Comments

Good comments, Jo. You are certainly right in saying that Governments need to invest in primary, secondary and tertiary care for all sorts of reasons, including public health, ethical, and political reasons. The question they face is, what is the "right" balance, given growing needs and constrained resources. There are certainly some expensive and technically complex operations that can only be done in hospitals - and possibly even overseas - that are justified on public health, public finance, and ethical grounds. Surgery to repair a hole in the heart (an NCD, but one often arising from rheumatic fever) for young children would often fall into this category. That is because it restores a young person to essentially good health. Removing cataract blindness, if necessary in a tertiary hospital, may also be entirely justified on public health, public finance, social, ethical and other grounds. But there are other examples where so called "curative" treatment at the tertiary level is hard to justify, other than on political grounds. The report shows that dialysis treatment in the Pacific can be very expensive in absolute and relative financial terms to Government, whilst being of limited effectiveness in terms of extending life (around two thirds had died within two years). Perhaps most importantly, expensive dialysis treatment in response to diabetes related kidney failure carried very high "opportunity costs". That is, every one thousand dollars spent on expensive but largely ineffective dialysis on an (often elderly, and often not particularly poor) dialysis patient was then another thousand dollars that then could not be spent on more cost-effective interventions, reaching many more poor people, to meet their needs, including immunisation, family planning, and other basic health services. As you very correctly point out, this all involves very difficult policy choices and trade offs for governments. My argument is that better and more effective primary and secondary prevention is often likely to be more effective, and equitable, in terms of health financing than some end - of - life 'curative' treatments at tertiary hospitals. And to the extent that primary and secondary prevention is effective it will also reduce - or at least postpone - over time the costs associated with treating complications of NCDs at the tertiary level. Thanks again for your thoughtful comments.

Thanks for raising this significant issue. I like the fact that you point out the strategic approach can have 'win-win' consequences. My comments may relate to what was said in the video, which I am unable to watch due to data limitations. So my apologies if I am repeating what is already said. It seems to me that one of the issues regarding finances is that governments actually need to invest simultaneously in health promotion/primary prevention and secondary prevention (in order to prevent future NCDs and the progression of disease in those with early risk factors or disease) and tertiary care for those who already experience the consequences of advanced disease. There are difficult trade-offs to be made and the people who will die if they don't get dialysis (for example) often have an emotive pull over those who do not yet have signs of disease. Further, this is not merely a challenge for any country's health system. It is multi-sectoral, related to wider issues, such as income, land access, education, gender roles, and cultural perceptions surrounding body size and image (to name a few). Addressing NCDs and their risk factors requires social and economic changes. To my mind, it is certainly a 'wicked problem' that requires a whole-of-government approach and coordinated action. I will read your report with great interest.

Ian, thanks for this amplification. Will look forward to learning more about this very important topic.

Thanks Tess for your thoughtful comment. There will always be more demands for health care than there are resources, so in that sense there is a conflict. However I think the more important point for Pacific Islands is that with limited resources ("fiscal space") Governments have to use their resources in the most effective and equitable way. The report shows that some governments in the Pacific allocate quite large shares of their scarce resources to very expensive, and not very effective, "curative" care, often in hospitals where costs are higher. The argument I am making in the report is that reallocating scarce resources to primary and secondary prevention at earlier stages in the diseases will be a more cost-effective approach than end stage "curative" care, and improve public health more broadly. Being more affordable, primary and secondary prevention will also be able to treat more people as well. But even then, there will always still be budgetary and other constraints (eg availability of skilled health workers) to address needs.

Thanks for this post Ian, it raises some very important points. However, I can't help feeling that within your 3 points above, the third is largely contradicted by the second. Yes there are significant financial and economic benefits to focusing on primary and secondary interventions to manage risk factors but if the 'fiscal space' really is that limited then is this actually achievable?

Hi Stephen, Thought your response was worth a quick reply though a chat over a coffee might be more effective. The most evident error in your blog, which I thought was clear even from my rushed response, is that Australians need not be involved in all ACIAR funded projects. And I am not sure how a competitive process would ensure the involvement of the limited best developing country researchers as ACIAR projects have. On the benefits question, which I said flow automatically from the collaborative model, recently taken up in AusAID's recent AIP Program, this is appearing in the UK aid debate at the moment. The position to not cut aid whilst domestic programs are being cut is being defended on the grounds that such aid delivers the socio-economic benefits to the UK that ACIAR requires to be estimated ex ante in its projects for all countries and formally measured by independent assessors ex post. Best regards Ray

While I congratulate the PM and his Government, I want to post this comment regarding the 2013 Budget. The budget still does not address the needs and aspirations of ordinary Papua New Guineans today. About 75 per cent of it is based on assumptions and not deducted facts and figures due to several reasons. One of these is that its intial framing never considered the principle of putting the last first which is only possible through a bottom up planning and participatory budgeting approach. I think the government has not been placing value on data and information.

Thanks John for this post. I think this topic is an important one not only for PNG but also for other Pacific island countries. I think one of the most significant hurdles to supporting informal economic activity is a lack of information, by its very nature it is difficult to map and quantify. Some countries (e.g. Solomon Islands) are now taking steps to include questions in their Household Income & Expenditure Surveys which attempt to capture some of this information which is one step in informing policy by governments and development partners.

Thanks for your comment, Ray, but I must say that I couldn't find the errors you identified, and nor do I think we wrote from a narrow (let alone an AusAID) perspective. Unfortunately, you make an error by saying we suggest "the mutual benefits rationale" is important "over" development. What we say is that ACIAR adopts a mutual benefits rationale (that projects should benefit both the developing country and Australia). It does this so often and so pervasively that I thought it was in its legislation. It isn't. ACIAR is the only part of the aid program required to justify its spending in part in terms of benefits of commercial benefits to Australia. That's unfortunate. Downer dropped the commercial objective back in 1996. ACIAR should catch up with the rest of the aid program. This is not to say that some projects won't have commercial benefits. But it shouldn't be the objective. Second, I take it you think ACIAR should continue to require the involvement of Australian researchers in all its programs. Again, the rest of the aid program has made, not complete, but considerable progress in terms of untying over the last 15 years. As we say, there are good arguments for continuing to link to Australian researchers. And there are certainly good arguments for encouraging collaborative approaches, as you show. But there are also good arguments for, as we put it, "encouraging ACIAR to seek out the best researchers wherever they are, rather than the best Australian researchers. For example, ACIAR might open a competitive funding window which would be available to researchers worldwide." I'm surprised you implicitly dismiss this argument without considering it directly. Think of AusAID's ADRA: the best Australians compete against the best from other countries for the Australian development research dollar. As you have pointed out, there are lots of good Australian agricultural economists, and there are no doubt many good Australian agricultural scientists as well. They should do well in a competitive process. In summary, requiring ACIAR projects to provide commercial benefits and tying all projects to the involvement of Australian researchers are unfortunate, and one might say narrowing, or even protectionist, features of ACIAR's work. That was the argument of our submission, and I don’t see anything in your response which convinces me that we were wrong. None of this is to argue that ACIAR does not do good work, or that AusAID is somehow better. I have more than once argued for more funding for ACIAR. But the aim of the Farmer Review is to look at what can be improved, and that was the focus of our submission and post. Thanks again for your response. I'd be interested to hear what others think. Stephen.

Gulf Province I am sad to say is like the rest of the Papua New Guinean Provinces, neglected and starved of money and resources,not to mention the women and men who can work to turn the Provinces around.It seems every body has left the Provinces for better lives for themselves and their families.We cannot blame them because they had to do what seems right for themselves. What saddens me is that the Provinces were given more then enough monies(over 30 years) but it is the governors (small g not capital G) who obviously misused all the money hence PNG with its Districts and Sub Districts have all 'gone to the dogs'. Port Moresby has had to accommodate all the human beings from all these disfunctional and neglected districts and sub districts not to mention people from the many villages all over Papua New Guinea. I can only see PNG becoming another African country,the rich becoming richer on the backs of the millions of rural Papua New Guineans.It makes me so angry,when I know that there is enough money to start a come back to good and better living standards for the 30 years of misuse of all the millions - tens of millions and hundreds of millions and millions upon millions into billions. It is all needless, all this suffering something has to be done, God help us Gulf Karus- Papua New Guineans !!!

Have you seen any relationship between maturity of development and PEFA scores? My anecdotal observation is that there are many mid-developed small countries (i.e. in the Caribbean) that have not been subject to significant donor pressure for governance reform. On the other hand, smaller countries that have had donor intervention can leverage advantages in PFM reform from being small: adopt international standards like IPSAS & GFS, operate on a single information system to achieve timliness & completeness of reports and transparency. Financial controls and predictability of revenue and expenditures can be managed more easily in smaller countries. The other challenge in small countries is that the government is often providing the traditional national, regional and municipal functions.

The USP website may well be vastly better than the one not maintained by UPNG but as anyone with any meaningful contact with USP systems will tell you, there is very little to crow about otherwise. And with the 'owning' countries increasingly looking to establish their own tertiary institutions (Fiji has several, Samoa has one, Solomon Islands appears to have made a start and it has been mentioned in Vanuatu) it is only to be expected that their commitment both financial and political to the regional university will wane rather than wax.