Greater government focus and financing is helping to reform the health care sector

While Papua New Guinea continues to contend with a number of health issues related to both environmental risks and provision of care, recent progress suggests that positive changes are in the works. The prime minister has made this sector a top priority and relevant efforts are starting to pay off. Sufficiently financing the sector may be a challenge, as will delivery of resources; however, health care is receiving considerable attention and early signs suggest that this attention will likely produce tangible results.

Rising Spending

The numbers already indicate that funding is on the rise. Total health expenditure as a percentage of GDP hit 5.2% in 2012, up from 4.2% in 2011 and 3.5% in 1995. The ratio now exceeds that found in Indonesia (2.9%), Malaysia (3.8%) and Thailand (4.1%). The PNG health budget for 2014 was set at PGK1.38bn ($560.97m), up from PGK1.09bn ($443.09m) the previous year.

Most of the increase is the result of the PGK267.2m ($108.62m) Hospitals Infrastructure Redevelopment Package that will see the upgrade of 16 hospitals, including PGK65.2m ($26.5m) for the Angau Memorial Hospital, PGK50m ($20.33m) for Enga Hospital, PGK30m ($12.2m) for Port Moresby General Hospital, PGK20m (8.13m) for Boram Hospital and PGK20m ($8.13) for the Mt Hagen Hospital. A number of other hospitals will also be receiving this special infrastructure funding over a number of years.

Fee - Free Health Care

One of the most important line items in the budget is expenditure for the Fee-Free Primary Health Care and Subsidised Specialist Services Policy. The government committed PGK20m ($8.13m) to the programme in 2014, which began officially on February 23, 2014.

A total of PGK6.4m ($2.6m) went to the provinces for government-run hospitals, PGK9.0m ($3.66m) went to public hospitals and PGK4.9m ($1.99m) was granted to the Christian Health Services. These funds are set to be used to cover the costs of treatments that are proved at a discounted rate or free of charge. In addition to providing the necessary funding, it is also now illegal for hospitals, clinics and aid posts to charge patients for a long list of basic services, including: inpatient care, prescriptions, antenatal care, radiology, cardiology, diabetes, asthma, tuberculosis, HIV care, ambulance costs, treatment of mental illness, minor surgery and eye glasses.

The roll-out of the fee-free health care policy actually began in 2013, in two phases. As of August 2013, health care was declared free at all rural facilities run by the government and by the churches. From October 2013, basic health services would be free at provincial hospitals and referral hospitals.

Long Time Coming

The fee issue in the country has been a long time concern. In the early 1990s, fees being charged at health facilities were not regulated at all, according to the paper “User Fees for Primary Health Care in PNG: Productivity and Equity Implications” published by the Nossal Institute for Global Health at the University of Melbourne. The 2001-10 National Health Plan did call for free care for maternity, children and domestic-violence-related injuries; however, the authors of the study found that there was nothing preventing the charging of fees and that fees were charged at most facilities covered in the study. They also found that the existence of the fees resulted in reduced utilisation and was a barrier for many potential customers.

Additionally, according to the study, policies regarding fees were inconsistent, with some institutions charging for what should otherwise be free and some not. When patients were charged, the money was often used for operational or related expenses, such as cleaning materials, transportation, drugs and medical supplies. Fees ranged from about PGK1 ($0.41) to PGK3 ($1.22) for outpatient services, according to the study. While this may be a small sum, it is more than many people in PNG can afford and represents a significant barrier to care. The introduction of the fee-free programme will allow the sick and injured to get care and avoid the catastrophic debt that often comes from unexpected medical events.

“User charges can prevent the poorest people of PNG from enjoying the right to access primary health care,” wrote the Department of Health, in a 2013 presentation entitled “Implementing the Alotau Accord”. The accord is a platform for action issued by the government of Prime Minister Peter O’Neill.

Health care has been a major priority for Prime Minister O’Neill. The fee-free programme was a notable element of his campaign during the 2012 elections, while since then health care overall has remained a major focus for his administration; providing free basic education and health care is one of his five major priorities. The longer-term trend in policy, irrespective of the politics of the moment, is also promising. The 2011-20 National Health Plan is focused on basics, which the international community saw as a good way to rebuild the country’s health care foundations.

Pom general

The biggest developments have been made at Port Moresby General Hospital. In May 2013, the National Executive Council appointed Australian Grant Muddle as the new CEO of the hospital, which is the country’s highest-level referral institution. The appointment required a change in law, as the hospital is a government company and the heads of state-owned enterprises need to be PNG citizens.

While it is still early in the appointment, the change has so far been dramatic. It began with a simple clean up job; Muddle set out to renovate all the hospital’s 12 wards, and by early 2014 four renovations had been completed. The refurbishments involve new floors, ceilings, windows and beds as well as a fresh coat of paint. While simple and relatively cheap, the overhauls improved care considerably, as they contribute to better hygiene, better morale amongst staff and an improvement in the mood of the patients. In addition, Muddle went about buying new uniforms for all nursing staff and moving the hospital administrative centre to a disused building, with the previous office space set to be used for additional beds.

The changes to come will be more substantial. The purchase of a 128-slice CT scanner is currently under way and funds have been procured to acquire an MRI scanner. The facility is also working to purchase and implement a hospital information system, and while proprietary technology has been ruled out for cost purposes, an open source solution would be within budget and could greatly improve efficiency. According to Muddle, a nursing programme is being developed as well, as this will help the hospital quickly address its human resources bottleneck.

The goal is that progress made at Port Moresby General Hospital will influence care throughout the country, setting the tone and providing a model for efficient and effective patient care. As systems, processes and practices lead to better outcomes and an improved working environment at the country’s top hospital, this could in turn trickle down to the district hospitals, clinics and aid posts. Importantly, Muddle’s plans are receiving the highest level of support. He says that his vision is shared by that of the prime minister. “The prime minister has stood up and said that Port Moresby General Hospital is the catalyst for change in the health sector,” Muddle told OBG.

Money & Structuring

The changes at Port Moresby General Hospital are getting significant support in terms of both finance and organisation. In 2013, PGK50m ($20.33m) was paid directly from the government to the hospital, bypassing the Department of Health altogether. Moreover, in 2014 the hospital will become a statutory body, still owned and financed by the government but with its own budget and independence on how funds are spent. This will allow it to make decisions free of the bureaucracy and, more importantly, to set wages to attract the talent needed. At the moment, the hospital is pegged to the government pay scale and the staff are managed like civil servants, leading to less competitive wages and an environment that might not be suitable for an ambitious health professional. Full privatisation is not, however, anticipated as the hospital needs state funding to operate and is obligated to provide care regardless of a patient’s ability to pay.

The sector has also been helped considerably by what seems to be a thawing in the attitude toward importing relevant labour. In 2012, Port Moresby General Hospital hired 10 nurses from the Philippines; however, a severe backlash resulted. The unions protested, saying that the imported nurses were not qualified to practise in PNG and could compromise the quality of care. But in late 2013, the government lifted a ban on the hiring of foreign health professionals, and in early 2014, 20 Fijian nurses were brought into the country without any apparent discord in the health care community.

To Do

Despite the progress so far, PNG still has work to do. While the health sector has made considerable advances in the last year or so, the country has serious issues to address and some major work to do on its health system. Basic challenges common to most developing nations, such as the lack of access to improved water sources and modern sanitation, remain. According to the World Bank, in 2012, only 39.7% of the country has access to the former and 18.7% has access to the latter. This leads to a higher risk of water-borne diseases. The country also has a high incidence of malaria and tuberculosis, some of which is multi-drug resistant, while domestic violence also remains a persistent issue. According to the PNG Law Reform Commission, 80% of women in the country report being abused by their husbands, while 75% of the children in the country face physical abuse in the home, as per UNICEF data.

Other Indicators

Infant mortality is high. It remains at 48 per 1000 live births, according to the World Bank, while under-five mortality is 63 per 1000 births. Meanwhile, maternal mortality is estimated at 220 per 100,000 live births and only 43% of births are attended by a skilled health care professional. As PNG develops economically, problems of modern society are cropping up. Diabetes, heart disease, alcoholism and cancers are all on the rise as people live longer, as modern stresses increase and as more processed food is consumed. These issues are especially challenging in PNG as many people are rapidly transitioning from living simple but healthy lifestyles, eating natural, unprocessed foods and working outdoors, to more urban and fast-paced existences.

Many of the challenges facing the country’s health care system are simply a result of the difficult physical environment and the weaker economy. PNG is a relatively poor country with a population spread throughout a massive archipelago with vast expanses of mountainous terrain and dense jungle. Logistics are difficult and costs are high, with some areas only accessible by remote, difficult-to-maintain airstrips. Even under the best of circumstances, PNG would be a hard country for the health care sector.

Structural Issues

In addition to the difficult environmental and economic conditions, systemic failures have also been identified as contributing factors to the short-comings of the PNG health care sector. A 2011 report by the WHO highlights a number of the structural issues faced by the country. At the preventive level, health and risk awareness is generally low among the population and little has been done on a large-scale level to improve this.

Structurally, the health care network is somewhat complicated, leaving room for miscommunication. Health care services are primarily provided by the government, church organisations and at private projects (such as mines). Management of public facilities is split between the Department of Health, which is in charge of the management of provincial hospitals, while provincial and local governments manage all other facilities such as health centres, rural hospitals and outposts. The current arrangement is largely the result of the Organic Law on Provincial and Local Level Governments of 1995, which saw central control of some facilities devolved to the regions.

The Department of Health is responsible for developing sector policy, providing training, monitoring performance and managing public hospitals under their purview. Meanwhile, provincial and local governments are in charge of the implementation of polices and funding programmes for rural facilities. Due to conflicting priorities of the non-national governments, health care has often remained underfunded, despite more than 87% of the population living in rural areas.

The result of the Organic Law has been a marked decline in the quality of care and facilities. A function and expenditure review in 2001 reported that some 600 rural facilities had closed or were not functioning effectively, while the quality and quantity of services at other rural facilities had declined considerably. Recognition of current issues facing the health care system were in part what inspired Prime Minister O’Neill to make the sector one of the key focus points of his government. During a 2013 visit to Port Moresby General Hospital the prime minister told local media, “[The health care sector] has taken 40 years of neglect, we can’t fix it overnight. Be patient with us but in five years’ time we will do something.”

Growing Pains

Despite the raft of programmes being introduced and the general goodwill in the health sector, it will not be easy to overcome many of the problems that persist within the system. For example, the free health care programme may be difficult to implement. Because some people have avoided seeking health care due to prohibitive costs, the country is currently facing pent up demand for services and medicines. Many medical facilities may not prepared for this added influx.

Service definitions also remain a problem, with confusion persisting about whether charges can be made for ancillary services or supplies. Furthermore, who is to pay for specialised services and how much they pay remains unclear. Funding is also likely to be an ongoing issue, as long-term sustainability will depend upon the hospitals being able to remain solvent despite the increase in demand and the loss of an income stream. The question that hangs over all free health care programmes in other parts of the developing world also hangs over PNG: will the removal of user fees result in a decline in services and infrastructure?

The referral system is under particular strain, as smaller medical facilities are sending patients to larger hospitals immediately rather than acting as frontline gatekeepers. Observers also say that the system cannot work effectively until the programme has full buy in from all the participants. Currently, they note, patients are not always being welcomed with open arms, because the employees are stretched and because the care is free. Furthermore, without the right infrastructure in place, improvements at the some hospitals will be all but meaningless for people in very remote areas. Airstrips need to be repaired and roads need to be fixed and linked into the national network.

Direct Funding

One possible solution to many of the country’s health care problems is the introduction of direct payments to hospitals in a transparent, open manner, similar to the way in which schools receive funding for the tuition-fee-free programme. Doing so would end the delays to funding, approving expenditure and accessing cash. Direct funding was tested in a limited trial at nine hospitals in the Autonomous Region of Bougainville starting in August 2011, and this Direct Health Facility Funding (DHFF) programme was evaluated by the WHO in August/September 2013 at the request of the Department of Health. While a number of problems were identified, the pilot programme did show promise.

In some cases, institutions did not have proper procedures in place for the withdrawal of funds from the DHFF-linked bank account, and some hospitals did not prepare timely reports, making it difficult for the Department of Health to evaluate performance and financial need. In two cases, patients paid for ambulance services, and one centre continued charging user fees and was dropped from the programme.

A number of recommendations were made in the report to improve the DHFF programme. According to the WHO, the petty cash ceiling should be raised, the physical environment of health centres should be improved and the referral process needs to be fine tuned. DHFF does not finance drugs, so the mechanisms for delivering medicines should be made more effective and information systems should be improved. Overall, the WHO found that services provided at participating hospitals were better overall as a result of the programme, and the WHO and some officials within the Department of Health would like the DHFF system to be continued and expanded to make health care funding more efficient and responsive.

Outlook

Health care in PNG is poised to see major changes. Money is being provided and political support is coming from the highest levels, potentially marking the point at which care and service delivery can see improvements and begin to approach levels more in line with international standards. However, sector participants warn that the window for achieving meaningful change may be brief. The country needs to put the resources being committed to good use while they are available and not waste the political capital that is being expended. Successful reform could have a widespread social and economic impact.