Reflecting on 25 years of research into health service delivery and the health status of women and children in Papua New Guinea, it is distressing to observe the current catastrophic failures and continued decline in services for women and children. The anticipated improvements to health services from mining and liquid gas royalties have not eventuated, and the problems of corruption and inefficiency in service provision are compounded by the government’s apparent lack of concern for the health of the population. This has led to a crisis in public health. Although the budget allocation for the Department of Health has increased, most interventions in public health remain dependent on foreign aid agencies. Research assessments of population health are almost all managed or funded by outsiders.
Decades of financial and technical assistance from the Australian government, other international donors, and a range of NGOs notwithstanding, the health of PNG’s population is declining. Diseases that in the past had been brought under control through immunisation now seem to be reappearing with the reduction in fully immunised children and the increased difficulty of maintaining a reliable delivery of vaccines. Tuberculosis (TB) is now categorised as a pandemic, with PNG one of the worst-affected countries in the world. Health service delivery to rural areas is increasingly difficult, with a lack of trained staff, low wages, deteriorating buildings and frequent lack of critical drugs and dressings.
Of all the Millennium Development Goals that were not achieved by PNG, those specifying improvements in women’s and children’s health are perhaps the most egregious failures. PNG’s maternal death rate of 215 per 100,000 is the highest in the Pacific region and among the worst in the world. While infant mortality has shown a steady decline since 2000, currently it is 37 per thousand live births compared to 14 in the Solomon Islands. Women’s and children’s health is disproportionately at risk, particularly in rural areas, and TB is now the major cause of death of women between the ages of 15 and 44 years. Leprosy has increased by 25 per cent in recent years, with a high proportion of those affected being women and children in rural areas. Childfund Australia observed that TB was becoming a scourge for children, many of whom are not diagnosed or treated.
Recent reports of very high rates of child malnutrition and stunted growth in children under five years are cause for alarm for the future mental and physical health of a generation. Hou’s 2015 examination of the stagnant rates of child stunting in the country found that: “Malnutrition in PNG is prevalent and severe… the overall stunting, underweight and wasting rates are high, 46 per cent, 25 per cent and 16 per cent respectively and varies across regions.”
Where does the money go?
As many researchers of PNG health service delivery over many years have found, health funds go missing. An independent assessment of the PNG National Department of Health in 2013 found that in spite of millions of dollars in donor aid and an increase to the national health budget, service provision, infrastructure and management were not functioning effectively. The problem of accountability generally and the muddled reporting mechanisms do not permit clear figures for expenditure – making it difficult to trace funds accurately. Corruption and misappropriation are rarely examined in the context of health services but rumours and anecdotes support the view that funds are very often diverted or simply ‘go missing’. There is a great deal of slippage and blockage of funds, and funding simply fails to arrive at its designated destination.
But it is not always just funds that go missing, critical staff are often not to be found. A recent case is one of many examples of system failure. Desperately needed HIV anti-retroviral drugs, syphilis treatment kits and oxytocin drugs needed to treat newly delivered mothers had run out and a New Zealand aid-funded shipment of drugs was on the wharf waiting for customs clearance, but the person responsible for processing the release of drugs was ‘missing’ and apparently nobody else was able or available to perform the task. There are a number of anecdotes of health shipments waiting on the wharfs for months.
Resolution of some of the problems requires commitments to change in numerous departments that no government of Papua New Guinea has been prepared to undertake. The “locked-in absence of political will” observed by Susan Crabtree extends to all areas of health service provision.
Governance in health systems
Governance of the health system remains a problem. The enthusiasm of development theorists and practitioners for improvements in governance embraced the introduction of corporatist managerial methods as a means to this end. Endless audits, flowcharts, grids, log frames, workshops and surveillance strategies later, this approach appears to have achieved little. Failures of leadership, breakdowns in communication, lack of transparency, and a host of other systemic problems have been identified, and managerial solutions prescribed to resolve them. But assumptions about the universal applicability of managerial systems not only ignore the practical difficulties for the health sector staff in PNG, but are also blind to their neo-liberal foundations.
The gulf between rich and poor is widening and economic dependence on resource extraction incomes to narrow that gap has proven chimerical. There is no political will to tackle the multiple complex problems that are manifest in poor public health generally, women’s and children’s health in particular, and declining services to remote rural communities.
This blog post is based on this article in Development Bulletin No. 80.
Thanks for sharing valuable information with us.
Thanks for sharing.
Dr Kitau
The rural community fall victim to a selfish Government! Australia Aid needs to be delivered tangible to the rural communities.
Thanks for your timely and important insights Martha. I really wonder how to maintain visibility on this human catastrophe. And beyond that, how to get action out of visibility. I published a piece on the PNG health/medicines crisis in the New York Times late last year, figuring that the APEC moment was ripe to put these into the frame. The story set out to join the dots between corruption and the total breakdown of the medicines and medical supplies systems, and the shattering human consequences of that. Which were and are absolutely explicit (under underlined by some punchy quotes from Stephen Howes joining the dots on Australian political squeamishness and Manus). And it got … zero traction. (Story was here fyi https://www.nytimes.com/2018/11/13/world/asia/papua-new-guinea-apec-polio-health-crisis.html)
Thanks for the link Jo, I missed that article. And yes, it is so dispiriting seeing the situation worsen on every front.
Great to see this blog Martha – long overdue.
You might be interested in the article I published from a small post-doc project.
Crabtree, Susan, and Hilary Clare Tolley. “Governance for maternal and neonatal health.” International Journal of Health Governance 23.1 (2018): 4-17.
I shall read it with interest. Your thesis is indubitably one of the best studies of the health situation for women in PNG that I have read in years. Is it to be published? I hope so. But alas, good analyses can only identify ways of dealing with the problems. The political will to solve it is what is needed now.
As a rural doctor for the last 15 years, I can only ‘shut up’ and accept these well outlined facts rather than pretending that everything is okay. We the rural majority are feeling the pinch of all these facts; while the few urban advantaged seem to be challenging the facts presented here. I wonder who they are representing.
Taiye, I am well aware that often the facts are hard to acknowledge, especially when they are made by an ‘outsider’. Over the years I have spent a lot of time talking with people who work in the PNG health system. I have enormous admiration for their dedication and capacity to carry on treating people in extremely difficult circumstances. But as you can read in the longer version, my criticisms are also directed at the sort of aid programs from Australia that concentrate on systems but cannot be implemented because the basic things are not there – good facilities, reliable pharmaceuticals and equipment, well-paid staff, emergency medical service provision. I was constantly amazed at how low wages are for highly trained nurses – maybe I should write another blog!
Martha, it’s really a nice piece
Your story line really denoted what was actually the sad situation in PNG health system. I am a village boy once in the 1980s, lived through with the changes in the basic service delivery in the 1990s in my youth, now am an educated father facing this reality.
I have seen the reality on the ground; on the economic front, I lived to witness extremely gross and highly ignorant corruption in the country systems, basic service delivery is far than corruption. Not only in health but its right across the different sectors.
Also PNG has a weak basic service delivery enforcement capacity including law enforcement body, so what in hell that we live in. Policies and programs are developed, but there is weak institutional capacity to enforce it.
Now the country debts has gone up past the 35% fiscal limit so PNG is nowhere near to delivering a decent or nearly adequate basic services to its citizens. The country needs to service the debts first before funding basic services.
Donor funds will not adequately address health problems in PNG. It’s the government that needs to take the lead.
I Have been working for oil, gas and mineral companies as senior medical officier for the past 6 years (western highlands, gulf, new Ireland). Some companies play the game and provide the same level of health care as their workers and families would find abroad (TB prevention, malaria, dengue, thyphoid , child and mother..). The budget put in was over 4 million US every month for health in these companies (for about 2 000 workers). We saved so many lives just thanks to early diagnostic and proper management. On another hand some companies don’t play the game . I have been working for companies who don’t play the game, one making over 9 billion dollars profit every year over the world and would save money over health: proud to purchase toys for paramedics and not providing proper management for TB in Gulf province. Proud to point out they had a budget of 400 000 dollars in a year when in their own country , the budget would have been around 10 million a year. Medical board is great in PNG, They should visit these sites and fine companies who don’t have a proper health policy for their workers and families. A fine of 10 000 dollars for each worker not screened properly for TB (QFT minimum and Xray as needed), not vaccinated properly…..
Thanks for your response. I agree entirely.
Yes indeed – having undertaken research in Lihir for a decade (1995-2005) and seeing various other facilities in areas affected by mining, the variations are deplorable. But ultimately the PNG government is responsible for the health of the population and income from resource extractive projects seems to vanish into thin air. When some places have adequate, or even excellent, health care provision and others have none at all the government should be held to account.
Martha
Spot on – except here in Western Highlands where we are making some progress as we have a great team who are committed to improving health. I invite you to come and see for yourself as being the CEO, I might be a touch biased. I cannot offer fares etc but can accommodate you in secure and friendly environs. And contrary to rumours we stopped eating babies a long time ago. So come and have a look at what can be achieved. Of course the pity is the Port Moresby narrative makes it difficult for donors to invest in the pointy end – where the action is – and many keep telling me why they can’t invest here rather than how they could. I guess that has to do with career aspirations and sticking to the script.
I would love to take up your offer. It has been a while since I was in PNG, but I follow the health reports, newspapers and literature as much as possible. As an anthropologist who worked in PNG for forty years I feel deeply upset by the downward trend in rural areas.
A significant piece. Time is well overdue for available facts to be reported about health services and the treatment of women in PNG.