World Health Day 2022: Health and wellbeing in Fiji with Dr James Fong, Permanent Secretary, and Dr Aalisha Sahukhan, Head of Health Protection, Fijian Ministry of Health and Medical Services

World Health Day this Thursday, 7 April will focus global attention on urgent actions needed to keep humans and the planet healthy and foster a movement to create societies focused on well-being. 

After two years of a global pandemic, it’s a time to reflect on the fact that the health of our planet and the health of our people are inextricably connected. The WHO estimates that more than 13 million deaths around the world each year are due to avoidable environmental causes. 

Our region, the Indo-Pacific, is at the forefront of the climate and health crisis. On today’s episode we are joined by two of Fiji’s health leaders who have been at the forefront of its COVID response and our now at the forefront of the country – and region’s – efforts to continue to strengthen health systems, for everyone. 

Dr James Fong is a Fijian obstetrician-gynaecologist who serves as the Permanent Secretary for the Ministry of Health and Medical Services. During the COVID-19 pandemic, Fong led the COVID-19 Incidental Management Team and was responsible for communicating with the public on the status of the pandemic.

Dr Aalisha Sahukhan is the Head of Health Protection for the Fijian Ministry of Health and Medical Services. A trained infectious diseases epidemiologist, Dr Sahukhan was appointed acting national advisor on communicable diseases in 2017. In 2018 she became acting head of Health Protection before being appointed head in 2021. Health Protection is a newly formed national programme in Fiji bringing together the departments of environmental health, health emergencies and climate change, and communicable disease.

Drs Fong and Sahukhan talk to Ambassador Williams about the importance of testing and quickly adapting to evolving needs and understanding all factors that influence the health of a society, including environmental factors. We ask, what is effective leadership when responding to a health emergency? And what role do health care workers play in broader social challenges? 

We hope you enjoy the conversation and learn more about World Health Day 2022. @WHO @CentreHealthSec @AusAmbRHS #WorldHealthCareWorkerWeek

Transcript

Dr Stephanie Williams 0:01

Hello, and welcome to Contain This. My name is Stephanie Williams and I'm Australia's Ambassador for Regional Health Security. 

On today's episode, we're joined by two of Fiji's health leaders who have been at the forefront of its COVID response and now at the forefront of efforts to continue to strengthen the health system for everyone. 

We speak first to Dr James Fong, the Permanent Secretary for the Fijian Ministry of Health and Medical Services. I ask Dr Fong how Fiji managed its successful vaccination rollout for COVID and what lessons he learnt in the process. We then speak to Dr Aalisha Sahukhan, the Head of Health Protection for the Fijian Ministry of Health and Medical Services. Dr. Sahukhan reflects on the challenges of adjusting the COVID response strategy in real time, and how she grew as a leader over the period. Dr Fong's and Dr Sahukhan's own reflections in this episode demonstrate qualities of health leadership in the COVID pandemic period. 

On World Health Day this year, the theme is our people and our planet. And we should be thinking about the type of health leadership required to take the urgent actions in all sectors needed to address the health impacts of climate change. This is an important conversation for now and the future.

Dr Fong, we have listeners on this podcast who are in Australia, and all over the world, and many are familiar with the Indo-Pacific but some are not. I wonder if you could describe some of the lessons learnt during Fiji's very successful vaccine rollout for COVID, over the last year and a bit?

Dr James Fong 1:50

Yeah, I guess I need to start the answer by just stating that we had a challenge, in that, whilst we've had a long-standing vaccination programme that would function well and deploy low immunisation needs, our experience with escalated deployment of vaccine was, whilst it was present, it was a bit more limited and our capability to rapidly escalate vaccination needs was more limited. We did have prior experience with the measles and meningitis C programme that allowed us to develop some capability to to scale up. So that was the big problem was the one problem was the ability to scale up. 

The second one was the fact that this programme required that we had to be connected together with a digital platform that allowed us to digitally register all the vaccinations. That was a significant problem. As with many of the Pacific Island countries, we were used to just doing it on deploying and writing it and exercise books. And then later on, we come back and then we consolidate all the data together and prepare a report. In this case, we were consolidating as we were deploying. So that was that was a huge challenge. 

I think one of the biggest things that we did learn though, was because we had begun to repurpose the health system to have a more flexible command and control structure, we were able to ensure that you know the the vision and the and the purpose of all the exercise was effectively narrated and tracked. So, what we did was that we had developed command centres, three command centres for the three divisional teams. And each command centre had a number of sub divisional operation centres and they all had IT support - so they had screens, Zoom link and also a lot of these various command centres and operation centres had put together Viber groups, groups, Viber chat groups. So and in those Viber chat groups, many of us, Dr Aalisha, myself and Dr Jemesa are all in the Viber group, so we could see in real time what everybody was doing and how they were progressing with regards to their percentage coverages. And we could you know, provide ongoing encouragement, ongoing, ongoing feedback also on some of the activities. 

The the other thing that we, you know, that we had to work very quickly with and we had to develop extra capability in, was in relation to community engagement, looking at new ways of, of new strategies for community engagement. And, of course, the risk communication that was involved in, in that exercise. So by having those structures that I mentioned, the command centres and the operation centres, ensuring that the digital space was stable enough for us to provide a measure of command and control over the operation, then allowing us all to have a shared vision of where we wanted to go, it allowed us also to share lessons learned and what we needed to do, especially with regards to community engagement. I think community engagement was the hard part. 

But we couldn't do, we couldn't even get all those lessons out, we could not even look at strategies unless we had a stable digital space to work with. 

Dr Stephanie Williams 5:35

Can I ask some more questions about this command and control structure? These were set up purely for the vaccine rollout? Are they continuing in any form or with a short term structural change?

Dr James Fong 5:51

Oh, no, no, what happened was that in the first wave, after the first wave came to Fiji, we once the first wave settled down, we reorganised or we reorganise the health system, so that we could have this command and control structure that will allow us to do anything. The whole purpose was being able to scale up and scale down. So what happened was that when if there was one issue that would if for example, if it's an epidemic, the command and control structure will reflect only on the epidemic, but as soon as the epidemic is over, we will change the agenda and get them to start dealing with other such issues that relate to NCDs, leptospirosis, dengue. 

So there is an ongoing capability within each of the of structures or command and control structures to be able to, to adequately manage challenges as they came along. One of the key aspects of the command and control structures is for each of the operation centres to have what we call line lists. And basically we started off with line list of vulnerable persons. So what you did was that you went right down to the most peripheral area in the medical what we call the medical area. Each medical area then would have a line list of all the vulnerable persons that stayed within that area. And I mean, okay, even more, more more peripheral is the zone nurses, the zone nurses would have a list of all the diabetics that they had the names, the address and everything. And then that would be that was fed back up the chain so that each operation centres in each of the subdivisions too have online list of vulnerable persons, their contact numbers, what medications they're on. And all they do is they provide oversight over over the management to ensure that they are appearing for the clinics that they are appear for, and that their medication if they're not appearing that the medication supplies given. 

The idea was to try and get vulnerable as stable as possible. And that was one key area. So it meant that for for vaccination, it meant that we we outlined all the vulnerable groups. And then we in each medical area, they had to look for those people personally and talk them into seeing if they can get them vaccinated. There were a few of them that actually refused vaccination. That's okay. But at least we could tick off if they were counselled and offered the the vaccination option.

Dr Stephanie Williams 8:27

So how are you using that, in terms of improving booster coverage in Fiji, which I know is a challenge. 

Dr James Fong 8:36

So because we have we caught up with the majority of them on our line list that makes it easier for us to concentrate on the vulnerable and the willing. Those who are willing to be vaccinated plus the vulnerable. So that makes it a bit bit easier. 

But having said that, as I mentioned, one of the other parts of our success was the was the fact that we could scale up. And unfortunately for a country like Fiji scaling up meant that you had to have a whole of government approach. One of the reasons why we are struggling at the moment without booster doses is because now we don't have the whole of government. We don't have access to all the transports, we don't have access to all the various other logistics support that we had before. And so. 

But despite that, we have been able in some of the vulnerable groups, we've been able to achieve 25/30/40% coverage, in some of the subgroups. I know that overall we've gone through we are about 20% of the of those who have had a second dose have had a booster. So that in itself is we've got we've got some traction there. 

I should also mention one more small thing is that we were a little bit hampered in our deployment of the booster doses. Because after two years of working, everybody needed to go on leave. A lot of our medical staff were beginning to feel the difficulty of sustaining energy. So they're gonna leave. And also now we have to do catch up of our immunisation programmes that are not related to COVID-19. So the same group of people will also have to do other vaccination programmes. And because school has started, we now have to make sure that all our school children are adequately covered in terms of vaccination. So there's those are some of the key issues that are that are that have slowed us down a bit, but it's only slowing down our our reaching out capability. But, you know, we narrating the fact that the vaccines are available in the facilities for you for for people to, to come to.

Dr Stephanie Williams 10:43

So Dr Fong, you mentioned NCDs and leptospirosis and the routine immunisation as a series of other health challenges that don't go away when even when COVID is here and you also mentioned some of the workforce challenges, how are you thinking about what some of the health system priorities are for Fiji, in terms of the health workforce in particular, over the next couple of years?

Dr James Fong 11:09

Yeah, I, for for I think a lot of other directions or directions that we are currently working on. Reaching out into the private sector, having greater engagement with the private sector to be able to, to support us in some of our endeavours, especially in trying to reach into the community using the private sector. I believe that we, we will have to build a lot more relationships with our CSOs. And one of the key areas of function really is working with the network that supports disabled persons. That network has what we call community rehabilitation workers, they have village health workers and they also have a wider variety of of CSO related relationships that allow them to get and penetrate the community a bit a lot better. 

I think that at the end of the day, if we can use all the various networks, in the private sector, plus the non government organisations to bolster the message for prevention, but also more importantly, to to be able to refine our secondary prevention programme, through the line list management programme. Because the line list does allow us to target our energies to areas of need. I think what we what my biggest problem with primary prevention is that we spread ourselves too thin and we do not, we are not able to focus on the people that really need us. Whereas with secondary prevention, we are able to get to the people who who really need our message and need our service. And we able to achieve the idea of reaching the right people at the right time.

Dr Stephanie Williams 13:00

Can I ask you a last question, which is self reflective? I'm interested in what you have learned about yourself as a health leader over the last two plus years.

Dr James Fong 13:13

Oh, yeah, that's, I think, I must admit, there were some bits. There are some parts of of leadership that I didn't envision that I had the ability to sort through. A lot of it dealt with working in areas outside of health. You know, working with tourism, working with the private sector, the trade sector. But I think one of the lessons that I've basically learnt was that, you know, there were so many lessons that you learn through life, that you can actually apply in other areas. And it's amazing how, how there are shared shared strategies that cut across many, many different areas of living. That you know, that you don't envision because you're so tied down in one area. But as, I mean, I've, I've done I've been a doctor, I've been an obstetrician gynaecologist for most of my life. But in the course of doing obstetrics and gynaecology, in order for us to have a functional system, I had to step out of the speciality and engage with with procurements, pharmacies, stores, engage with, with the Ministry of Economy over many, many years, in order for us to keep our system tight and functional. And now I've realised that, you know, it's served me quite well in terms of becoming a Permanent Secretary, recognising areas that require my urgent attention, and being able to find not so much find a solution, but being able to put in place a structure that can find the solution for us. And that has become something that, I think that's probably one of the biggest lessons that that I've learned, is that I don't have to solve the problems all the time. As long as I know how to set up a structure that can find solutions, and give us good options. I think that's most of the battle, battle battle done. And I think I'm hoping that one of the one of the things that I didn't like about COVID is that it put very few people to the forefront like it made me and Aalisha and Dr Jemesa, stand right up in front. I'm hoping that, but I've learned very strongly that you know, sometimes in many times, the measure of our success will be when we can step back, and all the other directors and all the other line managers or start to get the limelight, and they begin to boot up successful programmes. That to me is going to be the final measure of, you know, whatever legacy that will you pay. 

Dr Stephanie Williams 15:48

Thank you for those reflections. 

Dr Sahukhan, Dr Fong just talked about being in the spotlight and having the relentless attention during COVID, which is something I know you faced in your role as the head of health protection. I wonder if you could reflect on what some of your biggest achievements, your collective achievements have been focused on laboratory testing, in particular, in Fiji over the last two years? 

Dr Aalisha Sahukhan 16:20

And so throughout the pandemic, it was very important for the public to have spokespeople from the Ministry of Health and Medical Services, particularly because the Ministry of Health agency, did take the lead role, particularly during the worst parts of the pandemic. And within the Ministry of Health. It was our permanent secretary Dr Fong, and our Chief Medical Adviser, Dr Jemesa Tudravu, as well as myself, who were the faces of the response. I think all of us would tell you that that role was not something I any of us envisaged for ourselves when we became doctors. And I think that's a that's something that we we really we learnt was very important. And I guess we took on that role really, really to try and try and show what the Ministry of Health was doing as well as advise the public about the progress of the of the pandemic, etc. 

In terms of lessons learned from the pandemic and specifically looking at laboratory testing. So during the pandemic laboratory testing really had to be ups up scaled at a very rapid pace. We have PCR testing in Fiji, our PCR lab actually opened in March of 2020. We were able, of course, you will know to keep the virus out of Fiji for a year, up until April of 2021. Once the delta wave hit us in April of 2021, we had to really vastly up upskill upgrade our testing. So we expanded the testing to six labs within the Ministry of Health and Medical Services. And that included of course, all the testing personnel that were required testing consumables that were required. And we ended up doing a massive amount of testing. At the peak of the outbreak, we were testing at about four or 4.5 per 1000 population, which is about 20 to 28,000 samples a week. And this is just out of six labs in Fiji. And that was a comparable level of testing to our neighbours and much more developed neighbours in the Pacific such as Australia and New Zealand.

What we did learn however, with the testing, we didn't know we were aiming to test as much as possible with the intent to try and contain the outbreak. So anybody who was getting symptoms needed to get tested needed to be isolated. However, there was a point where it became very clear that the outbreak was so widespread, that so many people had COVID-19 that we had to narrow down and prioritise our testing, because there's no point in testing indiscriminately, when you're not following up with public health action, or even clinical action. So testing diagnostics needs to be connected to action.

So what we did at that peak of the outbreak, we announced that we will be limiting our testing now to persons who are at most risk of developing severe disease and including testing before admission to hospital so that people could be it could be isolated in the isolation wards in the hospital. So I think that's a lesson learnt in the developing country where you do have limited resources. It may not be the best way forward in responding to outbreaks such as this. Of course, now, our testing is much more open. And it is very much used as a predictor early warning for surges of COVID-19. 

Dr Stephanie Williams 20:17

Dr Sahukhan, when you look back at that strategy change that you described about testing to enable containment versus  conserving resources for testing for the most high risk patients. When you look back at that, can you remember how long that change took to agree and to implement? 

Dr Aalisha Sahukhan 20:43

I will say it was difficult because all of us in the Ministry of Health, we were all in the mindset of trying to contain the outbreak. And that was just how we operated. So right in the beginning of the delta wave. For example, any anybody who tested positive for COVID 19 was admitted to hospital. Regardless of whether they were symptomatic or asymptomatic, or what their risk status was in terms of severe disease, they were admitted to an isolation ward in the hospital. As we got more and more cases, it became clear that we couldn't, it just did not make sense to put healthy, people who have mild disease or have no symptoms into a hospital setting. So then we expanded and started having what you call community isolation centres. So this may be schools, this may be hotels that were used as isolation centres, so anyone who tested positive regardless of what their symptoms or not, were put into this community isolation centres. 

Eventually, of course, what happened as we got more and more cases, all of these centres became full. And then the decision had to be made that now we will tell the public, if you test positive for COVID-19, please self isolate, isolate at home. So, so really, the progress of the outbreak itself forced us to make this these decisions as we as we went on, because it just became not possible to maintain the same strategies as the outbreak progressed. 

So a similar thing happened with COVID-19 testing, but I will say that it did happen a bit slower. We were still trying to test as many people as possible, give them their results, let them know that they need to isolate. However, of course, what happened, what happened here, and what happens in most countries that go through these big waves is that things like test turnaround time suffered, so we had someone that could get sampled and then they we may wait five, six or seven days before they became before they got a result. 

So we did have to we did have to really engage the public to do their own risk assessment, because essentially, that was that was, we had to make do with the resources that we had at the time. And we had to prioritise those resources towards making the most difference. And at that point, it wasn't about stopping transmission we're trying to do, it was about mitigating the risk of severe disease, so trying to reduce hospitalizations, trying to reduce deaths. And at the same time, of course, our vaccination programme was running along this response. So really, a lot of it around a lot of the containment efforts initially was trying to buy time to get more and more people vaccinated. But then it came to a point where we also had to change our response in in tandem with what we're seeing with the outbreak itself to make the most difference and to mitigate the risk of severe disease.

Dr Stephanie Williams 23:52

I'm interested from a surveillance and testing perspective, what is still on your to do list in terms of future improvements that you think are important for detection and response in Fiji?

Dr Aalisha Sahukhan 24:08

Well, we were fortunate that in the middle of the Delta outbreak, we were able to also deploy rapid antigen test kits. So of course, those those kits are much less labour intensive, and they're much faster turnaround time. 

Another issue that did come up very quickly with our laboratory testing is the support from for a results reporting, outlook. So as you get more and more and more samples and tests, and you need to report these tests, you need a system in place that is able to do this rapidly and with as much minimal input from from him or from people who are already doing the testing, already doing the swabbing. So we we saw that we needed a digital digital framework, a digital solution to reporting of test results. So of course, we took on Tamanu web based system where we could actually collect collect the data from a patient when you're taking the swab, and then feed a test result in once once a lab has done, done the test or once the testing provider has provided the rapid antigen test result. And of course, then the person who's getting tested could access their their result through a website. So that is that was a completely new system and a new way of reporting test results in Fiji that we had to put in place as we were in the middle of an outbreak. And that is a system which we are still using today. 

Dr Stephanie Williams 25:52

And how about thinking on genomic sequencing capability? It's a much talked about capacity. It's a challenging one to incorporate, mostly for the public health information requirements that come with genetic sequence data. How are you thinking about that capability in Fiji?

Dr Aalisha Sahukhan 26:16

So currently, in Fiji we're very fortunate that the Peter Doherty Institute in Melbourne has been our reference centre for a COVID-19 for SARS COVID 2 and genomic sequencing in particular. We don't yet have the capacity in country to conduct a whole genome sequencing. However we are in the process of having that capacity, specifically at Fiji CDC. So we are working with the Doherty Institute as well as the WHO to set up a lab at Fiji CDC and we hope to have that in place within the next six months. 

Of course, it is a very, it's not quite well understood that it's a very complicated technology, it's it's not the same as introducing a new testing modality like PCR, for example, because it has a laboratory component. It's got a bio informatics component, it's got a genomic epidemiology component. And for all of that, yes, you need equipment, yes, you need consumables for the laboratory. But you also need people who are trained in each of those three components. And that is, we don't have that capacity yet in Fiji. What we are doing right now is we're working with the Doherty Institute to build that capacity. 

But it's a very exciting, it's a very exciting development, we're all very excited about it, because it would, we would be one of the only centres in the Pacific to have this capacity in country. And I'm hoping that in the future, we could also extend extend this capacity to also include other other Pacific Island countries and become a regional centre for genomic sequencing. 

Dr Stephanie Williams 28:17

As we reflect on leadership over the last two and a half years, I'm interested in what you yourself have learned about being a health leader, some reflections from your own experience.

Dr Aalisha Sahukhan 28:30

Thank you, it's um, sometimes when I'm asked about a I'm asked questions like that, it's it's a little bit jarring, because the last two years we in the Ministry of Health really has been operating in, I guess, emergency mode. Responding, planning and responding to the COVID-19 pandemic. And now things in terms of COVID-19 have slowed a bit. And we are all moving more towards our normative functions. So plans and projects that we had put on the backburner since COVID started, we were going back to that, and now of course, it is also a time for self reflection. 

So in terms of leadership, I think what I really learnt is, leadership is much easier, it's very, it's much easier to lead, when you have the right people in place when you have a good team. It really takes a lot of the work out of out of leadership if you're able to have a very good team that you're able to lead, as well as the processes that maybe exist from before or that you put in place when a crisis happens, like the pandemic. So that's something that I really learnt. 

The other. The other lesson, of course, has been that dealing with persons and organisations outside of health. So by profession, I'm a medical doctor. I'm an infectious disease epidemiologist, my focus prior to COVID has really been health centric. And I'm very much used to basing my advice and my outlook very much just looking at the health side of a situation. What we learnt through the pandemic, of course, is that health is determined by factors outside of health. There are socio economic factors that determine health status and public health, the health of the population. So for example, in our response to the Delta outbreak, one of the really restrictive public health and social measures that we put in place was lockdowns. So, of course, we knew that lockdowns can be very effective when applied at the right time. And and it also depends on the quality of the lockdown on what the compliance of the community enforcement etc. However, in a developing country, in contrast to a developed country, when you put in place a lockdown, you really do need to have to have the social measures in place to protect the people in your society who are not able to do things like stockpile food. So that is something we did learn quite quickly. And it's it's it was definitely a lesson because it taught a lot of us to really look outside of just the problem, the health problems or the health problem being COVID-19. And understand that that is that if there's more at play than just one disease, you also have to look at the society and the the the acceptance of public health and social measures by that society. And that's, that's critical. So yeah, so I've learned a lot during these two years. And hopefully, we will learn to use all the lessons learnt for whatever whatever public health event that is coming our way, including the our long standing issues in public health.

Dr Stephanie Williams 32:20

And I'm sure we have more lessons to learn along the way. But thank you so much for those reflections. Dr Sahukhan. It's always terrific to talk with you and hear of your leadership with your team, as you have mentioned in Fiji, thank you so much for making the time today. 

Dr Aalisha Sahukhan 32:39

Thank you very much.

Dr Stephanie Williams 32:42

Thank you for joining us for today's episode of Contain This to mark World Health Day on the 7th of April. I'm Stephanie Williams, Australia's Ambassador for Regional Health Security. You've been listening to my conversation with Dr James Fong, Permanent Secretary for the Fijian Ministry of Health and Medical Services, and Dr Aalisha Sahukhan, the Head of Health Protection for the Fijian Ministry of Health and Medical Services. 

As at the 27th of March this year, almost 70% of Fiji's population has had two doses of the COVID-19 vaccine. This is amongst some of the highest rates in our region. Reaching this goal took a coordinated effort across medical and societal interventions. As our guests noted, leadership requires understanding factors outside of health and health systems, a lesson for us all as we face the ongoing challenges in our region, not only around an uncertain COVID-19 future, but also some of the pressing climate change and health challenges facing health ministries. We hope you have enjoyed this conversation. 

Contain This is produced by the Indo-Pacific Centre for Health Security. For more on World Health Day this year, do follow us on Twitter and Facebook.