger Together Job by Government equivalent to the minimum wage rate of $2.68 an FJ$1 million Support Scheme hour for three-month period when they employ eligible Fijians, in particular those in the informal sector. Government partnered with the Fiji Institute of Accountants (FIA), the Fiji Chambers of Commerce and Industry (FCCI), the Fiji Commerce and Employers Federation (FCEF) and Women in Business (WiB) for Business Assistance Fiji FJ$250K assessment and disbursement of the concessional loan to MSMEs. Grant FJ$250,000 was allocated to provide training and advisory services to assist MSMEs with the newly announced COVID-19 Recovery Credit Guarantee Scheme. To support local exporters, Government paid Biosecurity Authority of Bio-security Fee for FJ$1 million Fiji (BAF) fees on all exporters for 12 months effective from 1 August Exports 2021. Government paid stall fees for all market vendors (both permanent Stall Fees for Market casual) in Fiji for one year, effective from 1 August 2021. Fiji has FJ$2.6 million Vendors around 7,800 market vendors and total stall fees collected by City Town Councils totaled around FJ$2.6 million per year. Base Fees for Taxis, Government paid base fees for taxis, minibuses and carriers and Minibuses, Carriers and FJ$2.5 million sand fees for Omni buses for one year effective from 1 August, 2021. Stand Fees for Omni Around 8586 permit holders were assisted buses Government paid inshore fishing licensed (mooring license book fees, etc.) and other associated MSAF fees for the local fishing Inshore fishing license FJ$200K industry for the next 2 years for the benefit of all fishing license and MSAF fees holders and registered boat owners with an allocation of $200,000. This benefitted more than 3,000 license holders and boat owners Source: Republic of Fiji 2021d. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 77 Response to Contain the Outbreak Traditional houses of Navala village, Viti Levu island 4.7.3 Water, Sanitation, and Hygiene To ensure that basic hygiene standards were (WASH) maintained in the urban areas, the Suva City Council (SCC) installed hand sanitizers at the Suva bus stand, There is still an important gap in the delivery of water decontaminated and fumigated public domains such supply and sewerage services (Cowley 2020). Most as the Suva bus station, Suva Municipal Market, and urban areas have access to piped water, while more retail outlets, and is now extending its efforts to the than half of the rural population still lacks it. minimarkets. The Water Authority of Fiji (WAF) is the implementing agency responsible for sanitation and provision of clean water across communities. Summary 12:  Human Capital Perspective Tasked with implementing over 60 percent of the • The MEHA switched to digital learning WASH strategy, the WAF has focused on improving platforms, and support was provided to WASH facilities by providing septic tanks and access students who were not able to access to wastewater treatment at the Kinoya Treatment the internet. Plant. The WAF is also working with the Town Country Planning and the RISE (Revitalizing Informal • The government assisted two vulnerable Settlements Environment) project to further improve groups of population during the COVID-19 on this. Through its Ecological Purification System pandemic. The government allocated (EPS) program and the installation of chlorine tablets F$200 million to the unemployed at water sources, the WAF has provided clean water vulnerable groups, and F$145.5 million to to rural communities prone to contamination. the socially vulnerable groups. The RISE project team is working in partnership with • Businesses were also supported as the UN-Habitat and Fiji government agencies to provide government provided support through rapid response support to more than 70 informal concessional loan funding for MSMEs. Loan settlements to help alleviate the impacts of COVID-19 repayment holidays were also provided on these households (RISE 2020a) They worked with to businesses and customer service council health inspectors to visit settlements to hand personnel, and there were deferments out information and education materials on practicing of tax payments, targeted wage support, social distancing, for those living in communal and low-interest rate financing through the housing, and on how to wash one’s hands regularly, Reserve Bank of Fiji (RBF). despite having little or no running water (RISE 2020b). 78 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji 5. Covid-19 Impact on Uhc and Sustainability COVID-19 IMPACT ON UHC AND SUSTAINABILITY 5.1 Service Coverage 5.1.1 UHC index According to the WHO, at least half of the world’s population does not receive proper health services, and approximately 100 million people suffer extreme poverty due to out-of-pocket payment on health (WHO 2022d). The health status in Fiji and other Pacific Island countries has improved substantially in the last 20 years; however, progress has been slower compared to that of other countries (Kate 2019). The setback is caused by multiple factors such as intense tropical cyclones (location of country is vulnerable Fijian child visit his home destroyed by Severe Tropical to such disasters), continuous outbreak of arboviral/ Cyclone Winston in 2016 in the Yasawa Islands. zoonotic diseases, and increase in incidence of noncommunicable diseases. These factors have index (SCI) reported in 2019, Fiji scored the highest strained the Fiji government-resourced health in reproductive, maternal, newborn, and child systems (Kate 2019). health (RMNCH with 80 points, and the lowest in noncommunicable diseases with 39 points (Figure Data has shown that Fiji’s UHC index continues to 33). In comparing the UHC indexes among the Pacific slowly improve/increase since the year 2000, with Island countries in 2019, Fiji recorded the highest one, the country placing at 61 in 2019, 59 in 2017, 58 in with 61 points, followed by Tonga and Samoa, and 2015, 56 in 2010, 53 in 2005, and 45 in 2000. Out with the lowest one recorded by Papua New Guinea, of the four UHC services in the services coverage with 33 points (Figure 34). Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 79 Figure 33: Covid-19 UHC Impact Service on Index- Uhc and Fiji (2000 – 2019) Sustainability Figure 33:  UHC Service Index—Fiji (2000 to 2019) 90 78 79 80 80 80 80 80 Universal Health Coverage (UHC) 70 67 66 62 61 63 61 58 58 59 60 56 56 51 53 53 51 52 49 47 50 45 37 40 39 39 40 30 19 20 10 0 2000 2005 2010 2015 2017 2019 UHC Service Coverage Index RMNCH Infectious Disease Non-Communicable Diseases Service Capacity and Access Source: WHO, Global Health Observatory Data Repository The decrease in the UHC services index (from and noncommunicable diseases. These factors 2015 to 2019) is attributed to the impact caused by have strained the Fiji government-resourced health five intense tropical cyclones in the last five years, systems (Kate 2019). continuous outbreak of arboviral/zoonotic diseases, Figure 34: UHC Services Index- Middle Income countries in the PICTs (2019 Figure 34:  UHC Services Index—Middle-Income Countries in the PICTs (2019) Universal Health Coverage (UHC) Tonga Samoa Vanuatu Fiji Solomon Islands Papua New Guinea UHC Service Coverage Index RMNCH Infectious Disease UHC Service Coverage Index Service Capacity and Access Source: Global Monitoring Report, WHO, and WB 80 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Covid-19 Impact on Uhc and Sustainability Fiji is among the most at risk in the Pacific countries in terms of global economic contraction caused by COVID-19. 5.2 Impact of COVID-19 on the Use of provided by the MoHMS. These theories were Health Services derived from religious/traditional beliefs that inform behaviors. As an example, in Fiji, the public prefers The COVID-19 pandemic has had widespread to use herbal medicines and religion rather than impact on services provided to the public. First, the medical treatment at hospitals. Furthermore, the new enforcement of lockdowns and establishment of standard operating procedure for patients visiting containment areas restricted movement of public emergency centers/GOPD/SOPD also affected the service vehicles such as taxis, buses, and other delivery of health services. The process stipulated vehicles, as well as water transport modes such that patient need to be screened first at fever clinics as small punts, boats, and bigger vessels. This has before entering those units. This process has meant also contributed to the difficulty in accessing health long waiting times in line. As a direct result, patients services. For instance, health programs such as are anxious about standing in line and have returned immunization and mass drug administration were home without receiving the essential treatment altered during this period as health workers had they need. to locate children by visiting their homes. Second, because many health professionals were out in the The “No Mask, No Entry” policy also influenced field or sick from the infection, many hospitals’ SOPD access to health services. In the maritime zones, clinics were closed and surgeons were not able to health workers noticed that villagers were not wearing do elective surgery (numbers on surgical waiting list masks because they either could not afford them or increased), with only emergency services functioning. because rural areas had not been supplied with the Some dental procedures were not available, because same. However, only people with masks were able to of the risks of aerosolization of the COVID-19 virus in access the nearest health and non-health facilities. the atmosphere. Third, the pandemic has had an impact on people’s 5.3 Financial Protection income. As people lost their jobs or experienced reduced working hours, they had little or no earnings Fiji is among the most at risk in the Pacific countries at all. Hence, diets and nutritious food choices have in terms of global economic contraction caused by been compromised and visits to health facilities COVID-19. Most health systems in the Pacific are forgone as these have become costlier. Fourth, government funded, while others are sourced from fear of the disease and its transmission also had an donor agencies and from households’ out-of-pocket impact on accessing health services. Healthy people financing. The Fiji National Health Expenditure report are afraid to visit health clinics and other non-health showed that almost 60.2 percent of Fiji government services because of the risk of contracting the virus. health expenditure is government funded Also, people tend to believe various conspiracy (expenditure from 2011 to 2015) (MoHMS 2017). theories, which tend to hinder the uptake of services Hence this should not expose people to financial hardship or threaten their living standard Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 81 Covid-19 Impact on Uhc and Sustainability (Ibid). However, Ruest and Tandon (2020) stipulated Summary 13:  COVID-19 Impact on UHC and that the impact of COVID-19 on health financing Sustainability will depend on the extent, duration, and severity of the economic contraction and it will also influence • Fiji’s UHC index was at 61 in 2019, with RMNCH government revenue and borrowings (Ruest and having the highest coverage, followed by Tandon 2020). Fortunately, most countries in the infectious disease, service capacity and access, Pacific Islands were prepared for the pandemic, and finally noncommunicable diseases with the and resources (financial and human) were mobilized least coverage. specifically for COVID-19. In Fiji, the government • In the Pacific Islands Countries and Territories announced a COVID-19 response budget, valued at (PICTs), Fiji scored the highest with 61 points, F$1 billion dollars, where F$40 million were allocated followed by Tonga, Samoa, and Papua New to the MoHMS (MOE 2020). Further, health resources Guinea with the least. have been made available through the support of development partners such as the WHO, SPC, and • COVID-19 has hindered the usage of medical many others, and indications show that ongoing facilities and access to health personnel. support will depend on the revenue and economic Reasons for this include the restricted impacts of COVID-19. Out-of-pocket payment has also movement of public service vehicles due to been affected due to lower use of health services and enforcement of lockdowns and establishment lower household incomes.20 of containment areas, lack of health specialists/ professionals when they are out sick or working out in the field, and the suspension of 5.4 Financing for Vaccination certain medical procedures due to the risk of transmitting the COVID-19 virus. Securing COVID-19 vaccines has been equally important for the Pacific Small Island Developing • Fiji’s health system is primarily government States (PSIDS), as the devastation caused by funded, with some support from donor COVID-19 has spared no country in the world. Fiji agencies and household out-of-pocket and other small island countries were able to secure financing. During the pandemic, the batches of COVID-19 vaccines through working with government announced a COVID-19 response the WHO and the COVAX facility. Vaccines used in budget, valued at F$1 billion dollars, where Fiji have been donated by the COVAX facility and F$40 million was allocated to the MoHMS, other countries such as Australia, India, New Zealand, and support has also been received from and many others (Table 14). The Fiji government development partners such as the WHO, SPC, has administered more than a million doses of the and many others. COVID-19 vaccines. 20 https://www.who.int/health-topics/financial-protection#tab=tab_1 82 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji 6. Lessons Learned and Key Takeaways for Other Countries LESSONS LEARNED AND KEY TAKEAWAYS FOR OTHER COUNTRIES Fiji managed the first and second waves of the measures were not just in place, but also COVID-19 pandemic effectively and demonstrated monitored and adhered to, enabled the several good practices that resulted in successful country to enjoy early success in 2020. mitigation, preparedness, and response and that Also, given that the borders were not closed may be adopted by other countries. The government to returning citizens, an effective border pushed up its response as the number of cases quarantine facility system was important. increased during the second wave. Some of the best 6.1.4 The role of the Fiji CDC in facilitating good practices are described below: testing capacity led to the early detection 6.1 CONTAINMENT PHASE of cases, which prevented the direct transmission of the virus to the community. 6.1.1 Early formation of the Incident Management Initially, testing for COVID-19 was only Team (IMT) was important for the coordination done at the Fiji CDC laboratory, Mataika of the whole-of-government response. The House, Tamavua. Testing was decentralized, IMT is responsible for the implementation of implemented across the country as GeneXpert the COVID-19 Preparedness and Response machines kits became available. As demand Plan (COVID PRP). for testing increased, private laboratories later 6.1.2 Early activation of FEMAT was critical to came on board with testing. ensure a continuum of health services 6.1.5 Intensive testing, contact tracing, and timely delivery during the pandemic. FEMAT moved treatment are important in preventing further in to treat cases that hospitals would normally spread of infection. Through support and treat during the pandemic. aid from different countries’ governments, 6.1.3 Early closure of borders and strict private organizations/ companies, and donor implementation of border control measures agencies, the Fiji government was able to helped keep the COVID-19 virus out of the obtain and use the GeneXpert machines country. Fiji was successful in keeping out the and use the CareFiji App as a complement COVID-19 virus through quick containment to traditional contact tracing methods. These of the few cases that were found in the enabled health workers to track and test for community between March and April 2020 primary and secondary contact in a short and prompt closure of its air and seaports. period of time. Ensuring that these border restrictions and Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 83 Lessons Learned and Key Takeaways for Other Countries 6.1.6 Streamlining alignment and focus of the 6.1.9 Dispatching of the MoHMS Mobile Response national pandemic response, mainstreaming Unit was vital in the MoHMS response to WHO guidelines, and adopting international COVID-19. The unit went from house to house standards to suit local context in the national to locate patients who had tested positive planning, strategy, and policy are very for COVID-19. The chain of command began crucial. The MoHMS has closely followed with the receipt of information from the Fiji recommendations from the WHO and other CDC laboratory to the Risk Assessment Team, international practices to inform its actions then to the FEMAT, and finally to the Mobile as necessary. For example, to meet WHO Response Unit. standards, a validation exercise was carried out on the testing facilities, protocols, and strategies used by the Fiji CDC, during the 6.2 MITIGATION PHASE containment and mitigation phases of the 6.2.1 ICT applied to track COVID-19 infections outbreak. Fiji also recognized the role of and vaccine uptake in real time is useful in airborne transmission earlier than officially informing decision-making. ICTs have been embraced by the WHO. The government well used during the pandemic, especially involved international academic institutions in the new norm of working from home (such as the University of Melbourne) to assist (connection is vital) and with the daily updates and inform the country of the protocols to take of COVID-19 infections and vaccines. The during the pandemic. MoHMS staff appreciated the efficiency and 6.1.7 Publicizing of cases using spot maps was effectiveness of technologies and new apps, critical in informing people about the location as data collected was analyzed and made of cases and to prevent the spread of the available in a short period of time. Hence, virus. To prevent the spread of the virus, the the MoHMS executives were able to make MoHMS used spot maps to inform people on decisions based on this data, and the public the location of cases. was able to view the trends of infections and 6.1.8 The establishment of the Border Health vaccines through the MoHMS daily updates. Protection Unit was critical in the response 6.2.2 The use of incentives has been effective in to the pandemic. Fiji did not close its borders boosting vaccination coverage in Fiji. The to returning citizens, and the Border Health COVID-19 pandemic has driven people to Protection Unit was formed to manage seek financial support. Hence the government inbound passenger quarantine. The unit introduced a series of initiatives in the form includes personnel from the health , military, of incentives. The eligible applicants had and other agencies. There was no quota for to be 18 years of age and older and should the return of citizens to Fiji (unlike in countries have received the first and second doses of like Australia and New Zealand)—this was the AstraZeneca or Moderna vaccine. The essentially dependent on flight schedules. And vaccination coverage is reported to have citizens were not restricted from leaving Fiji. increased during the period that incentives Citizens were free to return if requirements were provided. for testing and quarantine were met. They 6.2.3 Retaining the trust of community institutions managed to keep out the Alpha, Beta, and all and leaders (especially religious leaders and other variants for an entire year since the last health care professionals) was pivotal in the community case in April 2020. The Delta was government’s success in combating COVID- the only variant that made its way through in 19. Leaders and health care professionals April 2021. play an important role in the acceptance of an intervention in a community. This was 84 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Lessons Learned and Key Takeaways for Other Countries evident, as most religious leaders in Fiji helped  ONTAINMENT AND MITIGATION 6.3 C disseminate vaccine acceptance messages to PHASES many communities in the country. In addition, health experts have been conducting panel 6.3.1 The development of a remodeled framework discussions in English, Hindi, and I-Taukei toward a remodeled health services provision to transmit information to the wider public. structure was crucial during the pandemic. Social media platforms such as Facebook and The MoHMS was able to look at: software such as Zoom have also been used. 6.3.1.1 Decentralization of Services—Services 6.2.4 Aggressive risk communication during the were decentralized from the main second wave was conducted to combat divisional hospitals to the subdivisional vaccine hesitancy. Social media platforms hospitals, health centers, and further down such as Facebook and Viber, as well as Zoom the hierarchy. calls, were used to get information out to the 6.3.1.2 Integration of Services—Prior to COVID- public. Panel discussions were conducted 19, there was limited interaction between between academia and health experts in Fiji clinical and public health services. and other countries. Discussions were also Integration improved services where carried out in I-Taukei and Hindi. health professionals provided both clinical 6.2.5 Establishment of the Pre-Hospital and public health services to patients. Coordination Care Centre (PHECCC) and 6.3.1.3 Increasing Outreach—Outreach services the MoHMS Oxygen Unit were critical during at all facilities were increased—that is, the pandemic. These were components of from tertiary to primary levels—to ensure the Care Flow Pathway, which was critical in easy accessibility and also to standardize bringing down death rates during the second care across all levels. This also addressed wave of the pandemic in Fiji. The PHECCC how to maximize the role of CHWs in strengthened the country’s health system providing information and basic care at the during the pandemic. People who were in community level. severe distress at home were able to reach a hospital through the deployment of ambulance 6.3.2 Timely and well-coordinated management services. As cases increased, so did demand plans are critical during a health crisis. This for oxygen. Hence, through the operation of helped in the mitigation and response to avoid the oxygen unit, the MoHMS was able to meet delay and use all opportunities, leading to daily needs. improved cost-efficiency and/or solutions to problems. 6.2.6 The government’s varied vaccination locations enabled the successful vaccination 6.3.3 The whole-of-government approach, of more than 90 percent of Fiji’s population. involving stakeholders from the government, The health ministry established drive-through private sectors, and local and international vaccination facilities. In addition, mobile nongovernmental organizations, combines vaccination drives were set up at identified in important tools in the fight against COVID. This health centers, schools, and village/community includes the Fiji Military and Police Forces, who halls. For people living in the interior of Viti were engaged in enforcing nonpharmaceutical Levu, health personnel worked with community interventions. health care workers and Turaga ni Koro to 6.3.4 Continuous capacity developments at the locate and vaccinate people. institutional, legislative, and individual levels were critical in the overall understanding of the preparedness and mitigation process in order to ensure trust. The coordination of activities requires engagement at a practical level with the different stakeholders in local government administrations. This facilitated capacity-building activities related to Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 85 Lessons Learned and Key Takeaways for Other Countries Fiji’s health care system allowed everyone to access health services for free without any burden during the pandemic. strengthening and improving administrative Development Bank, New Zealand Ministry and operational management, service delivery, of Foreign Affairs and Trade (MFAT), Korea and improved transparency and accountability International Cooperation Agency (KOICA), and toward constituencies. many others provided support in the form of cash assistance, equipment, and infrastructure. 6.3.5 Fiji’s health care system allowed everyone to Countries such as Australia, New Zealand, access health services for free without any China, Japan, India, and many others assisted burden during the pandemic. Unlike in several Fiji during the pandemic. other countries, Fijians were able to access free services during the pandemic. 6.3.8.1 Support from civil society organizations (CSOs) enabled the MoHMS to battle 6.3.6 MoHMS established mental health and through the pandemic. The MoHMS psychosocial services for its workers. The partnered with CSOs including Medical pandemic has placed tremendous burden on Services Pacific (MSP), the Reproductive & health workers. This was evident during the Family Health Association of Fiji (RFHAF), second wave of the COVID-19 outbreak, as the Fiji Red Cross Society, and many workers had to be away from their homes for others in ensuring that daily deliverables nearly four to five months (due to continuous were operationalized during the pandemic. work shifts). To monitor safety and well-being Support ranged from human resources to of health workers, the MoHMS was able to use of equipment and facilities. provide mental health and psychosocial support. 6.3.8.2 Arrival and contribution of AUSMAT and NZMAT Teams boosted morale 6.3.7 Good leadership was a prominent factor in and services delivery. They were able the fight against COVID-19. The Hon. Prime to convert non-COVID-19 facilities into Minister, together with other resident ministers COVID-19 facilities and facilitated the (whole-of-government approach), worked to correct use of PPEs. contain and mitigate the impacts of COVID- 19. Government ministries also worked with 6.3.8.3 Decentralization of workload has enabled technical agencies, tertiary institutions, and health workers to battle through the CSOs. containment and mitigation phases of the COVID-19 pandemic. With the 6.3.8 Full support from bilateral partner countries, increasing number of cases in the Central technical agencies, private organizations/ and Western divisions (especially from nongovernmental organizations, and June to August 2021), the MoHMS was communities enabled the MoHMS to able to decentralize services to avoid function effectively during the pandemic. burnout among health workers. For Agencies such as the WHO, DFAT, UNICEF, instance, during the first wave, the Fiji the European Union, World Bank, Asian CDC was the only facility used to test 86 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Lessons Learned and Key Takeaways for Other Countries COVID-19. However, as the number of 6.4 OTHER LESSONS LEARNED cases increased (due to community transmission), testing capacity increased 6.4.1 Continuous development of the surveillance and the GeneXpert machines were sent to system is pivotal in improving the health different areas in Fiji. Other health services system. The MoHMS continues to develop such antenatal care (ANC) clinics were and extend its surveillance system to the provided by civil society organizations community level. As part of the primary health (CSOs) such as Medical Services Pacific care approach, the MoHMS established and the Reproductive & Family Health community-based surveillance around Fiji’s Association of Fiji (RFHAF) to assist the four main divisions. Community health care MoHMS. workers are being trained to recognize and report symptoms of diseases or unusual 6.3.9 The MoHMS continued to train the health events. workforce on how to read, understand, and translate COVID-19 data. With support from 6.4.2 The pandemic has highlighted the dominance Fiji National University, workshops on data of the traditional communal lifestyle of the entry, analysis, and translation were conducted I-Taukei. Solesolevaki (communal gathering) among health care workers. and the need to do things communally—for example, gathering communally for traditional 6.3.10 The existence of toll-free helplines was events and rituals, deaths, weddings, and critical during the pandemic. The pandemic all religious events—were evident during has caused the absence of personnel from the pandemic and boosted transmission their offices, due to work-from-home initiatives/ of infection. Some of these events were lockdowns; thus people were resorting labeled super spreaders, such as the funeral to helplines (158) to ask for directions/ in Lautoka (Western division) that preceded information/assistance regarding vaccination, community transmission into the Central screening clinics, domestic repatriation, division at the beginning of the second wave. government financial assistance, and so forth. Toll-free line 165 was a pre-hospital care 6.4.3 Youth ages 18 to 33 years were identified as hotline. the most vulnerable population in terms of policing during the pandemic. 6.3.11 The strengthening of Fiji’s legal system helped address prominent issues during the pandemic. The establishment and enforcement of the “No Jab, No Job” policy, while controversial, has encouraged uptake of COVID-19 vaccines, and the mandate of the Public Health Infringement Notice contributed to the enforcement of nonpharmaceutical interventions. 6.3.12 The peak of cases for each health division and maritime zone occurred at different times. This allowed time for the MoHMS to mobilize and move health staff to affected areas. 6.3.13 The government continued to publicize daily COVID-19 updates on the health ministry website. People were being informed on the number of COVID-19 cases, hospitalizations, and deaths. Separate sections were publicized for vaccination and testing. In addition to that, the government responses/ interventions were also announced in this setting for the public’s attention. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 87 Drawaqa Island coastline and Nanuya Balavu Island, Yasawa Islands, Fiji Preparedness Recommendations 7. PREPAREDNESS RECOMMENDATIONS The COVID-19 pandemic has raised a few key as Zoom meetings and webinars led by Fiji legal issues for the ministry and the nation in their National University (Explain the Science), response. The same issues were raised as concerns provincial discussions, and the use of health to be addressed in HEADMAP 2013, as follows: experts from international academic institutions in public fora. 7.1 The development, adoption, and exercise of a national collaborative whole-of-government 7.5 Training and pilot testing should be framework that coordinates and synchronizes conducted to support staff members who are the various ministries’ action plans to achieve handling new software in data entry (as some a common response and goal are important data was not entered or has gone missing). when responding to future pandemics. 7.6 The health information system needs to be 7.2 The government and the MoHMS must upgraded and digitized, for access to timely develop and adapt a messaging framework health information. to counter misinformation, because social 7.7 The government should plan and develop media plays an important role in transmitting management systems on quarantining information on COVID-19 and its vaccine. returning Fiji citizens and health care workers 7.3 Guidelines must be developed to prevent during a health crisis, as this can become a abuse and exploitation of office when huge financial burden for the country. During non-health personnel are selected to assist the pandemic, the MoHMS heavily relied on during a pandemic response. This is in hotels to quarantine returning Fiji citizens response to the issue of vaccination cards and its health care workers. As the pandemic having been given to people who were progressed, schools, community halls, and not vaccinated—which was a breach of national arenas were opened to accommodate government policies and guidelines relating to citizens who were infected. uptake of COVID-19 vaccines. 7.8 Wastewater surveillance needs to be 7.4 Awareness is an effective tool to prevent developed, maintained, and regularly hesitancy. Uptake of vaccines has been monitored by the Water Authority of Fiji a controversial issue in most places, and (WAF) and allied partners. For early warning, fortunately Fiji was able to combat this through detection, and prevention of viral/bacterial stringent government measures and policies, diseases, wastewater surveillance needs to be awareness sessions using ICT tools such developed and maintained. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 89 Preparedness Recommendations 7.9 The switch from containment to mitigation 7.16 Psychosocial support through individual or phase should have been done earlier. To group counseling and training is critical to transit from one strategy to another takes a provide respite for health care professionals while, hence there is a need to begin changing and to continually motivate them to provide phases/ strategies early so that by the time services when they are dealing with lack of peak is reached, HCWs can manage the time, fatigue, and constant threat of infection. change effectively. During the containment 7.17 Clear policies and protocols should be in phase of the COVID-19 outbreak, the MoHMS place for data sharing between ministries reached a stage where it had exhausted during a pandemic. Information should its resources in pursuing containment of be shared between ministries during a transmission in the community, hence clinical pandemic—as the culture of protecting teams were called back to hospitals to one’s own turf (gate keeping) is still alive manage the expected wave of cases with within the ministries and is a barrier to severe disease. The testing policy was also effective responses. COVID-19 has illustrated changed (because mass testing and contact the importance of collaboration between tracing were no longer possible based on case government ministries. Hence, gate-keeping numbers and lab staff shortages, swabbers attitudes must be addressed for each ministry. and contact tracers were beyond capacity and exhausted). 7.18 More research is needed to determine cause of vaccine hesitancy among HCWs in Fiji. 7.10 Strengthening of Infection Prevention Control HCWs are the key people in health crisis (IPC) is critical during a health crisis. Due to response and should support any intervention the higher potential for contracting the virus introduced by the government with the among health professionals and non-health intention of benefiting the public. frontliners who help during such a response, it is important to strengthen IPC. 7.19 Dissemination of correct and reliable information by HCWs is critical to ensure full 7.11 Proper management of PPEs, from their cooperation by the public during a health procurement to their waste management, is crisis. very important. 7.20 Online capability training should be 7.12 Contact tracing for moderate- and low-risk conducted for health care workers and other groups can be done by non-health assistants. non-health ministries. During the COVID-19 7.13 The MoHMS should continue to develop, outbreak, many people were required to work strengthen, and use the Remodeling from home and connect via internet, thus Framework even after the pandemic training on the use of communication software such as Zoom, Teams, webinars, and many 7.14 The government should expand telehealth, others is critical to ensure continuous flow of telemedicine, and online learning into all work. health disciplines in the country through the provision of virtual platforms for engaging 7.21 A switch to digital learning platforms and patients. support for students without access can be replicated in future shocks or as an option for 7.15 There is a need for processes that clearly education (MEHA). define and demarcate when an event is a health issue and when it becomes a national 7.22 The COVID-19 Engagement of Private security issue. Medical Practitioners Scheme is a model that can be replicated in natural disasters, future pandemics, and other crises, ensuring that routine health services continue to be provided. 90 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Annexes ANNEXES Description Annex No. Page Numbers Link Alert Levels for COVID-19 Action Level 1 action: pages 22–25 Level 2 action: pages 26–27 1 Level 3 action: pages 28–29 https://www.health.gov.fj/wp-content/uploads/2020/08/COVID-19-Fiji-Preparedness-and-Response-Plan-2020. pdf The Local Government System in Fiji Distribution of councils and population: page 69 2 Summary of service provision in different spheres of government in Fiji: page 72 http://www.clgf.org.uk/default/assets/File/Country_profiles/Fiji.pdf COVID-19 Update: cases, deaths, and vaccination Cases and Deaths October 11, 2021—Link 1 (L1) September 25, 2021—Link 2 (L2) September 5, 2021—Link 3 (L3) 3 Vaccination October 20, 2021—Link 4 (L4) L1- https://www.health.gov.fj/11-10-2021/ L2- https://www.health.gov.fj/25-09-2021/ L3- https://www.health.gov.fj/03-09-2021/ L4- https://www.health.gov.fj/20-10-2021/ Health Emergencies and Disaster in Fiji See subheading: Cluster Approach to Disaster Management; flow diagram is under the topic: Fiji National 4 Disaster Management Clusters https://www.health.gov.fj/health-emergency-disaster-management/ Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 91 Annexes Description Annex No. Page Numbers Link List of Key Informants Interview Organization/Ministry/Agency Numbers Position Date of Interview Water Authority of Fiji 5.1 Chief Operating Officer for the Water Authority of Fiji August 13, 2021 Water Authority of Fiji 5.2 Acting Manager for Laboratory and Water Treatment, Water Authority of Fiji August 13, 2021 Police Director Strategic Planning, Policy, Research & Development Division, 5.3 Fiji Police Force August 13, 2021 Ministry of Economy 5.4 Head of Budget and Planning, Ministry of Economy. August 13, 2021, MoHMS 5.5 General Manager COVID Response Unit, MoHMS 5 September 16, 2021, MoHMS 5.6 Chief Health Inspector, MoHMS September 16, 2021, Ministry of Women 5.7 Director for Department of Women September 20, 2021 MoHMS 5.8 Chief Medical Advisor, MoHMS September 30, 2021 The Ministry of Local Government 5.9 Health Inspector, Nausori Town Council November 8, 2021 MoHMS 5.10 Senior Assistant Health Inspector & Prosecution Officer November 10, 2021 MoHMS 5.11 Manager Laboratory, Fiji CDC November 26, 2021 CareFIJI app Available online 6 https://play.google.com/store/apps/details?id=fj.gov.carefiji&hl=en&gl=US https://www.fbcnews.com.fj/news/carefiji-app-foundation-of-phase-2-recovery-pm/ 92 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Annexes Description Annex No. Page Numbers Link Vaccination Registry System 7 Pages 1–11 https://www.health.gov.fj/wp-content/uploads/2021/03/VRS_Manual.pdf Tupaia Available online—Last updated: September 21, 2021 8 https://tupaia.org/supplychain_fiji/FJ/COVID-19%20Fiji?overlay=FJ_COVID_TRACKING_Dose_1_SubDistrict_ Percentage_Vaccinated WBG Budget Breakdown ADB, UNICEF (March 1, 2021) UNICEF, together with the ADB, supported health care workers in Fiji by handing over more than 22,000 Cepheid GeneXpert test kits to the Fijian MoHMS. The ADB provided 20,000 of the test kits at a cost of F$396,000, while UNICEF provided the remaining 2,220 at a cost of F$43,000. The kits were financed through an ADB grant of F$7.9 million to UNICEF to support Pacific Island countries in their preparedness and response plans for COVID-19. 9 ADB, Japan, UNICEF (August 31, 2020) The ADB and the government of Japan delivered personal protective equipment and other medical supplies/equipment to the Fiji MoHMS to strengthen the country’s capacity to respond to the novel Coronavirus disease. The medical supplies and equipment include masks, face shields, coveralls, and gowns to improve infection prevention control, as well as biomedical devices such as thermometers, oxygen concentrators, and electrocardiogram recorders to improve the clinical management of COVID-19 patients. The medical supplies were procured by UNICEF. Component This is an emergency COVID-19 response with the aim of strengthening Fiji’s capacity 1—US$4.85 to respond to COVID-19. It also provides immediate support to implement prevention, million preparedness, and emergency response activities for COVID-19. This is the second component of the project titled ”Health Systems Strengthening.” It focuses on medium- and long-term health care system strengthening, with three main Component priorities: (i) enhancing health care waste management, including procurement and 2—US$1.40 installation of a medical waste incinerator at the Naboro landfill to serve the Central division million health facilities; (ii) training for health care workers on health care waste management; and (iii) construction of a warehouse to supplement storage facilities at the Fiji Pharmaceutical 10 and Biomedical Services (FPBS) Center in Suva. The third component is titled ”Implementation Management, Monitoring and Evaluation.” This component provides technical and operational assistance on project management, Component including supporting monitoring and evaluation (M&E), supervision and reporting, financial 3—US$1.10 management, procurement, and environmental and social risk mitigation activities; and million sharing lessons learned from response exercises and joint learning, domestically and internationally. Total: US$7.35 million Public Health Act 11 http://www.paclii.org/fj/legis/consol_act/pha126/ Public Health (Infectious Diseases) (Infringement Notices) Regulations 2021 12 https://www.fijivillage.com/documents/gazette-fines.pdf Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 93 Annexes Description Annex No. Page Numbers Link Immigration Act 2003 13 http://www.immigration.gov.fj/images/pdfs/immigration_act_2003.pdf The Education Act 14 http://www.education.gov.fj/wp-content/uploads/2019/04/EDUCATION-ACT.pdf Fiji Coronavirus Preparedness and Response Plan Scenarios and Strategies can be found on page 18 15 https://www.health.gov.fj/wp-content/uploads/2020/08/COVID-19-Fiji-Preparedness-and-Response-Plan-2020. pdf Prime Minister Voreqe Bainimarama’s Statement on COVID-19 16 MoHMS—easing of COVID-19 restrictions https://www.fiji.gov.fj/Media-Centre/Speeches/English/PM-JVB-STATEMENT-ON-COVID-19-160921 Easing of COVID-19 Restrictions 17 MoHMS—easing of COVID-19 restrictions https://www.health.gov.fj/ease-of-covid-19-restrictions/ 90 Percent Full Vaccination 18 MoHMS—easing of COVID-19 restrictions https://www.health.gov.fj/90-full-vaccination/ Fiji COVID-19 Emergency Response Project—ESMF 19 Strategies to optimize the availability of PPE—pages 100–105 https://www.health.gov.fj/wp-content/uploads/2020/10/Fiji-COVID-19-Operation-ESMF.pdf MoHMS—Strategic Plan 2016–2020 See strategic pillars and priority areas, pages 9 to 13 20 https://www.health.gov.fj/PDFs/Corporate%20Plan/Strategic%20Plan%202016-2020%20Executive%20Version. pdf MoHMS Budget Allocation (2017 to 2022) Total Gov. Year Operation ($F) Capital ($F) Total ($F) % of allocation Budget ($F) 2017– 2018 251,572.70 56,693.80 308,266.50 4,356,830.80 7.10% Link: http://www.parliament.gov.fj/wp-content/uploads/2017/03/Budget-Estimate-2017_2018.pdf 2018– 2019 259,989.70 60,461.90 320,451.60 4,650,546.00 6.90% Link: http://www.parliament.gov.fj/wp-content/uploads/2019/02/2018-2019-Budget-Estimates.pdf 21 2019– 2020 303,529.10 34,748.50 338,277.60 3,674,604.10 9.20% Link: http://www.parliament.gov.fj/wp-content/uploads/2019/06/2019-2020-budget-estimates.pdf 2020–2021 316,218.30 66,050.80 382,269.10 3,840,928.90 10.00% Link: http://www.parliament.gov.fj/wp-content/uploads/2020/07/Budget-Estimates-2020-2021_1.pdf 2021– 2022 332,557.40 59,425.20 391,982.60 3,690,545.60 10.60% Link: https://www.economy.gov.fj/images/Budget/budgetdocuments/estimates/BUDGET_ ESTIMATES_2021-2022_Web.pdf 94 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Annexes Description Annex No. Page Numbers Link Recovery During a Pandemic Health Concerns, Supply Disruptions, and Price Pressures 22 See page 115 to 117—Table A4 contains real GDP for emerging markets and developing economies. Link:https://www.imf.org/en/Publications/WEO/Issues/2021/10/12/world-economic-outlook-october-2021 Funds for COVID-19 National Deployment and Vaccination Plan Intended for Funded by Amount Fiji’s COVID-19 National Deployment and (New Zealand Ministry of Foreign NZ$2,890,400 Vaccination Plan Affairs and Trade (NZMFAT) 23 COVID-19 Vaccine Assistance NZMFAT NZ$765,043 COVID-19 Response and Preparedness ADB US$3,018,218 COVID-19 PPE Assistance Indonesia US$200,000 Fiji COVID-19 Emergency Response Project World Bank US$5,374,894 Interview Questions—Case Study on Containing, Mitigating, and Responding to COVID-19: Knowledge Generation and Exchange on COVID-19 Preparedness and Response—Fiji Case Study, 2021 Ministry: Ministry of Health and Medical Services Interviewee: Dr. Jemesa Tuidravu Introduction Please introduce yourself—your name, your position in the ministry, how long you have worked in this position, and what your specific role is with regards to the ministry’s COVID-19 response. Topic 1: Primary Care and Hospital Response 1. Please briefly describe how primary care and hospitals have responded to the surge of confirmed cases. 2. Have some hospitals been designated as COVID 19 hospitals while others as hospitals for treating 24 non-COVID-19 patients? Please briefly list how many hospitals in different divisions have been listed as COVID-19 hospitals. 3. Has it been easy to mobilize beds for treating confirmed cases? 4. Has the private sector been cooperative in resource mobility? Topic 2: Infrastructure and Work Capacity 1. Please describe what type of health care facilities are available for infectious diseases, and what measures can be taken to separate patients with infectious disease from those without it. 2. Provide the number of negative pressure isolation rooms, ventilators, intensive care units, etc. (Actions—He will get the numbers to us). If possible. Also describe the capacity for laboratory testing and supplying medicines and personal protective equipment (PPE). 3. Please describe workforce capacity who are specialized in infectious diseases, including training programs for capacity building, and what measures can be taken for mobilizing and protecting health personnel during pandemic. Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 95 Annexes Description Annex No. Page Numbers Link Topic 3: Human Resources for Health 1. Please briefly describe the distribution of health personnel in the containment of COVID-19. 2. Please briefly explain how health personnel have been mobilized to cope with the outbreak of COVID-19. 3. Please briefly describe how health personnel have been remunerated and what measures have been taken to protect them from tremendous burden including burnout. 4. Please briefly describe how the Ministry of Health ensures that medical/quarantine professionals are protected at screening facilities (without making such sites potential clusters of infection). Topic 4: Health Service Delivery 1. Please briefly describe health service delivery system, focusing on how strong primary care is in the country, access to hospital services, and the role of public and private providers in health service delivery. 2. Please describe to what extent telemedicine is allowed in case of health emergencies. Topic 5: Service Coverage 1. Please briefly describe a potential impact of COVID-19 on UHC index, for instance (WB/WHO indicator) in terms of service coverage. 2. Please describe the extent of disruption in provision and access to health services. cancer, mental health conditions, etc.), and antenatal care and childbirth, how have priorities been given to some health services over others? 24 (continued) Topic 6: Ensuring Access to Essential Health Services 1. Please briefly describe how access to essential health services for non-COVID-19 patients has been ensured since the outbreak of COVID-19. 2. Given that there are various types of essential health services, including prevention and treatment of communicable diseases (TB, HIV/AIDS, measles, etc.), noncommunicable diseases (hypertension, diabetes, Has any modification been made to deliver those essential services? 3. To what extent has digital health or telemedicine been used flexibly? Topic 7: Health Financing 1. Please briefly describe the major financing mechanism for health care, tax, or social health insurance, and to what extent universal health coverage (UHC) is achieved. 2. Please describe how treatment cost for infectious diseases is subsidized and if copayment and/or insurance premium is reduced in circumstances of pandemic. Topic 8: Public and Private Partnership 1. Please describe any collaboration between governmental agencies and private companies to cope with the outbreak of COVID-19, particularly in contact tracing, test-kit development, and risk communication. 2. Can you provide some examples of the government using private information on credit card transactions, cellphone GPS records, and transportation history to rapidly trace the potential case? (Note: The interview question attached is a sample from the MoHMS). Levels and Types of Health Services Provided in Fiji 25 Health Service Delivery profile (2012)t Details can be seen on page 3 of 12—Table 2. https://pdf4pro.com/cdn/fiji-health-service-delivery-profile-26nov-10d21.pdf 96 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Annexes Description Annex No. Page Numbers Link KAP Study Done by the MoHMS and AusAID 26 Understanding knowledge, attitudes, and practices in the context of COVID-19 in Fiji. https://www.health.gov.fj/wp-content/uploads/2020/08/COVID_KAP_Summary-Report.pdf Link: https://www.health.gov.fj/health-emergency-disaster-management/ 27. See subheading: Comprehensive Emergency & Disaster Management https://www.health.gov.fj/wp-content/uploads/2018/08/Fiji-Communicable-Disease-Surveillance-and-Outbreak- 28 Response-Guidelines-2016-1.pdf See pages 38–41 Intergovernmental and International Support Intergovernmental Organizations • Provided medical supplies worth F$750K; consists of 888,500 surgical masks, 53,400 N95 masks, 29,200 face shields, World Health Organization 2,000 protective goggles, 4,000 isolation gowns, and 26,750 GeneXpert testing cartridges.21 • Provided funding of US$7.35 million to support the government of Fiji in preventing, detecting, and responding to the threat posed by COVID-19 and strengthening national systems for public health in Fiji by improving emergency preparedness and response, strengthening health systems, and managing World Bank implementation and monitoring and evaluation. Breakdown of funding can be seen in Annex 10. 29 • Provided medical supplies including personal protective equipment (PPE) and intensive care unit beds and ventilators, as well as the installation of a medical incinerator that will serve three divisional hospitals in Fiji.22 • In 2020, a total grant of US$2.4 million has been provided by the Asia Pacific Disaster Response Fund (under ADB) to respond to COVID-19 and Tropical Cyclone Harold. The ADB also prepared a Asian Development Bank US$65 million facility to provide liquidity support for Fiji Airways. This funding assisted Fiji Airways through the COVID-19 crisis (ADB, 2021). Other information can be seen in Annex 9. • Provided F$50 million to support the government budget during the COVID-19 phase.23 European Union • The government of Austria, as part of the Team Europe, provided PPEs worth F$156K, to assist the MoHMS in containing COVID- 19.24 21 https://www.who.int/westernpacific/about/how-we-work/pacific-support/news/detail/24-09-2020-fiji-receives-more-medical-supplies 22 As above 23 https://www.fbcnews.com.fj/news/covid-19/more-projects-in-line-by-eu-to-help-assist-fiji-through-covid-19-phase/ 24 https://reliefweb.int/report/fiji/government-austria-donates-ppes Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 97 Annexes Description Annex No. Page Numbers Link International Organizations –Australia and Fiji set out the 2019 Vuvale Partnership to embrace a new era of enhanced cooperation, consultation, and friendship. This partnership enables Australia to support Fiji in responding to and recovering from COVID-19 and to lay a foundation for a stronger and more prosperous nation. –Australia also supports the Pacific, including Timor-Leste, in providing COVID-19 supplementary funding of AU$304.7 million, as part of the COVID-19 response package. This Australia package is aimed at providing support to deliver critical, temporary, economic support to address pandemic impacts (DFAT 2020a). –The government of Australia moved quickly to respond to the impact of COVID 19 on the Fijian economy. In May and June, Australia provided AU$19.5 million to promote stability in Fiji’s position. The budget was delivered in coordination with the ADB, WB, and New Zealand, and the budget was in place to ensure that Fiji would finance spending priorities (DFAT 2020b) Donated more than F$200,000 worth of medical supplies. President of the Fiji China China Friendship Association Fang Jamnadas says most of the medical supplies were donated by the Chinese government and various private Chinese businesses (Filipo 2020). 29 Provided F$200 million (approximately 10,000,000,000 yen) emergency loan. This money Japan (continued) is directed to strengthening health and medical services (MOFA 2021) (Vishaal 2021). New Zealand and the UNDP donated PPE worth F$85,500 to the Fiji Police Force to help New Zealand protect individual police officers from potential health risks. The PPE items consist of 10,000 KN95 masks, 30,000 gloves, and 300 bottles of hand sanitizers (Reliefweb 2021) The KOICA Fiji Office has donated medical supplies containing personal protective Korea equipment (PPE), together with noncontact infrared body and surface thermometers worth International F$290,000, to the MoHMS to support Fiji’s response to COVID-19. The agency has also Cooperation donated an additional F$130,000 worth of PPE kits to the Fiji MoHMS. These totaled up Agency (KOICA) KOICA’s donation to F$420,000 worth of medical supplies to the MoHMS for COVID-19 response (MoHMS 2020f) The US government, through the United States Agency for International Development (USAID), partnered with UNICEF to respond to the Fiji government’s request for critical assistance needed to confront the development of COVID-19. The USAID project, titled United States “Preventing and Responding to COVID-2019 in the Pacific,” has a total funding of US$1.85 of America million and is implemented in Fiji, the Federated States of Micronesia, Kiribati, Solomon Islands, Tonga, Tuvalu, and Vanuatu. USAID was able to provide emergency provision of disinfectants, sanitizers, soaps, and other infection prevention supplies to assist the government of Fiji in quelling the localized outbreak before it spread further (USAID, 2021). 98 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji Annexes Description Annex No. Page Numbers Link 30 Fiji’s Summary Estimates—Household Income Expenditure Survey (HIES) Report 2019 to 2020 Estimated Distribution of Area Absolute Poverty Poverty rate population the poor National 864,132 208,021 24.1% 100.0% Rural 386,632 141,301 36.5% 67.9% Urban 477,500 66,720 14.0% 32.1% Sex Male 434,914 108,705 25.0% 52.3% Female 429,218 99,317 23.1% 47.7% Geographical Division Central 361,459 67,779 18.8% 32.6% Eastern 36,274 14,233 39.2% 6.8% Northern 135,965 39,433 29.0% 19.0% Western 330,434 86,577 26.2% 41.6% Geographical Areas Rural Central 101,422 36,753 36.2% 17.7% Rural Eastern 32,724 13016 39.8% 6.3% Rural Northern 98,550 33,588 34.1% 16.1% Rural Western 153,936 57,944 37.6% 27.9% Urban Central 260,037 31,025 11.9% 14.9% Urban Eastern 3,550 1,217 34.3% 0.6% Urban Northern 37,415 5,845 15.6% 2.8% Urban Western 176,498 28,632 16.2% 13.8% Marital Status Never married 162,418 39,822 24.5% 30.0% Legally married 357,524 77,349 21.6% 58.3% De-facto 10,978 2,748 25.0% 2.1% Widowed 46,606 9,288 19.9% 7.0% Separated 12,375 2,466 19.9% 1.9% Divorced 7,087 1,010 14.2% 0.8% Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji | 99 Annexes Description Annex No. Page Numbers Link 31 Key Multidimensional Poverty and Deprivation Results—HIES Report 2019 to 2020 Multidimensional Poverty In 2019-20, three out of every ten adults and children (30%) were multidimensionally poor–they lived on low incomes and were deprived of essential things that they needed. Over a quarter of a million people (256,000) in Fiji are multidimensionally poor. Multidimensional poverty rates in rural areas (38%) are higher than in urban areas (23%) of Fiji. Deprivation results There is a broad consensus among the general public in Fiji on the necessities of life for a minimum decent standard of living. Almost one in four adults (23%) were deprive from the essential clothes they needed. Over two in five adults (43%) suffer from financial deprivations. Half of the adults (50%) suffer from social deprivations – they cannot fulfil their social obligations and fully participate in Fijian society due to a lack of money. One in five children (20%) do not have the essential food they need – their diet is inadequate by Fijian standards. • More than one in five children (22%) of school age suffer from educational deprivation. • Nearly one third of children (28%) do not have the new clothes they need. • Almost four in ten children (38%) suffer from material deprivation – their parents cannot afford to buy them the essential things they need. 100 | Republic of Korea – World Bank Group Partnership On COVID-19 Preparedness and Response | Country Case Study: Fiji References REFERENCES 1. ADB. (Asian Development Bank), 2021a. “Fiji: 10. COVID-19 Response Gender Working Group. Country Classification”. Accessed online: https:// 2020. Gendered Impacts of COVID-19 on www.adb.org/sites/default/files/institutional- Women in Fiji. April 2020. Accessed at: http:// document/753796/fiji-country-classification.pdf www.fwrm.org.fj/images/Gender_and_COVID_ Guidance_Note_-_Rapid_Gender_Analysis.pdf 2. 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