Purpose Quantitative facility assessments have identified gaps in surgical, obstetric, and anaesthesia (SOA) care in Fiji. This qualitative study aims to elucidate the barriers and enablers for surgical system strengthening to inform policymaking. Methodology We undertook semi-structured interviews with 31 SOA providers and policymakers. Thematic analysis was conducted using deductive and inductive codes. Results Significant chronic deficits in surgical infrastructure, human resource, and information technology are exacerbated by internal (supply chain and maintenance) and external shocks (climate change, natural disasters, pandemics). This impairs the type and quality of care. Hospitals operate on ‘emergency mode’, with delays in elective surgery, increasing costs and complications. Geographical isolation poses a barrier to timely access, provision of specialised services, and the maintenance of complex equipment and human resources. Solutions include mobility of care through outreaches, regional collaboration and connectivity across Oceania. There is a disconnect between the clinical reality on the ground and policymakers. Clinical governance and initiative have been highlighted as a strength. There is a need to build resilience through forward planning, coordinated use of resources, preparedness, and sufficient buffers. Increased financial investment from policymakers to meet population needs is required. Conclusion Policies to improve SOA care must be contextualised to local barriers and build on existing solutions from the ground up. In addition to policy implications, our results can inform theoretical health system and resilience frameworks.