PNG uses PPPs to improve health care delivery

The health care landscape in Papua New Guinea is informed by its topography and culture: its highland mountains and deep valleys are home to a multitude of indigenous peoples maintaining traditional ways of life while coping with health issues symptomatic of a developing country. Meanwhile, on the coast and in cities such as Port Moresby, rising incomes are increasingly leading to the kinds of non-communicable health issues more often seen in developed countries.

The government is thus faced with the complex challenge of funding and delivering appropriate health care to at least two distinct populations at once. Private investors, including churches and NGOs, already play crucial roles in bridging gaps and developing innovative solutions to the country’s health care needs, and such partnerships are both encouraged and expected to expand in the foreseeable future.

Basic & Universal

PNG’s health care system is delineated in the National Health Plan 2011-20, which places an emphasis on the provision of basic care for the country’s poor and rural population. The plan aligns with the PNG Development Strategic Plan 2010-30, as well as the nation’s Vision 2050 goals – one of which is to be among the top 50 countries in the UN Development Programme’s (UNDP) human development index (HDI) by 2050. PNG also measures its progress against the UN’s Millennium Development Goals.

Complementing the National Health Plan, the National Health Service Standards of 2011 outline a seven-level model of health service delivery. For the first time, minimum standards for health facility infrastructure and staffing levels were defined, standard equipment lists for each level of service delivery were compiled, and an accreditation system for hospitals and health centres was implemented. With the tacit acknowledgement that improvements in health care service delivery are required at all levels, the plan targets better integration between hospitals and rural health services such as community health posts. It also calls for the construction of new hospitals, including at the district level, as well as regional specialists and national referral mechanisms.

In addition, as its primary and principal objective, the National Health Plan aims to provide universal health coverage and equal access for the country’s rural population and the urban poor. At the national level, the National Department of Health makes and administers health policy, but the management of the National Health Plan is devolved to the provincial, district and local level governments under a system of decentralisation. The central government administers the national referral hospital, Port Moresby General Hospital (PMGH), along with specialist, regional and provincial public hospitals. Health services can be accessed at public hospitals and clinics, as well as at church-run health centres, which supply about half of all rural health services, and at aid posts staffed by community health workers and run by local governments and NGOs.

Church Assistance

Indeed, church-provided health services form an integral part of the national health system in rural areas. The Churches Medical Council (CMC) is the main body representing churches in PNG that are involved in the delivery of rural health services. Church organisations operate the majority of the country’s nursing schools and community health worker training schools, as well as many rural aid posts and clinics. These not-for-profit organisations are subsidised heavily by the government to the tune of about 80% of their service costs, but are overseen by the CMC. In general, they operate autonomously in terms of management, with no formal contractual arrangements with the government and no apparent connection to PNG’s health workforce formation or requirements.

Private Care

In addition to the public and church care facilities, PNG has 15-20 private health facilities – concentrated in Port Moresby and Lae – that provide inpatient and outpatient medical and diagnostic services. Enhancing these are clinics and centres set up by large companies operating in PNG to provide onsite health care for employees and their families.

Alternative Health Care

Traditional medicine and healers play an important role in PNG’s health system, especially at the village and district levels, and in areas that lack aid posts and health centres. To encourage and manage the use of traditional medicine, the government in 2007 passed the National Policy on Traditional Medicine, which aims to integrate traditional medicine into PNG’s basic health care system.

Funding

The government of PNG spent 4.5% of GDP, or about $114 per capita, on health care in 2013, according to the World Health Organisation (WHO). Approximately 20% of health sector spending comes from donors, with Australia being the largest of these. In addition, PNG has received special funding due to its status as a priority country according to the WHO’s Commission on Information and Accountability for the Global Strategy for Women’s and Children’s Health.

The coordination of these donor funds is managed by the Health Sector Improvement Programme, with the programme’s trust account pooling funds received from donors, government and global initiatives. Meanwhile, the Independent Annual Sector Review Group conducts health sector reviews, while a partnership policy steers cooperation between the PNG government and non-governmental health service providers.

Free Access

A new free primary health care programme, launched by the government in 2014, eliminates all user fees from medical centres and clinics, with the aim of making basic health care free for all Papua New Guineans. The government allocated PGK20m ($7.6m) in 2014 to launch the new system.

However, according to the “Promoting Effective Public Expenditure Project” report by the National Research Institute and the Australian National University’s Development Policy Centre, which examined expenditure in the country’s health sector and beyond, the new free programme might be the wrong prescription for the health of the nation. This is in part because user fees have been the only source of funds for 29% of health clinics surveyed in the report. Although the enhanced government subsidies should prove beneficial for clinics, this may not be the case in practice, according to one report author, Stephen Howes.

According to Howes, most of these health facilities do not have bank accounts and use cash derived from user fees to pay suppliers, and so have limited ability to receive the subsidy. The authors of the report, which was conducted over three years from 2012 to 2014, argue that the free system will actually leave clinics in worse shape than they are already in. Indeed, many of the health facilities surveyed in the report are already in dire straits. The report authors found that in 2012, 67% of surveyed clinic rooms and 77% of health worker accommodations required rebuilding or maintenance. A little over half of clinics they visited had year-round access to water, some 40% had electricity and refrigeration, 30% had access to fuel, about 20% had beds with mattresses and a kitchen, and only 33% had the ability to make patient transfers. Meanwhile, 75% of health workers said they had used a portion of their own salary to contribute to the clinics’ operations.

A Diverse Population

To say that PNG is multicultural would be an understatement. PNG is home to about 7.8m people speaking more than 800 indigenous languages and disbursed over 600 islands. For much of its history, the people who have inhabited the country’s mountains and valleys have lived in isolated settlements with minimal access to the amenities of modern life – including, in many places, health care.

The population of PNG is growing at an estimated annual rate of 2.1%, according to 2013 statistics from the World Bank. PNG is also a youthful country, with 38% of its citizens younger than 15 years and only 5% aged 60 or older. The fertility rate of 3.8 live births per woman contrasts with an infant mortality rate of 49 deaths per 1000 live births. Furthermore, people born between 2010 and 2015 can expect to live only into their early to mid-60s – compared to Australians born during the same period, who will live into their 80s.

In 2013, PNG scored 0.5 on the UNDP’s HDI, a ranking that places it below the average for the low human development group of countries and equal to that of the Solomon Islands. Lower respiratory infections, tuberculosis, diabetes and malaria were the biggest causes of death in 2012.

One of the main problems hindering the health sector’s development is that there simply are not enough medical professionals in the country. According to the WHO, PNG has 0.58 health workers per 1000 people. The organisation recommends 2.5 health professionals per 1000 people solely to maintain primary care. Indeed, this is borne out by the country’s ranking in the lower 20 countries – 149 of 161 – on Save the Children’s health worker index, a measure of the density of health workers, vaccine coverage and skilled birth attendance. The country’s low score is a reflection of the relative density of physicians in urban areas to the shortage in rural areas.

Of the overall urban population, about 318,000 live in the capital, Port Moresby, which is also where most modern health services are located. Furthermore, of the country’s fewer than 400 doctors, only about 50 practice outside Port Moresby. This concentration of physicians in the capital significantly skews the already startling statistic of one doctor per 17,068 people, since large portions of the country’s inhabitants do not have access to a physician at all. Still, a comparison of PNG’s doctor-to-person ratio to neighbours Fiji (one per 1000) and Australia (one per 302) highlights how important it is that the health sector receives urgent attention.

Disease Profile

While PNG is seeing rising rates of communicable diseases such as HIV/AIDS, malaria, tuberculosis, leprosy and water-borne diseases such as cholera, it is also seeing rising non-communicable diseases such as obesity, hypertension, diabetes, cancer and heart disease. This combination of typically developing- versus developed-country health issues makes providing the right kind of care to the right population even more complicated and costly.

Partnering For Health

An important objective of the National Health Plan is the implementation of the National Public-Private Partnerships (PPP) Policy, under which innovative and cost-effective options for delivering health care services are to be introduced. The plan defines PPPs as partnerships with capital investments of more than PGK50m ($18.9m).

Clearly, opportunities abound for private investment in PNG’s health sector. More teaching hospitals are needed to complement the PMGH, which has a partnership with the University of Papua New Guinea (UPNG). Until recently, PMGH had been the country’s sole clinical school. In fact, the country is beginning to reap the benefits of PPPs involving not only the private sector and government agencies but also in partnership with NGOs. A good example came in August 2014 when upgrades to Port Moresby’s Kaugere Health Centre were commissioned, resulting in a brand new PGK1.5m ($567,600) health facility with emergency services and an outpatient ward, as well as doctor, dental and family health services, and clinics specifically to treat tuberculosis and sexually transmitted infections.

At the inauguration of the new church-operated hospital, the prime minister, Peter O’Neill, said, “Today is an important occasion not only for Kaugere, but for PNG. It is an example of private, church and government partnership. We are able to achieve great things like this, the opening of the health centre at Kaugere.”

Two months later, in October 2014, O’Neill made another announcement about improvements to hospitals in the country. Goroka Provincial Hospital, in Eastern Highlands Province, is set to be redeveloped with funding from loans issued by Austria and the Czech Republic. Austrian company VAMED will conduct the redevelopment, which will see the construction of a new diagnostic and surgical centre, and a clinical school, the country’s second. A PGK30m ($11.4m) appropriation for the project will be included in annual budgets beginning in 2018 and will continue until the loan is repaid.

Clinical Schools

In February 2015, a memorandum of understanding between PMGH and UPNG was signed to establish an additional clinical school, either in Madang or on one of the New Guinea Island provinces. The hope is that as the country begins to train more physicians and other health care workers, more human resources to staff new hospitals and clinics will extend the reach of health care further into the country’s rural, hard-to-reach areas. “In a hospital environment you need people who care for human lives and I feel that the current administration has understood this fundamental issue,” Dr Jim Abrahams, the administrator of Angau Hospital, told OBG. New clinical schools will open up opportunities for medical students from all over the region. Space for students at UPNG’s medical school is limited, and most doctors for all 14 Pacific Island nations have traditionally been educated either there or at Fiji’s National University School of Medicine, with costs of up to $50,000 to educate each medical doctor.

Another long-awaited PPP initiative was announced when Pacific International Hospital (PIH), one of the country’s premier private medical and training hospitals, opened a new facility in Port Moresby’s Three Mile neighbourhood equipped with a cardiac unit, a heart lab and an MRI machine, among other cutting-edge medical devices. For the first time, PNG patients are now able to receive treatments such as open-heart surgery, previously not available at all in PNG. O’Neill has stated that the government intends to partner with PIH by allocating subsidies to treat public patients requiring cardiac operations and other specialist medical care.

“Our hope is to complement public hospitals, and for the government to have more PPPs to give more access to subsidised services,” Amyna Sultan, CEO of PIH, said in the run-up to the new hospital’s opening.

PPPs are also being leveraged to bring down disease rates. Oil Search, which controls more than 60% of PNG’s oil and gas assets, has called on the corporate sector to commit to regional health projects and embrace PPPs for development. Oil Search itself is working with the PNG Department of Health to combat HIV/AIDS, malaria and tuberculosis via its Oil Search Health Foundation. In conjunction with the government and NGOs, the foundation operates clinics in five provinces, providing treatment for HIV/AIDS, malaria, tuberculosis and maternal health. Oil Search’s managing director, Peter Botton, said the cooperation provides benefits for both sides. "Working with the Department of Health and others we can leverage our skills from all sides, and deliver much better outcomes than just on our own," Botton told Australian media in July 2014.

Another partnership, this time with NGO Australian Doctors International (ADI), sees volunteer doctors conducting health patrols to deliver basic health care services to rural communities in New Ireland Province. PNG’s largest bank, Bank South Pacific, donated PGK50,000 ($18,920) to ADI in February 2015, which will go towards more immunisations for New Ireland children, antenatal care for expectant mothers, dental services and general health education.

Good Neighbours

The disparity between the quality of life in PNG and neighbouring Australia, just 160 km south but worlds away in terms of health and wealth indicators, cannot be overstated. The Australian government recognises its responsibility to help those in need in its neighbourhood and has been a major contributor to PNG’s efforts to improve its health system, especially in the fight against HIV/AIDS.

On December 1, 2014, World Aids Day, Australia’s foreign minister, Julie Bishop, underscored her government’s particular focus on PNG by providing about $153m over three years to the Global Fund to Fight AIDS, Tuberculosis and Malaria in PNG. The fund connects various stakeholders with technical expertise and multilateral funding. Foreign donors provided 82% of total in-country spending on HIV/AIDS in PNG in 2012.

The Right Medicine

In 2012 the government updated the Essential Medicines List and developed its first National Medicines Formulary, and in 2014 the National Drug Policy was revised. The government is also continually instigating reforms to improve pharmaceutical and medical device procurement and distribution. A significant obstacle for rural health centres is acquiring adequate medications and supplies.

Between 1999 and 2010, the frequency that basic essential medical supplies were available in health centres seldom exceeded 60%. With the assistance of NGOs and other partners, novel pathways for procurement and distribution of drug kits saw this rate rise to 83% in 2011. However, without reliable electrical supplies and refrigeration, the storage of drugs and intravenous fluids at rural clinics poses another challenge.

Outlook

Many of the challenges in health care provision are linked to obstacles in other sectors, such as transport, infrastructure, manufacturing, education and security. The international community is contributing and playing its part to help PNG improve its health care delivery, facilities and services, but there is room for more activity, especially from the private sector.

As the free basic health care scheme becomes more established, the government will likely devise ways to further encourage more private sector participation beyond what is already on offer, and the number of PPPs already operating in the country will likely proliferate. Participation in this effort by firms involved in resource extraction is not only good public relations, but also good business practice. As the health of all PNG’s citizens improves, their ability to contribute to further economic growth also increases, to the benefit of all in PNG.