For almost fifteen years, Australian Doctors International (ADI) has been running integrated health patrols in some of the remotest areas of Papua New Guinea, beginning in Western Province in 2002. These patrols have consistently provided important medical services in a country where over 80% of people live rurally or remotely, the average standard of living is not high, and the decentralised local health system’s reach is often restricted. The doctors that go on these patrols are all volunteers.
ADI will imminently release its five-year evaluation of the integrated health patrols and in-service training programs it has been running in the province of New Ireland from May 2011 to 2015. This independent review, conducted by Dr Klara Henderson, is the first such that ADI has undergone and constitutes an effective means of examining the efficacy of ADI’s unique model. It is also most timely, as ADI presently seeks to replicate this model in new provinces. The analysis is solidly grounded in quantitative and qualitative data gathered from multiple sources, including, importantly, an extensive range of interviews with people on the ground in various capacities in New Ireland.
The evaluation’s first objective is to determine, inter alia, how well these programs have helped provide rural health services and develop the skills of local health workers. In terms of basic measurable outputs, ADI’s patrol partnerships performed well in both respects. 69 patrols have been run; 3128 patients have been seen by an ADI doctor; 24,215 services were delivered by an allied health professional; and 711 days were spent on patrol. At the remote aid posts they visited, ADI’s patrols also provided valuable group-based training opportunities to the local health workers stationed there, amounting to the equivalent of 2200 teaching hours over the five years. ADI, similarly, facilitated in-service sessions to complement these training opportunities, with 190 health workers—about 80% of New Ireland’s rural health workforce—attending at least one session.
The evaluation finds also that ADI’s model is peculiarly advantaged by its triple combination of (1) health service delivery and public health education, (2) extensive, on-patrol, practical training for local health workers, and (3) the concomitant opportunity for those workers to deepen or revisit their clinical skills in niche areas which are lacking. As the evaluation notes, the case-based and group-based training, which provides for more general skill acquisition, complements the in-service training, which allows health workers to acquire new skills in depth, and practise them safely. Likewise, health service delivery and public education complement all training activities, as the former address immediate health needs, whilst the latter build capacity for the future.
Importantly, the work of ADI’s patrols aligns firmly with the key result areas identified by the PNG National Department of Health in its 2011-2020 plan. The abovementioned efforts undoubtedly contributed to objectives such as improving the delivery of allied health services in rural areas, promoting public health, and improving the clinical skills of public health staff. ADI’s patrols, moreover, are conducted in close coordination with New Ireland Provincial Health and the main hospital in Kavieng, the provincial capital. Taken together, these close alignments underscore ADI’s ability to work effectively with the PNG government and its health agencies.
A crucial strength of the integrated patrols was that they targeted several pre-existing gaps in New Ireland’s health system. For example, a maldistribution of health workers leaves some populations without much access to services, so ADI’s patrol penetrated to the remotest areas of New Ireland, with 63% of patients that were seen by an ADI doctor living in remote or very remote areas. Similarly, the training and supervision provided by ADI’s integrated patrols helps to make up for the lack of extensive supervision and support of health workers in many facilities.
Under its first objective, the evaluation also provides 21 recommendations for future improvement, including ways to address other existing health gaps better. For example, TB, diabetes, malaria and respiratory infections remain particularly serious health challenges, so it is recommended that patrols should include a communicable disease control officer and education officer, and focus on identifying and properly training up workers who have not had adequate training in this area. Likewise, it is recommended also that patrols include a maternal and child health professional, and that we ensure that ADI’s volunteer doctors have gynaecological knowledge and obstetrics, to address persistent maternal health needs in New Ireland.
The evaluation’s second main objective is to ‘[d]efine and document a flexible and adaptive model’ that could potentially be replicated in other PNG provinces. The positive outcomes of ADI’s patrols and in-service training in New Ireland, the evaluation notes, are grounded in its effective partnering with local agencies, and its sensitivity to the unique circumstances of New Ireland. This requires, critically, a mandate from the local authority to work in the area. It also requires that ADI closely coordinate its work with local agencies to ensure that both agree on the purpose and objectives of the patrols and training programs. Deep local knowledge, needless to mention, is important for this, and this indeed will be the main challenge to extending the model. ADI’s integrated patrols and in-service training programs are unique and work well, and they have the inherent flexibility that will be needed to adapt them to the necessarily differing circumstances of other provinces.
The evaluation’s third and final main objective is to delineate a staged transition plan of its activities in New Ireland to New Ireland Provincial Health. This is being developed gradually, with great care taken to ensure that long-term funding and an effective managerial structure will be in place, and sufficient PNG doctors available, to ensure the durability and continued efficacy of the model when a full handover is eventually completed.
Liz Mackinlay is CEO of Australian Doctors International (ADI). Liz presented on the ADI evaluation at the 2017 Australasian Aid Conference; view her presentation here and listen to an audiorecording of the session here.
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