A recent report from the Burnet Institute, Compass and World Vision argues for a significant expansion of the PNG Village Health Volunteer (VHV) program (a form of family and community care) to deliver a range of cost-effective interventions to improve the parlous state of maternal and child health in Papua New Guinea. The report claims that full coverage of family and community care in PNG could prevent up to 32% of maternal deaths, 70% of newborn deaths, and 50% of child deaths.
Underpinning this claim is a cogent and accessible mixture of international and more limited PNG evidence to support the content of cost-effective packages, and to make the case that these packages can be delivered by non-professional community health workers (Village Health Volunteers in PNG).
There is much to recommend in the report. In particular it does a good job in assembling a vast array of technical information, and prioritising these into sensible, graduated packages for potential delivery to the women and children of PNG.
However it is the question of how the recommended interventions are to be delivered in the PNG context that requires further consideration. The report recognises there is “limited evidence on the impact, cost and effective implementation strategies of many maternal, newborn and child health interventions in PNG” and a stronger evidence base is required to support scale-up (p. 31). This is certainly true. There is an urgent need to conduct an evaluation of the performance (and reasons for good/poor performance) of the existing VHV schemes in PNG – particularly those that have been long running.
However, even without such an evaluation, there is evidence from both PNG and internationally to suggest that considerable thought is required as to the best way to expand community-based access to maternal and child health services in PNG.
WHO has conducted a comprehensive review of the international evidence of the effectiveness of community health worker (CHW) programs. This report concludes:
- CHWs can contribute to improved access and coverage of basic health services, particularly in child health, and some disease control programs (although there is limited evidence of maternal health improvements). However, CHW schemes do not consistently provide services likely to have substantial health impact and the quality of services they provide is sometimes poor.
- For CHWs to be able to make an effective contribution, they must be carefully selected, appropriately trained, and adequately and continuously supported. Large-scale CHW systems require substantial increases in support for training, management, supervision and logistics.
- CHW programs are therefore neither the panacea for weak health systems nor a cheap option to provide access to health care for underserved populations. Numerous programmes have failed in the past because of unrealistic expectations, poor planning and an underestimation of the effort and input required to make them work.
- CHW programs are vulnerable unless they are driven, owned by and firmly embedded in communities themselves. Where this is not the case, they exist on the geographical and organizational periphery of the formal health system, exposed to the moods of policy swings without the wherewithal to lobby and advocate their cause, and thus are often fragile and unsustainable. Evidence suggests that CHW programmes thrive in mobilized communities but struggle where they are given the responsibility of galvanizing and mobilizing communities.
Without pre-empting the findings of an in-depth evaluation of the PNG VHV experience, it is likely that most, if not all of the above issues will be present in PNG.
- The question of health impact of the schemes in PNG is critical but to date is unknown.
- Even if a heath impact can be demonstrated, it is likely there will be critical institutional questions of if/how existing or expanded schemes are being supported and sustained – both from within the formal system and from communities. Insights from the Burnet/World Vision report suggest these issues are substantial in PNG. The report points to “challenges in providing refresher training, and supervision and supply shortages” (p. 19), and concerns from volunteers around payment, workload, and lack of support from village leadership (p. 32).
- There is also the important issue that despite a number of intensive efforts (largely supported by donors) to strengthen the management of VHV programs at the national and provincial levels, these efforts appear not to have taken hold (p. 31). The reasons for this apparent lack of commitment to the approach need to be understood.
- It is also relevant that the major historical effort in PNG to produce and support a community-based health worker (the aid post system) is in decline (at best only 70% of aid posts are functioning). Prima facie, this decline is driven by the same issues that have bedevilled international community health programs, and appear to be facing the various PNG Village Health Volunteer schemes – ie. lack of support, supervision and supply from the formal health system, and lack of acceptance and ownership from communities.
Thus in short, the key question in PNG is not knowing what interventions need to be provided to improve maternal and child health. The Burnet/Compass/World Vision report does an excellent job in synthesising and increasing the accessibility of this information. However, the risk is that the conclusions based on this information alone will lead to simplistic recommendations and claims that small amounts of money will produce dramatic results. This is the path to disappointment. Rather, the key question is how these services can be effectively and sustainably provided in order to reach an increased number of Papua New Guineans. It is important that the urgent need to increase the accessibility of cost effective, lifesaving maternal and child interventions does not override the need to think carefully and strategically about the best way to achieve this.
It is clear that VHV programs require significant commitment and capacity in term of training, supervision, and logistics. In the context of limited health systems capacity in PNG (which has been unable to consistently provide support to health centres and aid posts) an early strategic question is whether it is realistic to expect the system to be able to effectively support current or expanded VHV programs? If not, are there alternative ways this support can be provided – which are both cost-effective and acceptable to PNG stakeholders?
It is also clear that VHV programs need to be anchored in some form of community ownership. The limited evidence from PNG would suggest this has not been achieved – for VHV’s or aid posts. If this is the case, the key question is why previous efforts have failed, and are there other approaches which may be more effective?
Given the above, the key challenge appears to be institutional not technical. In essence, it is how to situate Village Health Volunteer programs so that they garner both the necessary health system and community support, and thus have the best chance of improving maternal and child health outcomes in PNG.
Fortunately, there is a rich reservoir of experience internationally and in PNG of efforts to deliver community-based health services to inform responses to this challenge.
First and foremost, the reasons for success and failure of past community-based delivery experiences in PNG need to be understood, and where relevant lessons learnt, incorporated into future strategies.
However at the same time, these reviews should not only look at what has been tried before. An in-depth understanding of the aid post and VHV experience to date in PNG will undoubtedly produce stories of success and failure. However, it may also reveal pockets of innovation that work in a different way than was intended – where managers, providers and communities in effect have created ‘practical hybrids’ that combine traditional and formal ways of working to solve problems in the local contexts. It is also likely there will be other providers and resources at a community level – private practitioners, traditional healers, pharmacies, retired/off duty public providers, community groups/associations – who are potential allies in the expansion of cost-effective packages.
These unexpected successes and untapped resources may contain the clues for possible new institutional arrangements that span the formal/informal, and as such provide for different, more sustainable ways to provide community-based health services in PNG. At the very least, such approaches need to be considered alongside the lessons learnt from traditional community/village health worker schemes in order to assess the full array of possible ways to improve the accessibility of community-based maternal and child health services in Papua New Guinea.
Chris Morgan and Abby Byrne have provided a response to this post on our blog here.
Andrew McNee is a Visiting Fellow at the Development Policy Centre at the ANU’s Crawford School.
The focal intentions of the health care personnel (clinicians) were now identified to be urban health facility oriented. The would mean, they want to enjoy the available services in the urban areas based on their own assumptions.
However, majority of our populations are living in the rural areas but they are reluctant to serve them. According to my undergraduate research study conducted in 2016 in SHP, I found out that 99% of the HEO ( Rural Health) , 67% Nursing officers and 23% CHWs are now working in the Urban health facilities. From my point of view, RH profession should serve the rural areas, not the urban populous. They supposed to define their profession as Rural Health, but their intentions to be in the urban areas falsify their profession!. NOs are utility, they can serve in any level of health facility.
Merely from my statement here, I strongly support the work of CHWs in the remote rural areas where they usually provide quality services to the people, especially mothers and children thus more better our responsible stakeholders make should make a full support to expand the CHW program in the country could be a satisfactory to the unmet people.
Bclor in Health Management & Systems Development
Thanks for the wonderful comments and insights put forward. It is of paramount importance to enhance, empower and upgrade the skills of our CHWs who tirelessly work in the rural health facilities with their limited knowledge and skills. It is also appreciative to see the great effort and aid from the Australian Government to facilitate maternity up-skilling studies for CHWs in PNG. Some hospitals have executed the plans and utilized the necessary funds for such trainings. Kundiawa General Hospital and Mt Hagen are two typical examples that are currently undergoing this maternity up-skilling program for CHWs from the rural health facilities and hospital as well. This I think is a way forward for all health personal to prioritize maternal child health issues and to further reduce the maternal and neonatal morbidity and mortality.
Midwife (Kundiawa Gen. Hosp)
Interesting arguements. I do qualitative and quantitative research around PNG on sexual health and related. As WHO indicated about CHW, most Church Health Service run facilities in PNG are manned by community health worker serving in very remote parts of PNG. They are doing a great job than government health workers I must honestly say. It is not a complete waste of time. It is needed as general nursing colleges in PNG have limited spacing. Especially for Church Health Services there is good evidence on community health worker’s contributions to maternal child health and HIV.
I do have reservations for village health volunteers. Volunteerisms is not well understood by Papua New Guineans. There is again enough evidence of failing programs and the issue of sustainability in engaging volunteers in PNG. Taking into account the detoriating health system in PNG, it will be overwhelming for health departments at all levels to monitor and coordinate VHV.
One way to go about change to meet those millenium goals is to build the capacity of existing health services in PNG. At least this has been working for Church Health Services in terms of staff capacity building, staff motivation, clinical upgrade, strong health management,adequate and timely resource management, quality assurance, M&E etc. There are other incentives that have been working well for maternal and child health programs in some parts of PNG. Eg. funding waiting houses for pre natal and post natal women near remote clinics to improve access. Continue supporting weekly and monthly MCH clinics (foot patrols) and annual foot patrol immunisation campaigns. MCH being intergrated to other health services like HIV, Sexual Health and family health etc to increase education and access.
I’m happy to discuss the models practiced at three highlands provinces of PNG under Catholic Health Services in comparision to government run clinics if you are interested.
Caritas Australia STI Management Program–PNG
I totally agree with marie mondu. The church run institutions in health services are doing well in providing maternal/child health care, immunisation etc.. despite limited funds, however government run health services are failing in providing services to most of the rural population. When funds run dry up they slow down services. Rachy B (PMGH) PNG.
I agree with Marie that church health services are doing their best under difficult conditions to improve the maternal health of this country. The VHV program in PNG I do not see the benefits. PNG is a country that we value our relationships and it is the families that help and people in times of need generally call for assistance and help from their families not VHVs. What we need is to increase CHW training programs, General Nursing, Midwifery programs and Medical School and improve the health system to develop strategies to retain professionals in remote and rural places where the population in need are.
I do are agree that health workers are doing much to save lives at where they are working and engaging. Currently, to be frank grandaunts from nursing schools, CHW training schools and medical schools are not performing competently unlike 10 years ago. Their work performance has gone down the drain. I used to wonder how did they get in to the training schools, as the saying goes “garbage in garbage out”. We already have incompetent health professionals who are suppressing the programs and the health system. There should be through investigation and monitoring of enrolling of new students in health training schools and also every employer should give competency test prior employment. Therefore, I recommend proper screening in both enrolling and employing.