MHMS Health System structure [20].

The Package of Essential Noncommunicable (PEN) disease interventions in response to the high prevalence of cardiovascular diseases and diabetes was implemented in Fiji commencing in 2012. This study aimed to understand implementation outcomes, and its contextual influences. Semi-structured interviews with health workers and patients across Fiji was conducted. Thematic analysis was mapped to the health system building blocks to understand PEN service delivery. The PEN program was well received by health workers formally trained. The frequency of use of PEN guidelines was influenced at the individual level by motivation, capability and capacity as well as external factors outside of the health workers’ control. The key challenges to routine use were lack of essential medicines and equipment for CVD risk screening and management, shortage of health workers, high turnover of staff, limited formal training, and no designated focal person. However, at the country level, the PEN program improved the quality of care by providing patients with regular follow-up visits depending on their CVD risk levels. The patients found care to be comprehensive when they were also seen by dieticians and physiotherapists. In most instances, the barrier to access to care were cost and distance of travel and non-availability of essential medicines. To improve use of PEN program requires strengthening health system components: 1) need for efficient supply chain system for medicines and equipment, 2) improving healthcare workforce retention, 3) establishing accountability mechanisms embedded within the health centres, 4) health information system to track patient level data and 5) multi-level governance structures across the health system.