5 Responses

  1. Grant Walton
    Grant Walton October 18, 2013 at 8:06 am

    Thanks for the reference Jane, we’ll be sure to check it out.

    1. Jane Thomason
      Jane Thomason October 22, 2013 at 4:47 pm

      Hi Grant,

      An understanding of history teaches us about the present – the table below is in the reference I cited – it helps understand the precedents of the “lost decade.”

      Table 1: Key contextual factors which have shaped the health system

      Pre-Independence (Pre 1975)
      • Significant gains made in the health status of the population, with improvements directly attributed to the provision of health services (2).
      • Centralised organisation and administration of health services, with highly-defined vertical public health programmes designed and implemented with emphasis at the district level.
      • Highly centralised control ensured effective management of resources by a functioning bureaucracy that closely supported delivery and management of health services.
      • Provincial hospitals provided technical and logistical support whenever required.
      • Significant numbers of international contract officers in line management and service roles at national, provincial and district levels.

      Early 1980s
      • Australia provided direct budget support after Independence.
      • No bilateral donors in the health sector (only the Asian Development Bank (ADB) and the World Health Organisation (WHO); and ADB funds flowed through the government budget).
      • Coordinated process in place for planning the development budget, and clear separation of the recurrent and development budgets.
      • Organic Law on Provincial Government (OLPG) – Rural health services were transferred to provinces; hospital services were delegated to provinces. (See also Day in this volume).
      • National Department of Health (NDoH) left with no effective mechanism to maintain standards and ensure health policy implementation in hospitals and rural health services.
      • Provincial governments saw the decentralisation as a chance to ignore the NDoH.
      • Appointment of provincial health officers became politicised.
      • Mobility of the health workforce declined as staff became part of provincial establishments.
      • Functional roles and responsibilities were poorly defined; leading poor resource allocation, lack of coordination and inefficient management of health services, and the deterioration in quantity, quality and coverage of basic health services.
      • Wingti Government redirected resources to economic sectors, resulting in a progressive decline in the available resources for the operation of health services.

      Late 1980s
      • 1986 – Australia began discussions about moving from budget support to programmed aid.
      • PNG reacted by turning to other donors. In a very short period, the following donors became active in the health sector: United States Agency for International Development (USAID; Japan International Cooperation Agency (JICA); People Republic of China and the European Union (EU). The net effect of multiple bilateral donors created a huge management burden on the NDoH. Much of the funds were extra budgetary funds and not reflected in official budgets.
      • 1983–1988: real per capita expenditure for health fell by 9%.
      • Capital expenditure on hospitals fell from about 14% in 1978 to 4.5 % in 1987.
      • Projected a shortfall of K24.7 million in 1995 to grow to K40 million by the year 2000 (19).
      • Aid post orderlies became public servants.
      • Rural patrol allowances were more than doubled in a single decision, but were not budgeted for, with the effect that patrols were significantly reduced.

      1990s
      • Major revenue shocks.
      • Bougainville crisis – Bougainville contributed approximately 16% of national revenue.
      • 1990 – 10% devaluation of kina.
      • 1994- further devaluation of 12 % and floating of kina resulting in further devaluation.
      • Progressive reduction in Australian budget support from 24% of total revenue in 1984.
      • Staffing shortfall estimated to be 1,440 nurses and 1,655 community health workers (3).
      • Public Hospitals Act (1994) makes hospitals quasi-statutory authorities, responsible to an independent board of management reporting to the national Minister for Health—largely causing hospitals to stop supporting the rural health care system.
      • Economic crisis point in 1994–1995, with several branches of government unable to meet debts or salary commitments.
      • Structural adjustment programme and a programme of microeconomic reforms including to reduce public servants— aid post orderlies, now public servants were shed in large numbers by provinces as part of the reforms.
      • By 1999, the Australian Agency for International Development (AusAID) had 16 separate projects and programmes operating in the health sector.
      • In 1999 the Secretary for Health reported he spent 70% of his time servicing donors.
      • In 1999, the NDoH requested that AusAID support a move towards a Sector Wide Approach (SWAp) in the health sector.

  2. Ron Duncan
    Ron Duncan October 17, 2013 at 7:59 pm

    It is disappointing to see that in the presentation of the results from the survey on the changes in Education over the past decade in PNG that there was no measurement of the learning outcomes from the increased expenditure. There are many other measures of outputs shown, such as enrolments, student attendance, and teacher behaviour. But there is no measurement of the most important outcome–whether students improved in the Three Rs. In his latest book, “Schoolin Ain’t Learnin”, Lant Pritchett reports that enrolments, attendance, and such have been increasing across the developing world. But reading levels have not improved at all!!

    I would have thought that the main lesson from studies on the effectiveness of aid–that we have to measure outcomes–would have been learnt by now.

    1. Grant Walton
      Grant Walton October 18, 2013 at 8:01 am

      Hi Ron,

      Thanks for the comments. The blog highlights some of the preliminary results from the PEPE survey. We’re still in the early stages of data analysis, which has been focused on outputs (we’ve got at least another year of analysis still to come). Over the next few months we’ll be examining how the schools we visited faired in terms of student performance, and we’ll look at some of the drivers of education outcomes.

      Having said this, the preliminary results do augment our understanding about the condition of schools and health facilities, and how this has changed over the past decade. Policy makers are finding these results useful. Our findings have informed debate around the new free health policy, and the Acting Education Secretary has said he’ll use the results to argue for a prioritisation of education funding. You can hear the Acting Education Secretary talk about the findings of the PEPE study here: http://www.radioaustralia.net.au/international/radio/program/pacific-beat/png-government-tackling-shortage-of-thousands-of-teachers/1203380

      Cheers,

      Grant

  3. Jane Thomason
    Jane Thomason September 28, 2013 at 2:28 pm

    The findings of this report are sadly unsurprising.
    In the Papua New Guinea Medical Journal Volume 52, Number 3-4, September-December 2009, Focus Issue on Health Systems Strengthening, edited by Professor Maxine Whittaker and me – we review the achievements and lessons from the past decade and provide some leads on where, investments should be made to improve the outcomes of the health system. We emphasise the need to focus on five basic elements:
    1. Effective interventions for main causes of morbidity and mortality; where and when required (these are well articulated in the national health plan)
    2. Skilled health workers at the point of service who are able to provide those interventions (this is an issue that was identied in the 1980’s and has received insufficient attention)
    3. Essential logistical elements to enable the health worker to provide the effective intervention (drugs, medical supplies, equipment, transport, treatment guidelines etc)
    4. Information, education and communications, and other health promotion initiatives andefforts directed at communities—to obtain their cooperation and acceptance of the interventions; and to support and empower their engagement in healthy behaviours
    5. Population coverage.
    These remain the priority needs of the PNG health system.

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