Leadership, governance, and accountability are among the World Health Organization’s core building blocks of the health system. They are foundational to strengthening the effectiveness and functionality of the system and improving people’s access to health services.
Perceived as cross-cutting components, leadership and governance provide the basis for all other components of the health system, including financing, workforce, medicines and medical technologies, information, services, and infrastructure. They also involve coordination of all levels of the health system to ensure efficient management and improve their overall performance.
Despite ambitious policies and program reforms by previous governments to strengthen health systems in Papua New Guinea, significant challenges remain in governance, leadership, and accountability at the subnational level, particularly at the Provincial Health Authority (PHA) level. A particular area of concern is the funding of rural health services.
Our recent survey on the implementation of tuberculosis (TB) infection prevention and control policy in the Highlands and Momase regions of PNG found that although 80% of the district hospitals had developed TB infection prevention and control implementation plans, no specific budget was allocated to implement them. Our conversations with health workers, facility managers, and district health managers at the district hospitals also revealed that they lack funding for community awareness and health education programs focused on TB in surrounding communities.
Health workers with whom we spoke explained that funding for rural health services is disbursed from the national government through PHAs, so that funding for rural health services is subject to approval by PHA leadership. Our research found that the lack of solid governance, leadership, and management at the PHA level was responsible for the lack of funding to deliver healthcare services in rural and remote districts. It also found that the availability of funding at the district level is associated with strong leadership, governance, and accountability at the PHA level.
The delay in approving funding is an indication of lack of good management and leadership in the provincial health system. (TB Programme Officer)
Accountability, in particular, is pivotal in leadership as it promotes teamwork and the coordination of activities towards achieving a common goal, including effective management of TB. Our study not only highlights opportunities for stronger leadership but also identifies the importance of leader–worker relationships in healthcare facilities for maintaining cohesion among healthcare workers and achieving better service delivery. When leaders are held accountable for their actions and understand the impacts of failing to meet expectations, employees will trust their leadership more, leading to improved performance. Accountability can also accelerate innovation on the part of healthcare workers, which can lead to better TB infection prevention and control policy implementation outcomes in the long term.
The most important result of our study was that healthcare institutions in the districts simply could not roll out TB infection prevention and control programs. Our findings reveal that institutional capacities are limited by many factors, including the long-term shortage of healthcare workers, the lack of medical technologies and drugs, inadequate funding for TB infection prevention and control programs and poor healthcare infrastructure. Building and sustaining healthcare institutions’ capacity is complex and requires determined leadership, management support, and long-term planning and investments to implement key public health policies.
Our discussions with community members and patients corroborate healthcare workers’ views that, over the past decades, community outreach programs have suffered significantly from funding and other resource constraints. Unfortunately, district hospitals responsible for providing comprehensive primary healthcare services to rural populations lack the necessary resources to provide these crucial services effectively.
TB is a complex public health issue. The development of partnerships between the PNG health authorities and other relevant actors, including development partners, non-government organizations and Christian Health Services, is critical to strengthening the long-term implementation of TB infection prevention and control policy in PNG.
TB is a complex health issue. We need support from the different tiers of the health sector and international partners to provide TB care. (Health facility manager)
In sum, the persistent lack of healthcare funding within rural primary healthcare settings in PNG is concerning, and PHA leadership, governance and accountability is part of the problem. This ongoing issue poses a significant obstacle to effectively implementing TB control policies and programs. A collaborative effort by all relevant actors is needed in order to support the objectives of PNG’s TB control policies.
The authors would like to acknowledge the contributions of Peta-Anne Zimmerman and Neil Harris to this blog.
Thank You for the informative article.
TB being broadly classified into two types, active and latent. In terms of funding, which is more expensive to manage by the hospitals or are both equal? Which is more common in Momase and Highlands?
Does your article include MDR TB too?
Thank you so much,
David
(interested student)
Hi David,
Thank you for your question. In PNG, TB is a serious public health problem despite the availability of anti-TB medications over the past decades. Active TB is invasive and affects other parts of the body. It is prevalent in all parts of PNG. As such, individuals with active TB become sick and are admitted to healthcare settings for medical treatments. On the other hand, latent TB may not become visible and do not show symptoms and cannot spread. However, it can lead to active TB disease in the future. Therefore, many individuals with active TB are admitted into healthcare settings seeking treatment through the DOTS treatment strategy. Subsequently, the congregation of patients with active TB in health settings potentially increases the risk of TB infection to health workers and patients in the absence of infection prevention and control programs. Maintaining adequate infection prevention and control program is paramount to minimise TB transmission in healthcare settings and spreading to communities. The emergence of MDR TB is a serious constrain to the TB prevention efforts given the existing weak health system. Funding plays an important role as it facilitates the implementation of TB control programs both in healthcare settings and into the nearby community. As TB infection is common in the community rather than health settings, funding should be available to provide regular and ongoing community health program. However, as discussed in our blog, lack of funding remains a serious impediment to effective TB control initiatives. It will be cost effective to prevent TB in the community rather than waiting for patients with TB to seek costly healthcare in healthcare institutions.
An informative and important blog. The WHO Global Tuberculosis Report 2023 also has some useful statistics and insights about TB in PNG. For example, Annex 3 of that report shows that PNG is one of only 30 countries worldwide, and the only country in the Pacific, classified as a “high TB burden”. Annex 3 also reports that PNG is one of only 30 countries worldwide, and in the Pacific, with a high burden of multidrug resistant TB / rifampirin-resistant TB. Data on page 8 and 10 of the report suggest actual TB notifications in PNG have been increasing from around 25,000 in 2016 to around 35,000 in 2022 (actual cases may be larger). Estimates on page 36 of the report suggest possibly up to 40% of TB patients in PNG experience “catastrophic” health related expenditure (defined as equal to or greater than 20% of household income): not as high as Solomon Islands and Fiji in the Pacific but still high by global standards. On a more positive note, the report does find (page 48) that PNG has recently transitioned out of the 30 global “high TB / HIV burden countries”. In short, the latest WHO report confirms TB is a particularly important – yet often preventable – public health, social and economic challenge in PNG, as well as the other 29 “high burden” countries globally.
Thank you, Ian, for your insights on TB context in PNG. Yes, I agree that PNG has transitioned out of the 30 global high dual TB/HIV burden countries. However, more requirement is needed to control TB epidemic in PNG. In PNG, someone diagnosed with TB is a dead sentence given the weak healthcare system. Frequent drug shortage in healthcare settings, particularly in rural and remote primary healthcare settings continues to challenge the national TB prevention objectives. The shortage of health workers remains an important issue. Equally important and life threatening, the emergence of MDR TB added to the complexities of effectiveness and functionality of the healthcare system. It is crucial to identify the source of TB infection to design appropriate interventions and reduce its spread within susceptible individuals. In healthcare settings, patients with infectious TB disease remains a major source of TB infection and threatens the health of other patients and health workers. Yes, TB is preventable and yet is a complex issue and require concerted efforts, including public policy, community, institutional, interpersonal and intrapersonal level to address TB.