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.