The Healthcare System of Papua New Guinea (PNG)

1. Background /the PNG context

1.1 Demography

PNG lies in the South West of the Pacific, northeastern end of Australia (see figure 1,

map of PNG). PNG had an estimated population of over 7.2 million in 2011 (Department

of Health (DOH) & Asia Pacific Observatory, 2019), and a Gross National Income (GNI)

of US$2530 per capita, is a lower-middle-income country (LMIC) (Mckay & Lepani,

2010; World Bank, 2017). PNG has a young and growing population with an annual

growth rate (AGR) of 2.7% in 2011 to 3.1% in 2016, of which, the majority (about 97%)

of the people are under 65 years (Asian Development Bank (ADB), 2020; Department of

Health (DOH) & Asia Pacific Observatory, 2019; Izard & Dugue, 2003).

1.2 Geography

PNG is one of the most geographically, linguistically and culturally diverse nation in

the world with over 800 languages, rugged mountains and swampy rivers (Cairns,

Witter, & Hou, 2018; Crabtree, 2016; Grundy, Dakulala, Wai, Maalsen, & Whittaker,

2019). Generally, PNG is a rural phenomenon. More than 85% of its population reside in

rural and remote locations, in dispersed and diverse villages (Asante & Hall, 2011;

Cairns et al., 2018; Jayasuriya, Whittaker, Halim, & Matineau, 2012). The people are

typically subsistence farmers, with significant and increasing inequalities in household

income per capita and other essential resources, with pockets of poverty remaining

across all regions (Cairns et al., 2018; Grundy et al., 2019; World Bank, 2017). According

to the Asian Development Bank (ADB) (2020), rural communities have minimum access
to income, quality housing, clean water supply and sanitation and limited knowledge of

health and personal hygiene.

Majority of the regions are accessible only by foot, air or boat with only 3% of paved

roads (Cairns et al., 2018; Grundy et al., 2019). The challenging topography in PNG may

be a crucial factor for the higher cost of services. Cairns et al. (2018) study on factors

driving the performance of rural health care in PNG reported a positive relationship between

remoteness and higher service cost such as outreach services. Surprisingly, more people

access outpatient health services despite the remoteness (Cairns et al., 2018). In

addition to geographical problems, increasing numbers of rural people migrate to towns

for job opportunities, better services and life. These migrants reside in unplanned

squatter settlements, increasing new sets of challenges for more health services (Cairns

et al., 2018). Improvement in accessing quality and cost-effective PHC, especially for

rural and remote villages, are essential for PNG to reach sustainable development goals

(SDG) on health.

1.3 Ethnicity and Education

PNG is known as a Christian country as enshrined in its national constitution. Many

Papua New Guineans believe that greed and selfishness result in suffering, and that

compassion and love bring health and development. Papua New Guineans placed great

emphasise and value on respect, politeness, and courtesy to sustain a healthy society.

Although PNG is known as a Christian country, traditional belief co-existed with

Christianity. For instance, ancestral worship is common in West Sepik province.

Traditional belief may act as barriers to health policy implementation and delivery of

health services. Marme (2018) study in Madang Province reveals that patients with TB
presented late at the health centre after consultation with traditional healers failed. In

addition, the educational attainment is unequally distributed, with more boys having

completed primary education than girls and a national literacy rate at 57.3% (Grundy et

al., 2019). There is persistent and strong spatial distribution of difficulty in educational

attainment, literacy rates, and malnutrition in PNG, with the poorest locations

indicating relatively slight development in the last three decades (Grundy et al., 2019).

Figure 1 Map of Papua New Guinea

Source: https://www.google.com/search?q=map+o
 2. Inputs Used in the Production of Health Care Services in PNG

In any production systems, manufacturers use inputs to produce an output

(Demir, Khan, Pulford, & Saweri, 2018). The PNG healthcare sector uses a varying

degree of inputs to provide health services to meet the healthcare needs of its

citizens. These inputs include physical infrastructures, funding, workforce, health

information, and drugs and diagnostic equipment (Demir et al., 2018; Field et al.,

2018). During the production process, the health sector uses these inputs collectively

to produce the outputs.

2.1 Physical infrastructure/facilities

In the vast majority of cases, health facilities should have good amenities, and with

sufficient resources to sustain the operations of the facility ( World Bank, 2017,

Government of Papua New Guinea, 2020). The physical facilities in PNG health system

encompassed of the national referral hospital, provincial hospitals, regional specialist

hospitals, urban clinics, district/rural hospitals, health/sub-centres and community aid

posts (Grundy et al., 2019; World Bank, 2017). The lack of maintenance, reconstruction,

funding and essential utilities remains a long-term concern in the majority of these

health facilities in PNG (Asian Development Bank (ADB), 2020; Demir et al., 2018;

Grundy et al., 2019; Mckay & Lepani, 2010). For example, this is most obvious in ADB

(2020) and Cairns et al. (2018) reports that 22% of the community aid post remain

closed due to shortage of funding, and staffing, lack of supervision and drugs. Since

community aid posts are the initial point of entry to the formal health system for the
rural majority, its closure has severely affected people’s access to healthcare services

leading to poor health outcomes (Asian Development Bank (ADB), 2020).

Despite the rapid economic growth in PNG since 2000 ((Batten, Gouy, & Duncan,

2009; Grundy et al., 2019), this growth has not translated into tangible investment in

the healthcare industry. Most hospitals and health centres are old, poorly maintained,

and are below national health standards (Asian Development Bank (ADB), 2020). In

2012, close to 70% of staff housing were in deterioration condition (World Bank, 2017).

Additionally, half of the health facility has no running water throughout the year.

Further, 40% have electricity and refrigeration, 30% have access to fuel, 20% have beds

with mattresses and kitchen, 68% have no maintenance and only 30% have the capacity

to repatriate patients to a tertiary facility (Asian Development Bank (ADB), 2020;

Australian Government, 2011; Demir et al., 2018; Izard & Dugue, 2003; National Health

Deparment (NDoH), 2020; (National Health Department (NDoH), 2011). The ADB

(2020) warned that several problems, which could diminish service quality, existed in

all levels of the facilities in the PNG healthcare settings, highlighting the need for capital

investments in the health industry. Poor leadership and political economy conditions

further aggravate the situation (Australian Government, 2011).

In PNG, there is a growing concern about the increasing deterioration of health

infrastructures and HCWs adherence with health standards and policies at the

healthcare institutions. Marme (2018) justify that HCWs did not adhere to TB infection

control (TBIC) standards in RHS in Madang Province, PNG, due to inadequate spacing,

overcrowding and improper ventilation system at the health centres. Under these

circumstances, isolating patients presented with cough were not possible due to limited
spacing at the outpatient and TB inpatient wards at the health settings (Marme, 2018).

From the evidence, it was possible to suggest that the generally poor conditions of the

health facility may increase nosocomial TB transmission and infection amid the health

employees, patients and community. The resource-constraints facing the health facility

poses as an impediment to TB control efforts and other public health programs in PNG.

In contrast, the best features of the existing Provincial Health Authority (PHA)

throughout the country seems to provide positive answers to the current problems. For

instance, the establishment of community health post (CHP) model in strategic

locations in the districts has shown promising outcomes for service delivery and

decision-making. The physical infrastructures of CHP met the national health standards

including the provision of clean and safe water supply to patients; provide reliable

electricity, safe and quality staff accommodation (Asian Development Bank (ADB),

2020).

2.2 Financing the healthcare system

Financing healthcare services remains a fundamental component of the health

systems to maintain and improve the health of the community. Without the necessary

funds, no new recruitment would take place, no drugs and medical supplies would be

available, and no health programs would take place (World Health Organization

(WHO), 2008). WHO (2008, p.3) define healthcare financing as “the function of a

health system concerned with the mobilization, accumulation and allocation of money

to cover the health needs of the people, individually and collectively, in the health

system… the purpose of health financing is to make funding available, as well as to set
the right financial incentives to providers, to ensure that all individuals have access to

effective public health and personal health care.”

In PNG, the national and sub-national governments remain the central funding agent

through the taxation system. The state funds all public and church-based healthcare

services in the country (Asian Development Bank (ADB), 2020; World Bank, 2017). In

2014, about 4.3% of the total Gross Domestic Product (GDP) was allocated to the health

sector (Grundy et al., 2019). Additionally, the external partners play a pivotal

partnership in supporting the governments’ financial shortfalls despite showing signs of

transition. For instance, in 2019, external partners contribute more than 20% of the

total healthcare expenditure (THE) (Asian Development Bank (ADB), 2020). Finally,

investment in private health sectors, health insurance and other sources of private

entities are very limited in PNG (Asian Development Bank (ADB), 2020).

The allocation and management of healthcare finance in PNG are generally inefficient

and ineffective (Asian Development Bank (ADB), 2020; Grundy et al., 2019). It becomes

clear that the allocation of funding to health services depends on the country’s economy.

Between 2015 and 2017, GDP dramatically dropped by 10%, from 12% to as low as 2% in

2017 (Grundy et al., 2019). The collapse in international commodity prices and natural

disasters experienced in PNG was the main reasons for the declining trend (Grundy et

al., 2019). Further, the National Health Department (2010) indicates that funding to

health services continues to decline slowly affecting health services delivery. The

unavailability of sufficient financial resources at the health facility has many negative

impacts on the population. For example, some health facilities impose user fees to

sustain its operations despite the introduction of free healthcare policy. Overall,
financial management in the health sector is ineffective and inefficient because of low

budget and allocation of available funds (Asian Development Bank (ADB), 2020;

National Health Department (NDoH), 2020).

Funding appropriation to the health sector in PNG remains varied and formidable.

Many administration and systemic variations contribute to the challenging healthcare

financing systems. These variations include delay in the release of funds to the health

facility, tedious financial management systems, slow facilitation of funds from the

provincial treasury to facility level, inadequate funding and timely availability of funds

to health facilities (Grundy et al., 2019; Izard & Dugue, 2003; National Health

Department (NDoH), 2011). The National Health Department (NDoH) (2011, p. 27)

reiterated, “chronic under-funding of health systems limits the capacity of the health

sector to provide adequate services that are of acceptable quality”. It is reasonable to

conclude that the under-funding situation in the health sector cannot continue.

Therefore, to improve the financial problems, the percentage of GDP allocated to health

should increase, improvement in transferring funds to healthcare settings; strengthen

health-facility budgeting and direct health facility funding.

2.3 Health information management

Access to accurate health services information plays an integral role to monitor and

evaluate the inputs, processes, outputs and outcomes of the health sector (Grundy et al.,

2019). Additionally, having sufficient and reliable information is essential for proper

health planning and management, decision-making and evaluation of the impact of

desired health outcomes of national health goals. In PNG, improving the management of
information and communication technology and supporting the National Health

Information System (NHIS) remains a central pillar of the health plan (Grundy et al.,

2019; World Bank, 2017).

In PNG health sector, the national health department coordinates the performance of

the healthcare system through the computerized national health information system

(NHIS). Management of health information is considered an integral part of the health

sector because of its importance in assessing the health needs/problems of people,

management of healthcare delivery and evaluation and monitoring of coverage and

effectiveness (Grundy et al., 2019; Newbrander & Thomason, 1988). The health sector

established the NHIS in 1989, with more improvement and establishment in 2002

(Newbrander & Thomason, 1988). The system is centralized and known to provide

quality information for monitoring and planning, with connections across the

healthcare systems in PNG. The information management systems uses globally

recognised health indicators for monitoring and evaluation of health facilities, district,

province and nationally.

At the end of the month, every aid posts submits their monthly summary to the

supervisory health center. The health center then forwards all monthly forms from each

aid post through the district health office to the provincial health office where the

Provincial Health Information Officer enters the data into a computerized database.

They system summarized the data and work out the percentage against national census

for immediate retrieval. The data is forwarded to national level where the data are

entered in the national health sector computerized health system (Grundy et al., 2019;

Newbrander & Thomason, 1988).

 The health centre records have many significant advantages. These books have the

capacity to record wide range of healthcare data, plotting the data and helps to explain

and interpret the trends and patterns. Given this fact, health workers do not use the

health center records for decision-making and planning health center programs. Even

the health center employees are not trained on how to use the book, plot the data or how

to use the health services data (Grundy et al., 2019). The effect of lack of staff training

and education lead to poor knowledge of the health facility data and setting priority and

mobilization of health inputs to maximize the outputs (Cairns et al., 2018). The output

of the health inputs are disseminated with other organizations, researchers and

stakeholders through annual sector performance reviews and provincial quarterly

planning meetings.

2.4 Medicines and diagnostic equipment

2.4.1 Procurement

PNG, like many other developing countries, faces persistent challenges with the

pharmaceutical management system that continue to put pressure on the quality of

health services (Asian Development Bank (ADB), 2020; Australian Government, 2011;

Connell, 1997; Demir et al., 2018; Izard & Dugue, 2003; National Health Department

(NDoH), 2020). The pharmaceutical management systems entail procurement,

management and distribution of the country’s medical supplies. In PNG, procurement

and distribution functions remain the responsibility of the National Health Department

(Asian Development Bank (ADB), 2020). Over the past years, the healthcare industry

has experienced ongoing long-term issues with the procurement of infrastructure,

equipment, drugs and other medical consumables. A myriad of ecological, structural

and economic factors, for instance, lack of roads & air infrastructures, limited

construction abilities, inadequate local manufacturers and weak currency add to these

complex phenomena (Grundy et al., 2019). In response to these challenges, the health

sector has developed specific strategies to address this long-term problem in the

National Health Plan 2011 – 2020 (Government of Papua New Guinea, 2020; National

Health Department (NDoH), 2011). However, given the current degree of governance

and corruption issues identified within the pharmaceutical management systems,

intersectoral support and commitment such as the Legal System and Crime and

Corruption Commission play a critical part in the successful implementation of these

strategies (Grundy et al., 2019).

2.4.2 Distribution

In PNG health sector, seven different private logistic distributors distribute medicines

and other equipment to provinces and districts (Grundy et al., 2019). In the last three

decades, the capacity to distribute and maintain the operations for and access to medical

and diagnostic equipment’s and drugs remains problematic in PNG (Asian Development

Bank (ADB), 2020; Australian Government, 2011; Grundy et al., 2019; Izard & Dugue,

2003; National Health Department (NDoH), 2011; World Bank, 2017). The health sector

performance reviews undertaken by National Health Department (2020) found that

non-availability of essential medical supplies and consumables at the health facilities

pose a major constrain for the health sector, particularly in rural and remote locations.

Despite the recent reformation in the management of medical supply, impediments with
procurement and distribution remain affecting the delivery of health services (National

Health Department (NDoH), 2020).

2.5 Healthcare workforce (more discussion in the next topic)

The health sector requires skilled, well-trained and adequate numbers of health

workers to provide quality healthcare. PNG has a relatively low number of all cadres of

health staff (National Health Department (NDoH), 2013). When comparing health

workers in PNG to population ratio with other neighbouring regions, the population

outnumbered HCWs. For instance, Australia has a rate of 1 HCW to 304 people, Fiji has

1:1000, while PNG has a ratio of 1 HCW to 19,700 doctors (Grundy et al., 2019; Izard &

Dugue, 2003; National Health Department (NDoH), 2013). Recent health systems

performance review has shown that human resources in the health sector are

inadequate or low skilled human resource because of the aging workforce and lack of

upskilling and training which leads to poor performance within the healthcare system

(National Health Department (NDoH), 2020).

 3. Organization, management and governance process to produce

healthcare services

3.1 Decentralization of health services

The PNG healthcare system has a decentralized model based on PHC approach. This

approach includes a network of primary care level facilities including aid posts,

community health posts (CHP), sub-health centres, health centres and district hospitals.

Other important aspects include secondary and tertiary level health facilities such as

provincial, regional specialist and national referral hospitals located in the nation’s

capital (Demir et al., 2018). The secondary and tertiary level facilities provide

specialized health care services and are predominantly centralized in urban centres

(Grundy et al., 2019). The lower-level health facility repatriates complex medical

problems to the secondary and tertiary level facility through formal referral notice (See

Figure 2) (National Health Department (NDoH), 2011).

The decentralization of healthcare services to Provincial Health Authorities (PHAs)

aims to strengthen RHS delivery (Asian Development Bank (ADB), 2020). Under the

decentralized system, several healthcare providers deliver health services in PNG. These

include the national and sub-national governments; church health services (CHS),

employer-related healthcare services, private sectors and traditional medicine sector.

The state and CHS provide the majority of the healthcare services, of which, the state

funds both (Australian Government, 2011; National Health Department (NDoH), 2011;

World Health Organization (WHO), 2020). The churches play a pivotal part in

delivering health services and own half of the RHS facilities in the country (Grundy et
 Referrals for increasingly complex care and severe cases
al., 2019). CHS has a long history of providing quality healthcare services despite the

resource-constraints and geographical challenges. The other health services providers

include employer-based health services that provide onsite health services for its

employees, like mining and agriculture. There is a growing number of the private health

sector in PNG, providing high-quality general outpatient services usually for the wealthy

segment of the population. The traditional healers also deliver health services

predominantly in rural and remote areas (Grundy et al., 2019).

Figure 2 Level of healthcare services in PNG healthcare system

Tertiary level care Pacific Medical Centre: Nations

capital
 Major referral & teaching hospital
Co
 Comprehensive specialised care un

Secondary level Specialist Regional Hospitals: ter
care Provinces
 Multi-faceted role as national specialist
hospital and provincial hospital
ref
 Provision of oncology services err
 Complex treatment of patients from its
individual region al
Provincial Public Hospitals:
Provinces an
 Clinical services include internal
medicine, surgery, Paediatric,
obstetrics and Gynaecology, accidents
d
and emergency and anesthetics fol
 Health promotion
 Health protection lo
Primary level care District Hospitals: Districts
 More complex care at a more local
level
w
 Clinical services include general up
surgery, maternal and child health,
malaria, HIV/AIDS & TB diagnostics
 Health promotion
 Health improvement
 Health protection
Health Centers: Districts
 General outpatient and inpatient
  Family health services
 Health promotion
 Community awareness
Community Health Posts: Districts
 Maternal & child health
 Midwifery
 Health promotion
 Community awareness programs
 Labour room
Aid Posts: Districts
 General outpatient
 Health promotion
 Community awareness

3.2 Management, leadership and governance system

Good management, leadership, and governance systems and structures may promote

the efficient use of health inputs to produce health services (World Bank, 2017). Thus,

without good management and leadership systems and protocols, health inputs are

prone to abuse and mismanagement jeopardizing the delivery of health services. World

Bank (2017, p. 59) stated that “effective and stable leadership and governance are

critical components of a successful workforce”. The attainment of stable leadership and

governance are present in various management traits such as time management, HCWs

punctuality, the establishment of the facility board, asset management, supportive

supervision and exercising authority at the organizational level (World Bank, 2017).
 In PNG health sector, staff reporting late to work is a critical concern and highlighted

the need for improvement in staff punctuality (World Bank, 2017). World Bank (2017)

highlighted that not all health employees report on time or available at the health facility

during their designated rotations. About 52 per cent of health services providers resume

duties as schedule in level 3 and 4 facilities compared to 60 per cent at level 5 to 7

facilities (World Bank, 2017). Additionally, the establishment of health facility advisory

committee plays a pivotal part to provide direction to the management of health

services. The World Bank (2017) survey indicates that level 3 and 4 church-based

facilities have facility committees than public health facilities. For this reason, church-

based facilities have a higher percentage of staff meetings compared to the state-run

health facilities (World Bank, 2017).

Asset management is an essential indicator of effective management practices.

However, only 10 per cent of level 3 and 4 public health settings had an inventory

management system compared to 40 per cent of other health facilities (World Bank,

2017). Furthermore, supportive facility supervision from provincial staff remains poor

across all health settings in PNG (Cairns et al., 2018). Hence, improvement in

supervisory appointments should focus on supply distribution; health services

management, facility and financial management. Cairns and colleagues concluded that

the proximity of health facilities might influence the level of supervision from higher

authorities. Yet, provinces with considerably good management structures reported an

increasing number of visitation, strengthening the effectiveness of RHS (Cairns et al.,

2018). Besides, the provincial health administration is responsible for the recruitment

and termination of health employees. The facility managers do not have the authority to
recruit and terminate health staff. Despite this level of decision-making authority,

health managers were satisfied with the current arrangement (World Bank, 2017).

Generally, these central ideas emerging from the information indicates weak leadership,

management and governance practices in the PNG health sector.

3.3 National Health Plan 2011 – 2020

The National Health Administration Act (NHAA) 1997 authorized the development of

the National Health Plans (NHP) as the overarching strategic document for the health

sector in PNG (Ambang, 2015; Government of Papua New Guinea, 2020; National

Health Department (NDoH), 2011) (See figure 2). The NHP provides directions and

guidance for health professionals, health administrators, government officials and

politicians (Ambang, 2015; National Health Department (NDoH), 2011). For health

professionals, the NHP provides the structure to determine the objectives and strategies

for daily operational activities to deliver health services. For the health administrators,

the NHP guides to ensure that the management of the health systems complies with the

National Governments criteria. For the decision-makers (policymakers, politicians), the

NHP provides priorities for decision-making, setting priorities, mobilization and

allocation of inputs to sustain the processes of the health sector. Besides, the NHP

provides information for key stakeholders on the country’s health status, development

and priorities. Thus, implementation of the NHP plays a crucial function for the

development of healthcare delivery in PNG.

 Figure 3 Process that links all relevant plans to the NPH (National Health Deparment

(NDoH), 2020)

National Health
Plan 2011 - 2020

Provincial Health Sector

Government Strategic Priorities
Development Plan 2016-2020

Provincial National
PHA Strategic Hospital Strategic
Strategic Department of
Implementation Implementation
Implementation Health Corporate
Plan Plan
Plan Plan

Annual Annual Annual Annaul

Implementation Implementation Implementation Implementation
Plan Plan Plan Plan

3.4 National Health Services Standards (NHSS) 2011

The NHSS is another core resource document of the PNG healthcare setting. Field et

al. (2018) highlighted that the NHSS perform three significant functions. It provides

directions for health workers on how to deliver safe and quality health care services. It

also provides guidelines on how to plan and design the physical health infrastructures.

Additionally, the NHSS provide essential information about the availability of health

services at each level of health facility to the public and stakeholders (Government of
Papua New Guinea, 2020). Furthermore, the health services standards outline the

priority public and curative health services expected at each level of the health facility

(Government of Papua New Guinea, 2020). The NHSS sets the minimum criteria for the

health sector health workforce, drugs, equipment, and infrastructure and funding for

each level of the health facility. For example, according to the NHSS (2011), a level 1-

health facility (community aid post) should employ 1 Community Health Worker (CHW)

working five shifts/week with after-hours on-call arrangement and relief for annual

leave and other extended absences (Table 1).

Table 1 Summarises the minimum staffing levels

Facility Staffing Requirements

Level
Level 1 1 CHW working 5 shifts/week with after-hours on-call arrangement

and relief for annual leave and other extended absences.

Level 2 3 CHWs (1 with Post Certificate Midwifery Training) covering shifts as

required with shared after hours on-call arrangement. Leave relief

provided from within existing staff numbers.

Level 3 Urban Clinic staffing numbers and skills mix based upon actual

caseload and 5 day shifts per week.

Health Centre staffing numbers and skills mix based upon actual

caseload and 21 shifts per week with after hours on- call arrangements

to supplement when required. Leave relief for annual leave and other

extended absences provided from within existing numbers

Levels 4 - 7 Hospital staffing numbers and skills mix based upon actual caseload of

each Unit/Ward and 21 shifts per week. Leave relief for annual leave
 and other extended absences provided from within existing numbers.

Essential overtime may be compensated by remuneration or grant of

‘time off in lieu of overtime’ at Management’s discretion.

Medical Officer and Allied Health Professional numbers are expected

to be at minimum levels in most facilities for the near future due to

nationwide shortages in most specialties, sub- specialties and

disciplines.

Source: National Health Services Standard 2011 - 2020

4. Implementation of health policies and plans at different levels of

healthcare

There is a strong relationship between the application of health sector policies and

improvement in healthcare systems, quality of healthcare services and the provision of

health services (Ambang, 2015; Australian Government, 2011). In PNG, the majority of

provincial and district health administration was unable to implement the national

health plans since the decentralisation of RHS in 1995 (Ambang, 2015). Some would

argue that there is poor implementation within the provincial and district

administrations which may seriously influence the health sectors strategies performance

towards the PNG Governments Vision 2050 because the National Health Plan addresses

the governments strategic priorities from 2011 – 2050 (Ambang, 2015).

 The successful implementation of health policies depends on HCWs motivation,

performance, and organisational capacity (Australian Government, 2011; Razee,

Whittaker, Jayasuriya, Yap, & Brentnall, 2012). The present health workforce

catastrophe is not only a matter of availability and retention. Motivation and

performance of the available HCWs play a significant part; yet, this area receives limited

attention (Razee et al., 2012). As such, improvement in human resource and facility

management at the organisational level are significant factors in the planning and

implementation of health policies. The health sector performance mid-term review in

2015 found that application of health policies “was sluggish because of mismanagement

of health employees and inadequate financial resources at the institutional level”

(National Health Department (NDoH), 2020, p. 7). The Australian Government (2011)

and NDoH (2020) discover that the shortage of frontline employees at the health facility

level remains the most significant factor that contributes to the sluggish performance.

Thus, the development of health workers improvement plan including training,

recruitment, allocation and simplification of the health policy strategies for frontline

health workers to develop operational activities at the facility level remains crucial

(National Health Department (NDoH), 2020).

The Australian Government (2011) highlight the significance of management ability

to recognise the capacity available and the skills to use them effectively. They maintain

that recruitment of qualified administrators in senior positions (e.g., district officers,

facility managers) is crucial to managing employees, funding, physical infrastructures

and medical supplies. Furthermore, providing enabling environments, tangible and

intangible incentives and motivators that enable the productivity of existing capacity.
The enabling environments include regular supervision, staff training and development;

clarify of roles, responsibilities and governance to administer services and procedures to

hold managers responsible for health outcomes (Australian Government, 2011).

Moreover, health facilities cannot implement core strategies as designated by the

NHSS due to lack of resources (National Health Department (NDoH), 2020). Besides,

programs that are funded by donors such as malaria, the Expanded Program on

Immunization (EPI), and TB Control Program have not delivered the expected results

(National Health Department (NDoH), 2020).

An examination of the options reveals that there remains a gap in health workforce

development. As a short-term solution, the health sector review proposed the

recruitment of overseas health workers to address the supply and demand issue in the

health sector (National Health Department (NDoH), 2020). Despite these constraints,

the review found that some regions, provinces and health programs performed well. The

implementation of PHA structure provides a clear framework for integrated planning

and management of both curative and public health services (Australian Government,

2011; National Health Department (NDoH), 2011). Poor implementation of health plans

and services was mainly due to lack of leadership, strategic focus and stakeholder

support and partnerships (Ambang, 2015; Australian Government, 2011; National

Health Department (NDoH), 2020).

5. Inequities and fragmentation in health policy implementation

 Historically, since 1996, the health sector has developed well-established national

health policies (Australian Government, 2011). However, its progress and development

has been slow and showed a declining trend in many core indicators since the rural

health services were decentralized under the administration and governance of the

Provincial and Local Level Governments in 1995 (Ambang, 2015). Many provincial and

district health administration were unable to translate the NHP into health services with

low performance as reflected in the country’s core health indicators and the United

Nations Development Programme (UNDP) Human Development Index (HDI)

(Australian Government, 2011). The Australian Government (2011) review on PNG

health systems delivery discovered that regardless of the constant efforts to improve the

health sector in PNG, health results remains unsatisfactorily low. Several challenges had

led to inequities and fragmentation in the application of NHPs from 1995 to 2020.

The lack of management capacity at the provincial and district health services

remains a fundamental challenge to policy implementation in PNG (Ambang, 2015;

Australian Government, 2011; Thomason & Kase, 1995). Ambang (2015) and Asante &

Hall (2011) highlighted that majority of the provinces and districts lack good governance

and leadership to provide strategic directions to adapt the national health policies into

the provincial and district annual implementation plans. Furthermore, some regions

and LLGs administration do not have the required resources to implement the health

services activity plans (National Health Department (NDoH), 2020). The Australian

Government (2011) concur that leaders lack training, supervision and leadership skills.

The other challenge identified by Ambang (2015) and the Australian Government

(2011) is inadequate numbers of health workers in the provinces and district health
services. Australian Government (2011) elaborate that having the right amounts and

qualified numbers of frontline health personnel’s especially in critical positions such as

district officers and officers-in-charge to coordinate and oversee resources capacity are

crucial for policy implementation particularly at the facility and program level. In PNG,

there is a chronically insufficient number of employees to carry out the national health

plans (Demir et al., 2018; World Health Organization (WHO), 2020). Under the

decentralisation model of healthcare delivery, the provincial and LLGs are responsible

for the recruitment of health personnel. However, many healthcare settings in remote

districts remain inoperable due to lack of workforce and old infrastructures (Ambang,

2015; Australian Government, 2011; Grundy et al., 2019).

Lack of supportive supervision of the health programs managers in the districts is

another concern affecting the implementation of health policy in the PNG health sector

(Asante & Hall, 2011). Under the present administrative structure, the Provincial Health

Office has little or no control over the management of health workforce in the districts,

as health workers are answerable to the District Administration (Ambang, 2015). The

evidence reveals that senior health managers from the PHA and NDOH did not support

the district administrators to supervise and support the district health workforce in the

implementation of health plans (Asante & Hall, 2011). Australian Government (2011)

review on PNG health systems commented that supportive supervision and mentoring

to health professionals is highly infrequent and problematic. Many of the employees are

not willing to accept supervisory responsibilities due to their lack of knowledge to

address technical problems discovered during their visits to districts and facilities
(Australian Government, 2011). It can be concluded that health workers need adequate

support and supervision to implement key national health strategies at the facility level.

6. Provision of healthcare services

The provision of healthcare services in PNG includes facilities and programs provided

under the dual healthcare delivery model (Government of PNG, 2017). The dual

healthcare delivery system allows both the public and the private sector to provide

health services to meet the government’s aspirations. Health services delivery is highly

centralized in urban centres. The healthcare infrastructures in metropolitan have a

higher proportion of beds and doctors than is the case in peripheral districts. Few

private hospitals and clinics provide high-quality healthcare usually for the affluent

segment of the population in urban places (World Bank, 2017).

In urban centres, the public sector provides the majority of the tertiary healthcare

services such as secondary, tertiary provincial and regional specialist hospitals. These

facilities consist of 22 general hospitals, four regional specialist hospitals and one

tertiary national referral hospital (150 – 200 beds) (Asian Development Bank (ADB),

2020). The other facilities are urban health centres and clinics that provide general

outpatient and inpatient care with 50 – 100 beds (Asian Development Bank (ADB),

2020).

In rural and remote locations, both the public sector and CHS provide mostly PHC

services encompassing district hospitals (60 – 100 beds), health centres (20 – 40 beds),

sub-health centres (10 – 20 beds), community health post, aid post and community
based primary healthcare or village health volunteers (VHV) (World Bank, 2017). The

CHS provides half of the rural health facilities in remote districts. According to Demir et

al. (2018), the CHS provide quality health services to rural majority despite the

resources constraints and geographical challenges. In contrast, CHS infrastructures face

similar challenges as the public sector with deteriorating health centres and constrain in

funding. Health services provision in PNG has been stagnant over the recent years.

There is a need to introduce new model of health care delivery mechanism (Field et al.,

2018)

Figure 4 Health structure of PNG healthcare system

 Tertiary &
secondary
facilities

Primary
facilities

Source: Government of PNG, National Health Plan (2011)

 7. Health Outcomes/Key Health Indicators

The core health indicators show the overall efficiency and effectiveness of the

country’s health care system. Cairns et al. (2018) point out three core health indicators

including reproductive health, prevention, and treatment of diseases. Although there are

some improvements in these areas and other core indicators not mentioned in this

review in the last two decades, the performance is still below the East Asia and South

Pacific regional targets (Ambang, 2015).

7.1 Reproductive health services

Family planning programs with modern contraceptives enhance women and family

health outcome. In 2018, PNG reported 32% coverage, compared to the regional target

of 48%. Besides, good-quality antenatal care (ANC) practice requires at least four visits

to a health facility during the pregnancy. PNG achieved 66%, compared to the regional

average of 89%. Supervised deliveries by skilled HCWs reduce the possibility of adverse

complications and promote a positive outcome. PNG achieved 44%, compared to the

regional target of 89% (Cairns et al., 2018). PNG’s performance is low compared to

other neighbouring nations.

7.2 Prevention/Public health services

The immunization rate and proportion of people with access to clean water and

sanitation are indicators of the resilient healthcare system. The percentage of children

receiving the third dose of the combined diphtheria, pertussis and tetanus (DPT3)

vaccines reflects the effectiveness of childhood immunization programs. In 2018, PNG

DPT3 coverage was at 62%, which was below the regional average of 86% (Cairns et al.,
2018). Access to clean water, sanitation and hygiene reduces disease transmission and

infections and promote healthy individuals. In PNG, the majority of the population lacks

adequate water supply, especially in rural areas. Cairns et al. (2018) discuss that only

40% of the people have access to clean water, which is below the regional average of

87%. The situation is worse for the rural locations, home to more than 85% of the

people, with only 33% access to improved water sources. Similarly, considerably low

proportion (19%) of the population have access to sanitation and hygiene

infrastructures, which is lower than a third of the regional average of 67%. The situation

is even worse in rural areas, with only 13% access to improved sanitary infrastructures

(Cairns et al., 2018).

7.3 Treatment of diseases/curative health services

The third sets of health indicators focused on the treatment of diseases. PNG

encountered double disease burden from communicable and non-communicable

diseases (Grundy et al., 2019). In PNG, HIV, TB, and diabetes are among the

fundamental causes of diseases and deaths (National Health Department (NDoH),

2011). Oguntibeju (2012) supports Cairns et al. (2018) claim that adequate treatment

with antiretroviral therapies promotes longevity for persons infected with HIV. Cairns

reported that HIV treatment and management is slightly higher at 44% in comparison

with the regional average of 38%. In contrast, treatment and management of TB remain

problematic at 68%, below the regional average of 88%, which is 20% lower than its

neighbouring counterparts are. In terms of diabetes management, PNG performed

slightly higher at 16% compared with the regional average of 14% (Cairns et al., 2018).
 Conclusion

The picture that emerges from the analysis in this review is one of many missed

opportunities, which seems intrinsic to the national healthcare delivery system. We have

established a link between previous experience specific work environments to address a

crippling and dysfunctional health system struggling to deliver basic health services in a

rurally based population. What is striking in this review is how little successive

government and bureaucrats paid attention to this dysfunctional health care system and

articulate clear directions, leadership and management to revamp this industry

experience (Asante & Hall, 2011). Majority of the health managers, policymakers,

clinicians and health services providers in the healthcare system tends to be living in a

state of what Mendes and colleagues call ‘pluralistic ignorance’ (Mendes, Lopez-valeiras,

& Lunkes, 2017). In general, PNG has a weak and resource-constrained healthcare

system despite continuous efforts to improve the health system (Australian

Government, 2011).
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