Papua New Guinea Health Profile 2012

National Department of Health's mission, vision and objectives

The overall mission of the National Department of Health is to promote the physical, social, mental and spiritual well-being of people in their communities, and to promote and encourage the maintenance of community health at an acceptable level by planning and delivering preventive and curative medical and other health services.

The vision of the Department is of a nation of healthy individuals, families and communities where self-reliance prepares all for healthy living in a healthy island environment, with the ultimate goal of improving the health of all Papua New Guineans through the development of a health system that is responsive, effective, affordable, acceptable and accessible to the majority of people.

The Government is focusing its efforts on improving child health and reducing malaria, tuberculosis and HIV/AIDS through specific programmes. To be a nation of healthy individuals, families and communities, and in the spirit of the National Goals and Directive Principles as enshrined in the National Constitution, Papua New Guineans strive for a future in which:

• fewer infants and children die before they have had a chance to experience life;
• fewer mothers die in childbirth from preventable causes;
• all Papua New Guineans have access to basic health care and good nutrition;
• Fewer Papua New Guineans die from preventable and treatable diseases including malaria, pneumonia, tuberculosis, diarrhoea and HIV/AIDS;
• women and men live healthier, longer, productive lives and age with dignity;
• villages have safe drinking water and a clean environment; and
• individuals make informed choices as regards health behaviour.

Organization of health services and delivery systems

Health services are provided by government and church providers (both of which are financed primarily from public sector funds); enterprise-based services (e.g. the mines); a small, modern private sector; and traditional healers (undocumented amount). Within the public sector, management responsibility for hospitals and rural health services within provinces is divided. The National Department of Health manages the provincial hospitals, while provincial and local governments are responsible for all other services (health centres and subcentres, rural hospitals and aid posts), known collectively as ‘rural health services’.

The National Health Conference 2001 supported a proposal to create a unified provincial health system. The proposal envisaged a single provincial health authority responsible for both hospital and rural health services, headed by a provincial director of health who would report to both the national and provincial governments. Thus far this system has only been implemented in four provinces.

Strategies to ease managerial difficulties include: amendment of selected public finance and management procedures; quarantining (earmarking) of health funds in provincial grants; delegation of powers over district health staff from the provincial administrator to the provincial health adviser; and alignment of treasury warrants to provincial budgets. Stronger monitoring mechanisms are being developed. A review of functions has recommended that provincial health budgets should make provision for each rural health facility individually, which may have implications for the current budget structure if all resources going to facilities from several different programme heads are to be captured comprehensively. This too still needs to be actually put in place.

Papua New Guinea receives significant levels of official development assistance (ODA), estimated to have amounted to US$ 203 million, or 7.2% of GNP, in 2001. Over recent years, ODA for health has fluctuated, but has been around 24% (2004) of total health spending.

A major new source of funds for health was opened up in 2005 with the signing for a US$ 30 million grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) for the country’s HIV/AIDS programme. In 2004, the Global Fund committed US$ 20 million for malaria over five years. A further proposal of US$ 21 million for TB was accepted in 2006 and, in 2008, a malaria proposal of over US$ 152.2 million.

Papua New Guinea does not have any form of private health insurance, although there is an initiative to introduce mandatory staff health insurance in the formal sector. In principle, health services are free. In most provinces, however, a fee is charged for outpatient visits. It is not clear in how much this acts as a deterrent to people accessing health services.

Churches are important providers of care, especially in rural areas, where they provide up to 80% of health services. They share many of the problems of public facilities, but appear to perform better in a number of areas. Papua New Guinea trains most of its health workforce and the churches run five of the seven nursing schools and all of the community health worker training schools.
Partnerships

Papua New Guinea has relatively few development partners. According to statistics provided by the Organisation of Economic Co-operation and Development (OECD), 96% of ODA for health in 1998-2000 came from Australia. Since then, other major external agencies providing loans or grants have included: the Asian Development Bank (ADB); United Nations agencies, including WHO; and the governments of Japan (JICA) and New Zealand (NZAID). Smaller contributions have been made by the United States Agency for International Development (USAID), the European Union and the World Bank.

In the last few years, there have been major government and partner efforts to ensure a more unified approach to health sector development. The 2001-2010 National Health Plan was developed after extensive consultation. There is now one annual activity plan for the National Department of Health and all donor partners. A Medium-Term Expenditure Framework was developed for 2004-2006, and was further refined to become a rolling plan. There are formal annual reviews of achievements, most importantly by the National Health Conference, attended by the National Department of Health, donor partners, churches and provincial government staff. In 2004, two bilateral (AusAID, NZAID) and three multilateral partners (UNICEF, UNFPA and WHO) signed a ‘partnership arrangement’ with the National Department of Health, formally entering into a sectorwide approach called the Health Sector Improvement Programme (HSIP), which ADB joined in 2006. This arrangement, through its management structure, has clearly strengthened day-to-day operations and coordination among development partners and with the National Department of Health. A jointly managed and financed Independent Monitoring and Review Group, which spends a couple of weeks in-country twice a year, is a key instrument in assessing the performance of the health sector in general and interactions between development partners and the Government, mainly the National Department of Health. This group provides recommendations on lessons learnt and best practices and guides the discussion on strategy development for the health sector.

The Country Coordination Mechanism (CCM), a requirement of the Global Fund to execute programme activities, has had a further impact on overall cooperation between the different stakeholders in Papua New Guinea’s health sector.

In 2006, under the leadership of the Resident Representative of the United Nations to Papua New Guinea, the EXCOM agencies (UNDP, UNICEF and UNFPA), as well as the other in-country and non-resident United Nations agencies (WHO, UNHCR, OCHA, UNIFEM, UNESCO and FAO), agreed to pilot a ‘Delivering as one UN’ approach in the country. Although Papua New Guinea (referred to as a ‘self-starter’) has not been formally included in the first eight pilot countries, there are indications that the Papua New Guinea common United Nations Country Programme is more advanced in the process. The bearing of this on the health sector remains to be seen.

Nurses and community health workers form the backbone of primary health care services in rural areas, and both are considered to be in short supply and dramatically reduced. These shortages constitute a serious constraint in implementing the National Health Plan, including the priority programmes. Some provinces and many districts have no doctor.

The passing of the Organic Law exacerbated existing problems in health staff supervision and support. Provincial health advisers lost much of their authority to supervise and discipline district health staff. National Department of Health oversight of provincial staff is also limited. Reasons include the limited capacity of programme units at the central level; the lack of funds for travel; the lack of economies of scale through joint training and supervision across programmes; and delayed disbursement of funds. As a result, rural health services are poor and deteriorating.

A function and expenditure review in 2001 described the health system in rural areas as being in a state of “slow breakdown and collapse, currently being saved from complete collapse by donors”. The review stated, “About 600 rural facilities are closed or not functioning effectively. Where services remain, the breadth and quality of the services are diminishing.” This dire situation has worsened since then, and more facilities have closed down. In spite of this being acknowledged for some time, little has been done yet to seek redress. The scarcity and maldistribution of human resources for health has not been addressed effectively, and there have only been limited and not very coordinated efforts in training and other approaches to capacity-building. Recommendations from the Human Resources for Health Forum, conducted in 2008, included the urgent need to upscale health care worker training and to develop a human resource development plan. Action on these recommendations is still pending.

There has been no proper assessment of the national health information and surveillance system for many years, resulting in a lack of timely and reliable information for decision-making. The surveillance system is weak and there is a lack of capacity for conducting proper surveillance. Consequently, most information on communicable disease outbreaks come from the media.

At all levels, there are very limited capacities for outbreak response, and current central government policy of putting a ceiling on staff numbers does not allow for recruitment of more staff for the health system, especially in the peripheral areas. The National Department of Health is making an effort to strengthen communicable disease surveillance and to build outbreak response capacities by re-establishing its Disease Control Branch and recruiting staff for communicable disease surveillance and outbreak response, but the process is still ongoing.

There is some laboratory capacity and a laboratory network in Papua New Guinea, but laboratory services are generally weak. The Central Public Health Laboratory (CPHL) in Port Moresby is responsible for overall coordination of operations for communicable disease diagnosis, while the regional and provincial hospital laboratories form the backbone of the country’s laboratory network. Some health centres also have some limited laboratory diagnostic capacities.

Medical supply and drug procurement and distribution face many challenges and ‘stock-outs’ are common occurrences. The distribution system is often dependent on ad hoc solutions. A 2006 survey showed a high level of susceptibility to corruption in the pharmaceutical sector. Although the necessary regulations are in place, they are not being enforced and there seems to be collusion between the approving and procuring authorities. There is anecdotal evidence that the prices paid for drugs may be up to several times higher than those available on international markets. In 2008, on the advice of an independent drug procurement mission, procurement was separated from the regulatory side in medical supply.

HEALTH & DEVELOPMENT
The major health problems have remained largely unchanged in the past fifteen years, although there are recent indications of an epidemiologic transition beginning to take effect among some populations. The leading health problems continue to be communicable diseases, with malaria, tuberculosis, diarrhoeal diseases, and acute respiratory disease as major causes of morbidity and mortality. PNG has a generalized HIV epidemic, driven predominantly by heterosexual transmission. Care and treatment for people living with HIV have improved significantly since 2006.

Although there has been a downward trend in infant and child mortality, the rates are high compared to other countries in the Asia Pacific region. Maternal mortality remains very high and the Demographic Health Survey 2006 suggests that it has increased over the last decade. Addressing effectively MDG 4 & 5 are therefore key priorities for Papua New Guinea.
Health services are provided by the Government and non-state providers, mainly the Churches and to lesser degree economic operators and primarily financed by public funds. To date, a high level of fragmentation in the institutional and fiscal relationships between national, provincial and lower levels of government has contributed to the poor health outcomes. There is an unclear allocation of responsibilities for service delivery which creates significant barriers to improving access to services. Improving of rural health services is perceived as a key to improve health outcomes and attaining the health related MDGs.

The new National Health Plan 2011-2020, is developed in accordance with the Government’s development strategy, along with a redesign of the sector-wide approach and pledges for a stronger involvement of Central Government Agencies in the health sector. These changes are being enacted within the context of increased emphasis on aid effectiveness, harmonization among development partners and the United Nations reform process. Together, these both compound the challenges and create new opportunities for the WHO country office.