Health policy initiatives are under-analysed in the Pacific region. Understanding how health policies develop and evolve is a first step towards improving their quality and contextual appropriateness. Through a document review and key informant interviews, this paper examines the evolution of primary health care in Fiji from 1975 to 2009 focusing on priority-setting, funding, implementation, political economy, the cultural context and interactions among communities, government and donors. Lessons learned from more than 30 years of experience with community health in Fiji are highlighted and reveal high levels of contestation over health policy processes. The paper identifies factors for consideration in renewed primary health interventions and calls for greater government ownership of priority-setting processes, more clarity on the links between policy and funding, more focus on evidence-based policy, greater awareness by development partners of the risks of policy imposition, and a deeper analysis of political economy and culture in relation to health sector policies.