Comments

Professor Mola, many thanks for taking the time to share your detailed knowledge on this topic. It's exceptionally valuable. I was particularly interested to learn that many women are already seeking out care at provincial hospitals, indicating that it's not demand for supervised births that is lacking but rather the supply of quality services close to where women live. Thanks also for highlighting the pilot project in Milne Bay (has that been published or more information available? I would love to read about it in more detail).

Fabulous analysis Camilla and yes, one positive is that this is being discussed by high-level leaders. This policy will certainly be doomed to failure unless there are huge increase in capacity building and funding for education of more human resources for health -. for PNG midwives, nurses and doctors in line with population increases, there needs to be a dedicated workforce for reproductive health. Funding for infrastructure, funding for heath supplies and drugs, funding for good health management in the LLGs, districts and provinces, funding for maternity waiting homes and emergency transport to referral hospitals when needed. It is so much more complex than making facility birth compulsory and bringing in Cuban doctors. How will women travel to health services? Who will provide them with skilled birth attendance when significant health system capacity building is needed? Why would women engage with the health system when there is not even gloves available in the national referral centre in Port Moresby? Thanks again for your blog on this vital development issue.

It is great idea and very commendable that the PM has decided that he is going to do something about the horrible rate of maternal and newborn death in PNG by encouraging (making it compulsory) women to have professionally supervised births in health facilities. However, this plan needs to be very carefully thought through, as it could end up as an enormous waste of money without very much good effect. There are about 260,000 births every year in PNG. Of these about 104,000 women come to health facilities to have a professionally supervised birth, but this also means that 156,000 women deliver their babies in their villages without professional assistance. This is a huge number, and while it is absolutely critical that women must have a supervised birth if we are to reduce risk of maternal and newborn death, the parts of the health system that the PM says he is planning to bring the women to for supervised birth (ie urban areas), hospitals are already overstretched and many are unable to cope with the numbers. For example at PMGH 15,000 women came to the public labor ward to deliver in 2015, - ie. over 40 per day, but we actually only have 24 delivery beds in the labor ward. This means that many women cannot be allocated a bed to have their labors supervised when they arrive, and some end up delivering on the floor or the in reception area. These circumstances, of course do not produce optimal outcomes, and if extra women are to be brought in from rural areas of Central Province (and the Eastern end of Gulf) to deliver at PMGH, bed space will be quite insufficient and staff will not be able to cope. In fact all over PNG provincial hospitals in the urban areas are being inundated already by women from rural areas coming to have a supervised birth in town. This is because rural health facilities are either not accessible to village women, or women do not trust them (because they are run down, ill-equipped and poorly staffed), or lack of supportive management in the health system over many years means that many rural facilities do not remain open 24/7 and thereby give women and their families confidence that by turning up at a rural facility in the middle of the night or over the week-end, that there will be a skilled person available to receive the woman in labor and look after during her birthing process. The figures paint a stark picture; 40% of women in PNG currently have a supervised birth, but rural facilities typically only supervise less than 10% of the births occurring in their catchment areas, - this is because women are either staying at home or are bypassing their local rural facility and travelling all the way to town for their supervised birth. I personally don’t think that it is sensible to ‘fund women to come to urban areas to have their babies’ as suggested by the PM; the hospitals in towns are already overburdened and having difficulty coping with the women who are already coming. What needs to be done is - Building capacity in the rural sector; upgrade birthing units in rural health facilities and equipping them properly, but also - Upskilling CHWs and nurses to provide quality birthing care for women in rural health facilities, and - Training more doctors, nurses, midwives and CHWs to provide quality health care for the expanded rural health service – so that the majority of women can access life saving supervised birth close to their villages. All this will require massive capital expenditure in health manpower training and upgrading, and also building, upgrading and equipping health facilities to cope with an extra 150,000+ women per year who will need birthing care in the PM’s plan. It can be done. In fact a pilot incentive program in Esa Ala district of Milne Bay province has been able to increase the supervised births from less than 40% to more than 70% in just 3 years by incentivizing both supply side (facilities and staffing) and the demand side (helping women to want to come to rural facilities by direct incentives to them and their families, to do so. Bringing women to urban areas to give birth will not only overburden the already overburdened city hospitals, and possibly thereby cause deterioration in birthing outcomes, but it will also lead to massive rorting of transport and accommodation monies. Calculation of the due date for the birth is at best plus or minus 2 weeks. Therefore women would have to receive expert antenatal care in their home areas in order to work out their due dates (not available at the present time), and then be transported to town at least 2-3 weeks ahead of the due date to await onset of labor. Most women would therefore end up spending 3-4 weeks in town. If we calculated that they could be accommodated for about K100-150 per week in purpose built hostels (yet to be constructed) or in the homes of wantoks with accommodation support from government, this would amount to about K100x4x150,000women per year = K60-90m per year in accommodation costs, in addition to the transport costs and the medical costs of the urban maternity care. Total costs could be several hundreds of millions of kina; money that would be much better spent on building capacity for maternity care closer to their village homes and incentivizing their use of rural services as has been done in Milne Bay province. The PM also needs to know that Cuban generalist doctors do not have O&G training or skills in maternity care. This is not how the Cuban medical training systems work. And, specialist obstetrician Cuban doctors are very narrowly trained to operate in advanced hospital environments. Therefore I don’t think “Our aim is to bring them (PNG women) into towns and cities and hospitals where there is adequate care that we are going to build up because of the Cubans and the sup¬port of the doctors that we are going to roll out,” Is going to be a viable strategy to achieve what the PM has in mind. Mr O’Neill needs to speak more with his local maternity care experts to help strategize his very laudable goal of supervised birth for all to reduce maternal and infant deaths in PNG. But above all, he needs to find many hundreds of millions of Kina to do it. The money is there in the DSIP and PSIP accounts. Let’s use the money for good effect rather than wasting it on misdirected strategies and overseas doctors.

This and similar camps are the responsibility of the international community - that means us as one of the most, affluent members of that community. Do we put so much emphasis on Nauru and Manus that we are distracted from the bigger, deeper problems of refugees elsewhere?

Very well said, Ellen, I couldn't agree more. There are certainly supply-side issues to take care of, but demand also needs to be looked at very closely. And, any proposed policy needs to recognise that those demand-side constraints will likely vary considerably, particularly in a country as diverse (culturally, economically, geographically) as PNG.

Hi Camilla, I agree, particularly, the idea of giving PNG women the ‘opportunity to express their views and experiences around childbirth’. There are several processes to follow, including consultations with women and various stakeholders before introducing any legislation. PNG continues to have persistent woeful maternal health outcomes despite huge investments by development partners in the health sector, growth over a decade before the current economic conditions, several major policy and political reforms and changes, and numerous studies on health service delivery. However, there has been limited attention given to significance of user (demand)-side factors that shape health beliefs of users, which ultimately influences health care-seeking behaviours (HSB), health service utilisation and outcomes. Maternal health outcomes and indicators cannot be improved if the focus of improving this area is provider (supply)-driven. The use of legislation to make it mandatory for all women in PNG to deliver babies in formal, modern biomedical health facilities, is like using a whip to force someone against their will. Without addressing barriers at health facility levels (supply-side) and not having an understanding of the constraints faced by mothers in accessing and utilising health services (demand-side), and introducing legislation to influence women to deliver at health facilities is insensitive. It does more harm than good. This is symbolic violence where the State uses legislation to legitimate its power and imposition over other groups and classes. There are deeper socio-cultural, economic, and physical factors to address on both supply-side and demand-side of health services. Any intervention to address maternal health outcomes need to understand these factors for the interventions to be practical and useful. Interventions aimed at improving maternal health service delivery are doomed to fail without considering barriers on the demand-side that prevent health service utilisation.

As far as agriculture, international development and economic coherence I understand and support this tax. I wonder whether through increasing the costs borne by farmers, the backpacker tax could lead to increased costs of fruit - really a detrimental outcome from a dietary perspective?

Thanks, Tony. Yes this is certainly prime territory for an RCT!

Hi Neil, Thanks for your useful notes. I've also read some critiques elsewhere of the JSY initiative, but didn't want to get too bogged down into the details in this post (not least because India and PNG are such vastly different contexts, and I think there can be real dangers in applying a cut-and-paste approach to interventions). Clearly any approach has to be comprehensive and evidence-based, taking these kinds of lessons into account but also being aware of the potential for unintended consequences. Thanks again, Camilla

Hi Camilla, Addressing demand side issues, such as compensating for the cost of travelling to a health clinic, is a good idea. Making it compulsory is a recipe for disaster, although one would need to seriously question any enforcement of the policy. An important question to be answered, which also applies to basic education, is what are the main demand side constraints. As with schooling, issues around cost (fees, travel costs, etc.) is important but not necessarily the main demand side constraint. I would argue, as you also mention, that service quality concerns are probably just as important. The Cuban doctors idea is great, but unless they bring their own water, electricity, drugs, equipment, and support staff then quality is not likely to improve. An RCT is needed to test how quality improvements, incentive payments to women for supervised births, and a combination of both treatments, impact on levels of supervised births and maternal mortality. Of course, this evidence is needed before important policy decisions are made.

Paraphrasing the IEG World Bank re: cash incentives increase facility deliveries but they also increased the fertility rates and without investment in health service strengthening, they did not alter the maternal mortality rates. My notes - not a quote ....Increasing utilisation of services alone does not necessarily lead to better health outcomes within the services. Janani Suraksha Yojana (JSY), a government initiative in India, gave cash to women who delivered in a hospital or health facility. The initiative also gave health workers incentives with a cash transfer for every delivery they attended. This combined effort led to a highly significant increase in both facility births and skilled birth attendance in general. Note JSY found a significant increase in SBA but also finds that while the cash incentives do increase facility deliveries, they also increased fertility rates and had no discernible effects on neonatal or maternal mortality. Note other successful interventions of this type included health system strengthening (e.g Progresa and CSR).

Hi Peter, I think what this shows is the complete lack of leverage the Australian government has in PNG. The Manus agreement under which Australia committed to pay for 50% of the Angau reconstruction also committed the PNG Government to pay for the other 50% and for PNG to meet "ongoing recurrent operational costs" See http://dfat.gov.au/geo/papua-new-guinea/Pages/joint-understanding-between-australia-and-papua-new-guinea-on-further-bilateral-cooperation-on-health-education-and-law-and.aspx Yet not only is Australia proceeding with the reconstruction without any funding from PNG (as Daniel Flitton has reported) but we are proceeding in the face of PNG slashing recurrent funding for Angau. It's not that PNG is cutting back because Australia is picking up the slack (the major investments are still to be made) but rather PNG cutting back and Australia proceeding regardless. Regards Stephen