ADI Integrated Rural Health Patrols & In-Service Training in New Ireland, PNG 5-Year Evaluation: 2011-2015 Analysis and Key Findings

Dr Klara Henderson August 2016 1

Acknowledgements This report relied on the input of many, from ADI staff in the Sydney Head office to staff in Kavieng. Patrick McCloskey conceived this work and provided ongoing guidance, input and support while staying impartial. Gemma Tuxworth went out of her way to introduce me to the key people in Kavieng. Dianne O’Brien conducted the financial analysis, spending considerable time to document patrol and in- service costs, this work is undoubtedly going to be useful in an ongoing sense. And finally Judy Lambert’s input during the work ensured the project was heading in the right direction. Thank you to all those of provided their interview time.

2 Table of Contents Acknowledgements ...... 2 Table of Contents ...... 3 List of Tables ...... 4 List of Figures...... 4 Executive Summary ...... 5 Structure and Purpose of Report ...... 8 Methodology ...... 9 The PNG and New Ireland Health Context ...... 10 Current status - New Ireland ...... 12 Report Findings ...... 15 Objective 1 ...... 15 Patrol Staff Composition ...... 17 Ideal Patrol Team Composition ...... 19 Topic Coverage for Group (In Service) and Patrol (Case Based) Training ...... 26 Health Worker Access to Patrol Staff for Training ...... 27 Health Workers at In-Service ...... 28 In-service Topics ...... 30 Trainers at In-Service ...... 31 Health Facilities ...... 32 Health Workers ...... 32 Health Worker Load and Support ...... 35 Financials ...... 37 Provincial Government Funding...... 37 User Fees ...... 37 Costings ...... 39 Summary of Recommendations for Objective 1 ...... 42 In Relation to the Patrol Team: ...... 44 In Relation to the Doctor Placement: ...... 44 Objective 2 ...... 46 Objective 3 ...... 48 Funding and high-level decision making ...... 49 New Ireland Health Education Committee ...... 49 Establish regular and sustainable PNG medical participation in patrols ...... 49 Patrol and in-service management ...... 50 Acronyms ...... 51 References ...... 52 Annexure 1: Health Facilities and Aid Posts (November 2015 status) ...... 53 Annexure 2: Clinical Survey Demographics and Scores ...... 57

3 Annexure 3: Cost categories 2013-2015 ...... 59

List of Tables Table 1: PNG health capacity and status ...... 10 Table 2: Maternal health data ...... 12 Table 3: Diabetes data ...... 12 Table 4: TB data ...... 13 Table 5: Select indicators for New Ireland - National Health Plan ...... 13 Table 6: Summary of key health issues - relevant for patrols ...... 15 Table 7: Patients seen and services delivered ...... 20 Table 8: Patients seen by remoteness ...... 20 Table 9: Health facility case based and group based teaching by remoteness ...... 21 Table 10: Timeline of in-service, attendees and topics ...... 24 Table 11: In-service costs ...... 25 Table 12: Health worker positions and their organisational base ...... 29 Table 13: Health worker load and support ...... 35 Table 14: Patrol costs, and cost centres ...... 40

List of Figures Figure 1: Outpatients - disease areas ...... 14 Figure 2: Patrols – number and duration ...... 16 Figure 3: Patrol health worker composition ...... 18 Figure 4: Topic frequency, 2015 ...... 27 Figure 5: Clinical survey response - health workers working and training with ADI doctor on patrol ...... 28 Figure 6: Health workers attending in-service by topic (until end of 2015) ...... 30 Figure 7: Aid post remoteness and open/closed status (end-2015) ...... 32 Figure 8: Ratio of health worker to population by area ...... 33 Figure 9: Health worker support - results from clinical survey (2016) ...... 36 Figure 10: Cost per examination ...... 40 Figure 12: ADI adaptive model ...... 47 Figure 13: Transition plan overview ...... 48

4 Executive Summary

PNG is in a period of working to improve its standards of living. Key macroeconomic and health indicators show some advances, yet at provincial level these results are not uniform. Indicators on the health system in New Ireland and the health of its population are mixed. There are declining trends at the health system level, for example there are worsening results for outreach clinics, and use of health centres for antenatal coverage and supervised births. Some health aid posts are closed, and remote and rural health workers feel unsupported by the system and their immediate superiors. In terms of health outcomes, pneumonia and respiratory illnesses remain largely unchanged over the last five years, and malaria cases have held steady for the last three years. The PNG National Department of Health (NDoH), through its 2011-2020 plan, identify a number of Key Result Areas (KRAs) that align with the programmatic work of Australian Doctors International (ADI). The KRAs cover objectives targeting the strengthening of health systems and partnerships and addressing particular priority health outcomes including: maternal and child health, communicable diseases and promotion of health lifestyles1. Central to ADI’s work is the achievement of PNG priority health outcomes and KRAs. In this context, ADI is providing health care to the rural and remote population in New Ireland in partnership with Kavieng Hospital and New Ireland Provincial Health through regular (monthly) outreach patrols. These patrols are unique, addressing unmet medical needs, providing clinical services to the New Ireland population and more recently providing public health education to local communities. Key outputs delivered through the 5-years of ADI patrol partnerships are: - 69 patrols, with over 220 New Ireland health centre, aid post or village visits - 13,762 patients seen by an ADI patrol doctor, with 63% of these in remote/very remote locations - 90,161 services delivered by an allied health patrol professional - 711 days on patrol These health services are provided to the rural and remote population where they may not otherwise have access to such services. Estimates here show it costs around 22 kina per person seen by a doctor on patrol. These results directly reflect the PNG NDoH’s aims to  Improve allied health services delivered to rural health centres  Improve coordination of outreach services and  Improve public health promotion and prevention strategies on patrols as stated under Key Result Areas 1: Improve Service Delivery, 2: Strengthen Partnerships and Coordination with Stakeholders and 3: Strengthen Health Systems and Governance 1. Importantly patrols also provide professional development opportunities for the cadre of health workers staffing the remote health centres and aid posts. These patrol based training opportunities are delivered to health workers explicitly during the provision of clinical services and after clinical services are complete each day, through group based training. For the 5-year period this equates to over 2200 patrol based teaching hours. Provision of continuing educational support and professional development that is easily accessible is one of the WHO’s recognized strategies – impacting on both skill attainment and retention for rural and remote health workers2. The existing system presents challenges In conjunction with these on-the-job training opportunities, ADI has been facilitating complementary in-service sessions, with 190 health workers attending at least one session in the 2013-2015 period. This equates to about 80% of the rural health workforce in New Ireland. The training and support provided through patrols and in-service helps health workers gain knowledge and confidence in key health areas to allow health workers to provide care to their populations throughout the year. These results directly reflect the PNG NDoH’s aims to improve clinical skills of rural health staff as stated under Key Result Area 1: Improve Service Delivery. The topics covered in these training sessions parallel the PNG NDOH’s priority health outcomes (Key Result Areas 4-5-6-7), equipping staff with skills on maternal and child health (child protection), TB, HIV and STIs and healthy lifestyles1.

5 The majority of results reported here focus on outputs (e.g. number of patients seen, number of health workers trained) because these are more straight forward to collect and report and can be directly attributed to ADI’s work. Drawing conclusions from these outputs on health outcomes in terms of maternal mortality, malaria cases or incidences of tuberculosis is more difficult, if not impossible to do due to a number of reasons: quality of data and reporting as well as numerous confounding factors. This complication is true for the majority of those working to impact health outcomes. This does not detract from the results achieved by ADI nor does it diminish the contribution or value the integrated patrols and in-service trainings programs achieve. The unique value of the approach implemented by ADI is the three-way combination of 1) clinical services and public health education delivered to remote and rural populations, 2) patrol based training that exposes health care workers to practical upskilling opportunities and 3) opportunity for those health care workers to deepen and/or refresh their clinical skills in a niche topic area previously identified as lacking. ADI’s programs are developed and delivered as close-knit partnerships with New Ireland Provincial Health and Kavieng Hospital, a sharing of goals, resources, systems, knowledge and people to implement solutions for long term health of rural and remote New Irelanders. The integrated patrol and in-service training model addresses specific gaps identified here in the current health system in New Ireland:

Gap in Existing Health Delivery Current ADI Activities which Address the Gap  Limited access to health services (some Patrols reach to the most rural and remote health centres and aid posts closed) populations in New Ireland (with 63% of patients seen in remote or very remote locations)  A maldistribution of health workers leaves some populations without access to health

 Supervision and support for health workers in Both patrols and in-service sessions aim to provide facilities is lacking health workers with access to education, supervision and new skills; and in doing so offer valuable support to health workers

Some gaps identified drive recommendations for future improvements in patrols and in-service training sessions that can be implemented:

Gap in Existing Health Delivery Recommended ADI Activities to Address the Gap  Maternal health needs are high  Include maternal and child health professional/midwife on patrol  Identify health workers that have not yet attended in-service training on maternal and child health and provide training to them  Ensure recruited ADI doctors are equipped with obstetrics and gynaecological knowledge  Given TB, diabetes, malaria and respiratory  Include communicable disease control officer infections are identified as areas of focus and education officer on patrol; both by PNG NDoH and for New Ireland, they  Identify health workers that have not yet need adequate representation on patrol attended in-service training on TB, diabetes,

6 malaria and lifestyle diseases and provide training to them

 Supervision and support for health workers in  Regularly include LLG managers on patrols facilities is lacking occurring in their area

ADI Allied Health patrol team member Jack Taliva delivering health education on dental health to primary school students

7 Structure and Purpose of Report

The report first overviews the methodology used to collect the data, followed by a brief examination of the health context in PNG in general and New Ireland. We then move to the core objectives of the report as noted below.

Note that a summary of acronyms used throughout the report is available on p 49 of this report.

Objective 1 Conduct a 5-year evaluation of the impact of the New Ireland Patrol and In-service programs, determining how those programs have assisted in rural health service provision and health worker development, and make recommendations for their improvement. Following the evaluation of the ADI core projects, a brief overview of the challenges facing New Ireland health delivery is presented with suggestions for how these might be addressed. Finally, the financials associated with the program delivery and NIP health care in general are discussed. Objective 2 Define and document a flexible and adaptive model of integrated patrol and in-service programs for potential application in other provinces of PNG and countries in the Asia Pacific region Objective 3 Document a staged handover and transition plan of the New Ireland Patrol and In-service Programs to local partners in New Ireland, and answer: what would it take to get NIPH to run patrols and in-service programs in the future?

ADI Doctor Bronwen Morrison watches on during In-service training at Lemakot School of Nursing

8 Methodology

A multi-pronged data collection methodology was undertaken, obtaining data from:

- The existing ADI patrol database, cleaned and validated - A suite of interviews with key stakeholders including former and current ADI Sydney based staff; ADI Kavieng based staff; former and current ADI patrol doctors; key medical and allied health professionals in Kavieng; a select group of health workers from government, church and private health centres in New Ireland; local level government officers, district health officers; senior level administrators in the provincial government and hospital and experts with some prior work or experience with ADI. - Field visit to health centres and aid posts in New Ireland - Focus group with health workers (x1) and patrol debrief (x1) - Relevant PNG and New Ireland policy documents - Previous patrol reports and in-service evaluations written during the 5-year period - ADI’s financial system - New Ireland Provincial health and their database on patient numbers, health centres, health worker numbers and salaries - Patrol health worker and community evaluation forms collected via patrols – translations and summaries prepared - UN recognized health indicator sources

- Clinical survey (with health workers conducted early 2016)

These data sources were triangulated during the analysis phase to identify the current operational and health context in New Ireland, to formulate findings, facilitate comparisons and to provide input to improvements and recommendations. Draft versions of the report, or specific sections were shared with colleagues for input and comment. Some materials were presented to ADI Program Committee for comment.

Notes on interpreting the data A note of caution needs to be applied to interpreting the data reported here. The quality and consistency of data collection is subject to many areas of variation. For example: 1) Over time different people have been responsible to collating, updating and reporting data (this applies for all data from different sources reported here ranging from World Bank through to ADI, although efforts are made to maintain consistency over time this is not always possible). 2) Population demand for health services may have also influenced trend numbers, as may have changes in availability and access to health centres. 3) Access to equipment required for data collection (e.g. diagnostic equipment) may have changed over time. These data quality issues are well known and recognized as an issue in many countries, and are a particular challenge for rural areas in LMICs.

9 The PNG and New Ireland Health Context

Current Status - PNG In development terms Papua New Guinea (PNG) (2014) is classified as a lower-middle income country, below the average of its East Asian Pacific neighbours. The World Bank observes that PNG needs to translate its strong macroeconomic performance into improved standards of living through improving public financial management, budget management, public spending and service delivery, and improving performance of the civil service3.

In terms of health capacity, defined as the ability of the country itself to respond to health needs of its citizens, the trend is a positive one (See Table 1 below). Utilising the limited data, we can observe small increases in medical staff albeit from a very low base. Government health expenditure per capita (GHEpc) has also been increasing, while out of pocket health expenditure has been decreasing. GHEpc can been seen as the country’s choice to invest in its citizens’ health and the size of the investment can provide some indication of the priority afforded to that sector, in this case, health. In PNG, a highly decentralized system, getting the funds to the right place is both complex and highly critical for the frontline services (such as health centres) to function4.

How does PNG fare overall in comparison to other lower-middle income countries (LMIC)? PNG’s GHEpc ($75) is slightly higher than other lower-middle income countries like Ghana ($60) and Bhutan ($66), but lower than its near neighbour, also a LMIC, Solomon Islands ($94).

In terms of health needs, and the translation of the health capacity given the context, into health outcome for the citizens - how does PNG fare? Both maternal mortality rate (MMR) and the under-5 mortality rate (U5MR) are decreasing, although data is a limitation here5. Life expectancy at birth has remained steady. These are overall positive signs of improvements. In comparison and using 2013 data, PNG with a MMR of 224 is faring worse than the Solomon Islands (122) and Bhutan (166), but better than Ghana (321). 2013 data on U5MR reflects a similar pattern, again with Solomon Islands (29.9) and Bhutan (36) below PNG (60.9), and Ghana (66.5) above.

Table 1: PNG health capacity and status

Health capacity 2006 2008 2010 2011 2012 2013 2014 2015 Trend

GNI, Atlas method (current US$) $1270 $1520 $1820 $2040 Increasing

Community health workers (per 1,000 0.624 n/a people)

Nurses and midwives (per 1,000 people) 0.457 0.565 Increasing

Physicians (per 1,000 people) 0.053 0.058 Increasing

Births attended by skilled health staff (% of 53% total)

General Government Health Expenditure pc $35 $45 $78 $75 Increasing (US$)

External resources for health (% of total 24% 25% 26% 21% Decreasing health expenditure)

Out-of-pocket health expenditure (% of total 16% 15% 11% 11% Decreasing health expenditure)

Health expenditure, public (% of government 8% 8% 12% 13% Increasing expenditure)

Population health

Maternal mortality ratio (MMR) (modelled 238 231 227 224 220 215 Decreasing estimate, per 100,000 live births)

Maternal mortality ratio (MMR) estimated5 500

10 Mortality rate, under-5 (U5MR) (per 1,000) 66.1 64.3 62.5 60.9 59.1 57.3 Decreasing

Life expectancy at birth, total (years) 62.0 62.2 62.3 62.4 Steady

Tuberculosis case detection rate (%, all 51 51 69 74 84 Increasing forms)

Incidence of tuberculosis (per 100,000 415 415 416 417 417 Static people)

Source: World Bank World Development Indicators

In addition, data from the Institute for Health Metrics and Evaluation on Global Burden of Disease for Papua New Guinea6, shows the top five diseases in PNG in 2010 as lower respiratory infections, diabetes mellitus, tuberculosis, diarrhoeal diseases and malaria as measured by Disability Adjusted Life Years (DALYs). Since 1990, DALYs for diabetes mellitus and tuberculosis have increased.

The Government’s National Health Plan (2011–2020) identifies child survival, maternal health, reducing the burden of communicable diseases, promoting health lifestyles and preparing for disease outbreaks and emerging population health issues1 as key health issues that support the objectives to increase life expectancy by 2030 from 56 to 70; reduce under-5 mortality by 2030 to less than 20 per 1,000 and reduce maternal mortality to below 100 per 100,000 by 2030. These areas of priority are summarised as follows and will form the framework of analysis for this evaluation: 1. Child health 2. Maternal Health 3. TB 4. Malaria 5. Diabetes 6. Respiratory Infections

11 Current status - New Ireland

The following tables provide key data showing New Ireland’s performance against the NDoH’s 6 Priority Health Outcomes:

Table 2: Maternal health data

2011 2012 2013 2014 2015 Trend Source

PNG

Maternal mortality ratio 231 227 224 220 215 Decreasing World Bank (MMR) (modelled indicators estimate, per 100,000 live births)

New Ireland

ANC coverage - 1st visit 75.1 75.3 58.8 61.3 42.5 Decreasing NIHS data

ANC coverage - 4th visit 47.9 44.5 32.9 35.2 27.1 Decreasing NIHS data

Average ANC visits 5.2 5.1 5.1 5.1 5.4 Increasing NIHS data

% ANC receive TT 68 107 66 54 64 Steady NIHS data

% deliveries supervised 49.9 52.9 43.9 43.6 31.5 Decreasing NIHS data

Number of maternal 15 16 8 5 5 Decreasing NIHS data deaths

Patrol data

Number of Anaemia 47 32 56 58 19 ADI patrol data patients seen*

Number of Antenatal 16 54 20 54 17 ADI patrol data patients seen

Number of Obstetric 1 12 31 15 14 ADI patrol data patients seen

Number of Postnatal 13 23 5 10 1 Decreasing ADI patrol data patients seen

Red - means trend in deteriorating direction

* - data for anaemia for 2011, 2012 not disaggregated by female/male. Data for 2013, 2014, 2015 only includes females.

The peak observed in 2012 for diabetes discharges (See Table 3 below) testing, and then similarly the decrease due to the unavailability of equipment and/or batteries and/or strips.

Table 3: Diabetes data

2011 2012 2013 2014 2015 Trend Source

New Ireland

Diabetes (discharges) 67 77 74 58 42 Decreasing NIHS data

Diabetes (deaths) 8 4 7 12 8 Steady NIHS data

Source: NIHS data

TB remains a pressing health issue in PNG, however data for New Ireland (see Table 4 below) shows declines in TB related deaths.

12 Table 4: TB data

2011 2012 2013 2014 2015 Trend Source

New Ireland

TB (discharges) 177 145 140 130 111 Decreasing NIHS data

TB (deaths) 22 11 12 4 8 Decreasing NIHS data

Patrol data

New Cases TB 86 Patrol database

TB Defaulters 2 396 Patrol database

Contact Tracing 392 Patrol database

Education on TB 115.5 Patrol database

Source: NIHS data and patrol database

The 2015 National Health Plan Sector Performance Review reports on key indicators by provinces. Relevant here are the results for New Ireland that show steady or declining trends (see Table 5 below). Many of the declining trends are at the health system level, showing worsening results for outreach clinics, vaccination coverage, supervised births and antenatal coverage as well as use of health centres. This paints a picture of a health system which is not meeting the needs of the population.

Table 5: Select indicators for New Ireland - National Health Plan

2011 2012 2013 2014 2015

Indicator 1: % Pneumonia Deaths in 0.55% 1.05% 1.58% 1.72% 2.10% Children under 5yrs at Health Facilities

Indicator 8 - Outreach Clinics per 82 76 74 60 31 1000 children <5 years

Indicator 9a - % Measles Vaccine 68.30% 73.08% 65.92% 40.70% 33.63% Coverage for children under 1yr

Indicator 9b - % 3rd Dose Pentavalent 95.00% 96.00% 86.00% 52.00% 61.00% Coverage in Children under 1yr

Indicator 10a - % Supervised Births at 55% 61% 59% 47% 43% Health Facilities

Indicator 11 - Antenatal Coverage 86% 95% 89% 73% 61%

Indicator 12 - Family Planning Use 56 60 38 58 33

Indicator 20 - Supervisory Visits 48% 50% 52% 0% 56%

Indicator 21 - Outpatient visit per 2.25 2.43 2.43 1.55 1.54 person per year

Indicator 26: Facilities with Telephone 86% 88% 90% 38% NA and/or Radio

Source: PNG Health Sector Review, 2015, New Ireland

13 New Ireland Provincial Health data on outpatients, shows worsening trends across disease areas over the 5-year period (See Figure 1. below). Malaria, skin diseases, respiratory infections and pneumonia represent the highest caseloads of outpatient data, with malaria recording the highest caseload of data across four of the five years. Reports of pneumonia and respiratory illnesses remain largely unchanged across the years and malaria at a steady level for the last three years. Table 6 below presents a summary of the key health issues identified above.

Figure 1: Outpatients - disease areas

Outpatients - disease areas

37995 28394 27376 19273 8288 2015 6010 6109 4917 1688 298 24353 27483 34149 18899 9080 2014 4862 6573 4110 1931 479 38129 22530 28879 16837 9027 2013 4657 8381 3492 1942 239 72993 31104 36584 19999 10638 2012 5884 12845 5387 1282 293 64343 27507 24226 16693 8794 2011 7898 8159 4558 791 238 0 10000 20000 30000 40000 50000 60000 70000 80000 Malaria total Skin disease total Respiratory total Pneumonia total Accident total Yaws total Diarrhoea total Eye infections total STI total Pulmonary TB total

Source: NIPH data

Participants completing ADI’s in-service training on child and maternal health

14 Table 6: Summary of key health issues - relevant for patrols

PNG National health focus Key health issues New Notes Key health issues areas (Key Results Areas – Ireland (based on 5 years of focused on here priority health outcomes) outpatient data and key indicators)

Child health Declines in access to Table 5: Select Indicators for Child health healthcare for children, New Ireland (NHP) immunisation coverage and increases in deaths from pneumonia

Maternal health Declines in maternal health Table 2: Maternal Health Maternal health coverage Data

Reducing the burden of Increases in TB infections Table 4: TB data TB communicable diseases but reduction in TB deaths Malaria from 22 in 2011 to 8 in 2015. High levels of malaria

Promoting health lifestyles Increasing number of Note increase in diabetes for Diabetes deaths due to diabetes. PNG overall, and increase in Respiratory infections Respiratory infections and New Ireland deaths pneumonia third and fourth attributable to diabetes. highest causes of outpatient (Table 3: Diabetes data) and visits. increase in diabetes DALYs between 1990-2010.

Report Findings Objective 1 Conduct a 5-year evaluation of the impact of the New Ireland Patrol and In-service programs, determining how those programs have assisted in rural health service provision and health worker development, and make recommendations for their improvement Introduction Australian Doctors International has a history of integrated rural health patrol work in Papua New Guinea going back to 2002 in the Western Province. Patrols started in New Ireland in May 2011. This section of the report examines the history, achievements, costs and outcomes of the New Ireland patrols which ADI was part of and were established in partnership with the New Ireland Provincial Health Department. Staffing The projects are supported by the following core ADI team members in New Ireland: ADI Health Projects Manager – 10-12 month volunteer position, Australian, reports to PNG Programs Manager (Sydney). To provide technical support to ADI in implementing specific primary health care projects, and overall responsibility for the management of ADI’s project portfolio in New Ireland, with partner New Ireland Provincial Government. Provide support and planning for in-service programs, and oversee their implementation. ADI Doctors – 6 month medical officer volunteer positions working in the Namatanai Hospital and supporting the Patrols. These roles report to both PNG Programs Manager (Sydney) and PNG-based ADI Health Projects Manager NIPH/ADI Patrol Coordinator – position reports to ADI Health Projects Manager, funded by NIPH.

15 Project Focus 1: ADI and NIPH patrols Since May 2011 Australian Doctors International in conjunction with New Ireland Provincial Health and Kavieng Hospital has been running outreach patrols across the New Ireland province. These patrols aim to fill the above identified gaps through provision of additional health services where there are none and through supporting rural and remote health workers with supervision and case based training. Sixty-nine patrols have been run over the May 2011 – Dec 2015 period. Patrols roughly occur once a month, with the first patrol of the year in February, and the final patrol in early December. On average, patrols are eight days long, with an average of two additional days’ travel time. Duration is influenced by the distance and travel time to and between locations. On average patrols stop at about three locations (health facilities, aid posts or villages), with one the smallest number of locations visited and eight the largest number of locations visited1.

Figure 2: Patrols – number and duration

153 148 146 151 113

10 15 14 14 16

2011 2012 2013 2014 2015

Number of patrols Duration of patrols

Source: ADI patrol database

Patrols in New Ireland had occurred previously (decades earlier), originating from the kiap model which has a historical precedence in PNG across law, education, medicine and agricultural sectors. In re-establishing patrols in New Ireland in May 2011, a number of prerequisites were required. While budget existed for the patrols, no coordination was occurring. In establishing the patrols, a number of simple guidelines were laid down: - Operate at the Provincial level, not the District level - Spend ~ 3 days in a health centre - Doctor’s role is to treat and train - Start with the most remote and most difficult - Don’t service aid posts (get them to come to health centres) - Services to cover: prevention, promotion, environmental health and disease control - Number of people on patrol limited by capacity of cars and boats (12 people) - User fees are not charged. (based on personal communications). Not all of these have held true over the years. In particular, the locations visited by patrols are no longer restricted to health centres, but now extend to aid posts and even villages. And the following refinements have been introduced:

1 Based on data in the ADI patrol database. Note some limitations in recording non-health facility and aid post locations, and this may underestimate the number of locations patrols visit.

16 - Pre-patrol meeting, discuss schedule, elect team leader, set departure and pick up times, discuss budget, safety regulations and the Child Protection Act - Elect a team leader to take responsibility for accommodation and food - Patrol members sign a code of conduct regarding behaviour on patrol Dr Peter Macdonald’s role and relationship with Sir Julius Chan was acknowledged as an essential ingredient to facilitating political goodwill and the motivation to kick-start the patrols in New Ireland (personal communications). This relationship is seen as key for successful ongoing relations. Sir Julius Chan provided the mandate and channelled the flow of funding for patrols directly to Australian Doctors International. From early 2013 funds were provided upfront for the complete schedule of patrols for each calendar year (400,000 kina). This was widely recognized as a key shift in operationalizing the patrols. The ADI doctor’s role has evolved over the years to take on a greater emphasis on education, this is supported by all previous ADI doctors interviewed, with one explaining ‘health education is what is going to cause improvement in the long term’. Planning and scheduling are key parts of the annual patrol process, and to date, much of the responsibility for this has fallen to the ADI Doctor and Health Projects Manager. However, there is increasing scope for a greater share of responsibility going to provincial and hospital staff for these tasks. The patrol year concludes with a debrief and lessons learnt discussion and planning session involving many of the year’s patrol staff.

Patrol Staff Composition Patrol staff are sourced from ADI, Provincial Health, Kavieng Hospital and occasionally District Health. The mix of staff is capped by the capacity of cars and boats (roughly 12 staff plus drivers and/or boat captains). The team of professionals is an Australian medical doctor, allied health professionals from Provincial and District Health and the Kavieng hospital, with support provided by drivers, cooks and logisticians. The value of the patrol is in the mix of skills and staff. The innovation of the patrol is in the integration of the allied team and increased opportunities for complementary diagnosis, treatment, management and education. (See Figure 3. below) Staff must seek release permission to attend patrol and the patrols sometimes conflict with their normal duties meaning that permission is not always granted. Until recently the hospital has had its own staffing pressures, requiring senior hospital management to balance the needs of hospital patients with the needs of rural and remote patients. To manage these simultaneous needs certain minimum thresholds of hospital staffing have been suggested by senior hospital management before release of staff to patrols can go ahead (personal communications)

17 Figure 3: Patrol health worker composition

Patrol health worker composition 14 13 13 13 13

12 12 12 12 12 12 12 12 12 12 12 12 11 11 11 11 11 11 11 11 11 11 11 11

10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 9 9 9 9 9 9 9

8 8 8 7 7 7 7

6 6 6 6

4

2

0 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Feb-12 Mar-12 Mar-12 May-12May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Oct-12 Nov-12 Dec-12 Feb-13 Mar-13 Mar-13 Apr-13 May-13 Jun-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Feb-14 Feb-14 Mar-14 Mar-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Oct-14 Nov-14 Nov-14 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15

ADI Doctor Education, information and health promotion (ADI and Provincial government staff) Dental staff (total) STI and HIV/AIDS services (total) Eye staff (total) Physiotherapy TB services (total) MCH + PAP smear nurse (total) Family planning (total) Hospital Doctor Number of patrol members

Source: ADI patrol summary reports

18 The smallest patrol has been with 6 staff, and the largest with 13 staff. Patrol composition over the 5-year period has been: - Dental staff have been on 97% of patrols - STI, HIV/AIDS health worker staff have been on 66% of patrols - Education, logistics support and information on 65% of patrols (ADI staff or provincial staff) - Eye care staff on 60% of patrols, with greater consistency since mid 2012 - Since 2013 physiotherapy have fairly consistently provided staff to attend patrols (attending 47% of patrols over the whole period). Physio team leader now says ‘every patrol should have a physio attend’. - TB staff only 34% over the 2012-2013 period, with none since the start of 2014 - Maternal- child health and PAP smear health workers have joined 24% of patrols, with only one attendance since March 2014 - Family Planning health workers have attended just 19% of patrols - Since late 2015 a doctor from Kavieng Hospital has attended three patrols

Ideal Patrol Team Composition - LLG manager covering patrol area - ADI doctor - PNG doctor - PNG RMO* - Dental staff x 2 - Eye health staff - Physio staff - STI/HIV/AIDS / TB staff (communicable disease officer) - Midwife/ Maternal and child health staff - Family planning staff - Logistics/education officer (to cover education and training, including lifestyle diseases e.g. diabetes, respiratory disease prevention and environmental health e.g. hygiene) - Driver x2 * ‘nice to have’, ‘plan to have’ In terms of management and communications, over the May-2011-Aug-2013 period only 41% of patrols had an LLG manager or someone from the LLG team on them, with none until the end of 2015. LLG managers could play a communications role by reporting on the status of their health staff and facilities and working with district and provincial officials to implement change. See action point 2 below. Some interviewees thought the gaps in maternal and child health and TB services needed to be filled, and to have both a maternal and child health person and a TB service person on patrol was important and a more efficient way to deliver the services. (Also see section Objective 3, for details of transition plans.) Patrol doctors and allied health team are seeing many patients and delivering a large volume of services, far above the number of patients usually seen in health centres (see Table 13: Health worker load and support). These figures only show one side of the purpose of patrols, education and training of health workers is not as easily documented. See Table 7 below). Patrols rely on the health centres to advertise their arrival and timing. This can result in mixed outcomes with some health centres, aid posts and village better prepared than others.

19 | P a g e

Table 7: Patients seen and services delivered

Year Average number of patients (ADI Total number of Total number of Total number of doctor) per day on patrol Examinations (ADI services delivery services delivered doctor) (Allied health (Allied health team) per day on team) patrol

2011 26 2057 83 6324

2012 30 2904 81 8057

2013 30 3249 240 31084

2014 26 2424 174 20481

2015 35 3128 169 24215

Source: ADI patrol database All patrol locations visited were given a remoteness designation:

Very remote = greater than 7 hours travel time (either boat, road, walking or combination) Remote = between 4 and 7 hours travel time Less remote = between 1 and 4 hours travel time Close by = less than 1 hour travel time

Flights to locations were designated very remote

Table 9 shows the breakdown of patrols by these designations over the review period.

Table 8: Patients seen by remoteness

Patients seen per day by remoteness

2011

Close by 6%

Less remote 32%

Remote 23%

Very remote 38%

2012

Close by 1%

Less remote 46%

Remote 22%

Very remote 31%

2013

Less remote 26%

Remote 27%

Very remote 47%

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2014

Less remote 41%

Remote 29%

Very remote 30%

2015

Close by 3%

Less remote 27%

Remote 37%

Very remote 33%

Source: ADI patrol database

Patrols have primarily focused on reaching the remote and very remote communities, with 63% of patients seen in remote or very remote communities.

Table 9: Health facility case based and group based teaching by remoteness

Case based teaching by 2011 2012 2013 2014 2015 remoteness (hours)

Close by 29 5 12

Less remote 108 132 113 136 110.5

Remote 78 69 161 149 96.5

Very remote 85 116 202 160 104.5

Grand Total 300 322 476 445 323.5

Group based teaching by 2011 2012 2013 2014 2015 remoteness (hours)

Close by 5 3

Less remote 32 30.5 21.5 28.5

Remote 20.5 31.5 32.5 29.5

Very remote 29 31.5 28 29

Grand Total 86.5 93.5 82 90

Source: ADI patrol database

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Action Point 1 Gap: low attendance of maternal and child health professionals on patrol Maternal-child health (and/or PAP smear nurse) have attended 24% of patrols, with only one attending one patrol (in October 2014) between March 2014 until December 2015. Although the three patrols in the last quarter of 2015 did have the O&G specialist join the patrols. The report written by O&G specialist, Dr Frank Apamumu, documents the importance of the patrol for rural health workers and their communities, and the importance of the educational component of the patrol (see report 4/9/15). Maternal health, including safe motherhood, is a much sought after topic - the second most taught group topic (based on patrol database, 2015), after diabetes. Qualitative feedback from health workers (collected during patrols) also indicates the value of education to maternal health care, for example: “I knew how to properly use the vacuum extractor” “I felt confident on the newborn resuscitation”. Patrol reports from 2014 and 2015 note use of partograms and misoprostol in visited health centres. Sustaining this knowledge is key, however this does not explain the decreasing coverage numbers for maternal health. These are perhaps explained by a combination of other factors that vary between health centres, e.g. distance to reach health centre for pregnant woman, attitude of some health workers, inconsistency of data entry and gaps in data. The first two are systemic issues that are well beyond the scope of patrol work. Recommendation: Include maternal and child health professional/midwife on patrol In a recent interview (November 2015) one PNG medical staffer said they are ‘quite worried about the level of maternal care available’ in New Ireland and requests that there is ‘always an Obstetrics and Gynaecological [specialist] on patrol for training.’ Broadening this to a midwife gives greater chance of having the appropriate health professional on the patrol, while still achieving a similar result for health workers and patients. Given health centres have specific days of the week for maternal health, patrol days overlapping with these days are prime opportunities for a midwife to offer a greater level of health services than usually offered in the clinic. Having a midwife on patrol and targeting women for maternal health coinciding with patrol visits could facilitate a greater level of antenatal coverage as well as support health workers in maintaining their level of knowledge on maternal and child health.

Action Point 2 Gap: Health workers in rural and remote clinics feel unsupported Based on interviews and feedback received on patrol, nursing officers and community health workers say they feel unsupported. LLG managers are the crucial link between the frontline health managers and district and provincial health, offering one of the only channels through which staff can raise issues that need attention in health centres. This makes LLG managers’ role and local knowledge of frontline health service, staff and clinics crucial for running a decentralised, functioning health system. The patrol summary reports indicate the last time an LLG manager attended a patrol was August 2013. Over the May 2011-Aug 2013 period 41% of patrols had an LLG manager or someone from the LLG team on them, with none since then. Of the seven health centre health workers interviewed in November 2015, none had had a visit from an LLG manager in the last 12 months with the exception of the clinic where a LLG manager is based. One health worker said ‘they [LLG managers] should visit, so they know the status of the infrastructure, staff and programs we are providing’. In comparison, in a PNG-wide study asking health centre staff about visits from health extension officers, 34% had received a visit in the last 12 months. Given the situation in New Ireland and the current lack of support for rural and remote health workers from LLG, the patrol model fills a current gap, providing rural and remote health workers with access to supervisors. Recommendation: Regularly include LLG managers on patrols occurring in their area

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In addition to the continuing of patrols and the supervision those directly provided to rural and remote health workers] by also including LLG managers on patrol we increase the opportunity for greater communications between LLG managers and frontline health managers. Some feedback indicates high willingness for LLG managers to be more closely involved with patrols and that the patrols are effective ways to open the line of communications with their health staff. This starts with including LLG managers in patrol schedule planning, but also encouraging frontline health staff to raise issues with LLG managers while they are visiting their health centre. In the longer-term, LLG manager could move to have their own schedule of visits in addition to and independent of patrols.

Action Point 3 Gap: Some patrols do not have the right specialists for diagnosing TB and other conditions, and PNG doctors should also be part of patrols Having a medical officer with knowledge of malaria, TB, diabetes and respiratory infections is key to meeting PNG and New Ireland health needs. Recent patrols have included a PNG medical officer. The key barrier to achieving this on a regular basis is lack of availability. Recommendation: Ensure Kavieng Hospital is adequately staffed to allow for release of doctors and specialists to attend to patrol work. Ensuring there is sufficient staff at Kavieng Hospital to release required doctors and specialists for patrol duties is critical for eventual NIP takeover of the patrols.

ADI doctor Ronald Oosterhuis examining a patient in Namatanai District

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Project Focus 2: ADI In-Service and Training While on Patrol Achieving universal health coverage relies on the distribution and skill of health workers to match population needs. In rural and remote locations like New Ireland ensuring populations have access to trained health workers is complex and challenging. What is needed are skilled and motivated health workers in sufficient numbers at the right location to deliver effective health services to impact upon health outcomes2. In-service training plays an important role in filling the health worker skills gap, and also assists with retention of health workers. Provision of continuing educational support and professional development that is easily accessible is one of WHO recognized strategies – impacting on both skill attainment and retention2. Patrol reports and information from stakeholder interviews (both health workers and those involved in delivering in-service training) highlights the lack of opportunity for continuing education of front-line health workers. Health worker skill gaps are consistently identified through patrol reports, e.g.:  There are currently inadequate staffing numbers and skill level to deal with the patient load. (Lipek sub-health centre, Tanir Patrol Report Nov 2011)  Need for ongoing education and monitoring of all staff to ensure improvement in clinical knowledge and skills [identified as a major barrier to health care] (Tikana Patrol Report Sep 2013) In-service training and patrol, case-based or group-based training is a way ADI can start to fill this gaps. In-service programs began in 2013, funding for (non-specialised) in-service has been less reliable than for patrols. In October 2015 the planned in-service was postponed until April 2016 due to the inability of NIPG to release necessary funds as per the signed agreement.

Table 10: Timeline of in-service, attendees and topics

In-service date Number of Topic attendees*

Apr-13 68 Maternal health, child health, TB, HIV/AIDS, STIs, drug therapies

Apr-14 64 Maternal health, TB, malaria, drug therapies

Sep-14 18 Pathology and lab methods

Apr-15 12 Family planning

May-15 51 TB, child protection, HIV/AIDS, lifestyle diseases, hygiene and healthy islands, family planning

Grand Total 213

Source: ADI register * includes count of individuals that have attended multiple in-service sessions

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Table 11: In-service costs

Date of in- Topics Number of Cost (kina) Cost per service attendees participant (kina)

Apr-13 Maternal health, child health, 68 141981 2088 TB, HIV/AIDS, STIs, drug therapies

Apr-14 Maternal health, TB, malaria, 64 124492 1945 drug therapies

Sep-14 Pathology and lab methods^ 18 77449 4303

Apr-15 Family planning 12 58130 4844

May-15 TB, child protection, 51 112864 2213 HIV/AIDS, lifestyle diseases, hygiene and healthy islands, family planning Source: ADI register, ADI financials

^ fully funded by BD

The two specialized training services are more than double the cost per trainee of the broader in-service covering larger numbers of participants. On average, NIPG contributes 40% of the funding required for in- service. In-service training provided by ADI is unique; there is no other comparable service available to health workers in New Ireland. The combination of in-service training, where the focus is on depth of acquisition of skill and the opportunity to practice new learnt skills in a safe environment, complements the case-based training and group training offered on patrol by the doctor and allied health professionals. In-service sessions (April 2013, April 2014, May 2015) have received very high levels of enjoyment from participants (96%, 94%, 89%) (Locke reports on in-service). Participants also report having their learning needs met to a very high level (94% in April 2013, 92% in April 2014, 93% in May 2015) (Locke reports on in-service). From the first in-service, the value of practical sessions was identified and implemented:  The Namatanai cohort gave its highest overall rating to taking a RDT blood test and slide for malaria (72%). This rating was followed by creating a cold smear for TB (60%), and managing shoulder dystocia (31%). It seems reasonable to comment that the problems of malaria, TB and birthing difficulties are major public health issues in PNG.  The item that rated highest across the five days was preparation of sputum slide (77%) and this was an incomplete procedure because of the necessity to comply with universal precautions. Neonatal resuscitation where participants were able to use the neonate manikin also rated very well (57%). Taking proper histories (65%) was mentioned twice with the higher rating being given following a role play where history taking was demonstrated thus appearing to become more relevant to the cohort. (Locke, Report on in-service, 2013) In addition to in-service, providing the New Ireland rural and remote health workers with practical on-the-job training opportunities has also become a core and important function of the patrols. The focus on continuing education of these health workers provides daily health solutions that are available to their populations 365 days of the year, while the patrol is there for only one or two days. Over the years the focus of patrols has shifted from provision of medical services to education of both health workers and the communities they serve. The overall trend is for an increase in hours for case based training (see Table 10 below) reflecting the growing importance of education, as opposed to a purely medical model of patrol. Interviews with stakeholders across the board noted the value and importance of education and capacity building offered on patrols. Incoming ADI patrol doctor 2015 ‘I was given the heads up to focus on education’. This is in a context where there is little 25 | P a g e opportunity for health worker continuing education, and the Nursing Council is struggling to implement a professional requirement for a minimum number of continuing education hours/days per year for community health workers (personal communication). Thirty-six percent of case based teaching hours over the 5-year period has been spent teaching the most remote health workers in New Ireland. With 66% of case based teaching time directed towards the health workers in remote and very remote areas. Health workers who are not receiving adequate support and who service a disproportionately large population highly value this educational input from the patrol team, with training an often cited comment in health worker evaluations: ‘Doctor taught us on some of the health topic that we are not very familiar with.’ ‘I felt confident on the new-born resuscitation.’

Topic Coverage for Group (In Service) and Patrol (Case Based) Training Case based topics taught on patrol are a function of both community health needs and skill of staff in the patrol mix. The high count for musculoskeletal teaching topic reflects the recent consistency of a physio as part of the patrol team (see Figure 9 below). Group based training topics better reflect the community needs – here we see maternal health (including safe motherhood) as the most frequent topic taught in group settings. Moreover, health worker feedback solicited at completion of patrols found maternal health skills taught were an often cited lesson learnt from the patrol. “I knew how to properly use the vacuum extractor” “I felt confident on newborn resuscitation”

ADI rural health patrol team transport an emergency patient to the mainland

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Figure 4: Topic frequency, 2015

Group

Diabetes Maternal health (inc safe motherhood) Drug therapy Other Cardiovascular Respiratory Child health (inc immunisation) Musculoskeletal Diseases (TB, Leprosy, Filariasis, Yaws) Womens health (inc. sexual health) Gastrointestinal

0 2 4 6 8 10 12 14 16 - Case Based

Other Musculoskeletal Respiratory Drug therapy Cardiovascular Diseases (TB, Leprosy, Filariasis, Yaws) Child health (inc immunisation) Gastrointestinal Womens health (inc. sexual health) Diabetes Maternal health (inc safe motherhood)

0 5 10 15 20 25 30 35

Source: ADI patrol database

Health Worker Access to Patrol Staff for Training In the clinical survey, all health workers reported having access to working with patrol staff, including on-the- job training.

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Figure 5: Clinical survey response - health workers working and training with ADI doctor on patrol

39% of health workers have worked with a patrol once or twice, 61% more than that and 40% of health workers have participated in patrol training once or twice, 60% more than that. These contacts while patrols are visiting health centres provide opportunity for remote and rural health workers to gain professional educational support, and in a context where many of the health workers feel unsupported they are valued. Results from the clinical survey also showed that working with an ADI doctor during the patrol visit, and attending training (both patrol based and in-service) gave health workers a boost in confidence (for maternal health and tuberculosis. Overall health workers felt confident in dealing with malaria (with 95% very confident, confident or somewhat confident), safe baby delivery (with 87% very confident, confident or somewhat confident) and tuberculosis (65% very confident, confident or somewhat confident). Health workers demonstrated adequate levels of competency with an average clinical knowledge score of 70%. See annexure 2 for other results.

Health Workers at In-Service The following analysis illustrates the coverage ADI has achieved over the 2013-2015 period in terms of training health workers in New Ireland. 190 individual health workers attended training over the 2013-2015 period. There are an estimated 235 health workers in non-Kavieng hospital settings. The following percentages are based on this denominator. 80% of rural health workers have attended at least 1 ADI in-service, 27% in 2015, 34% in 2014, 29% in 2013. 1215 person days of in-service training were provided over the 2013-2015 period.

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Table 12: Health worker positions and their organisational base

Positions/ Organisation Private Government Hospital unknown Church Grand based Total

Clinical Health Worker 4 67 1 2 30 104

Community Health Worker 5 7 12

Doctor, CEO 1 1

Lab Manager 1 1

LLG Health Manager, HEO 1 1

Logistics Officer 1 1

Matron 1 1

Medical Laboratory Assistant 1 5 3 9

N/A 1 1

Nursing Officer 3 32 34 69

Nursing Officer In Charge 1 1

Rural Laboratory Assistant 2 2

Scientific Officer 1 1

Senior MLT 1 1

Sister In Charge 1 2 3

Sister In Charge, Nursing Officer 2 1 3

Student 1 1

VCCT Councillor 1 1

Grand Total 9 119 1 4 80 213

The majority of attendees are clinical health workers/ community health workers (54%) or nursing officers (32%). This focus on front-line health workers is appropriate. Most attendees are government based (56%), followed by church based health workers (38%).

Action Point 4 Gap: 20% of Health Workers in New Ireland are yet to attend ADI In-service Training Monitoring the ongoing professional skills training of New Ireland’s health workers will assist with identification of gaps and development of targeted training plans. This will help to prevent health workers from ‘falling through the cracks’ in terms of updating their skills. Recommendation: Identify the 20% of remaining Health Workers and continue to monitor in-service attendance Ideally the Provincial Health Authority will maintain the register of health workers and their ongoing professional development so that we can strive for 100% coverage but as an interim measure the ADI database can be used for this purpose.

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In-service Topics The following figure illustrates the health workers and the topics they have covered through in-service training. The most training to date has been on TB and maternal health topics. All topics are reflective and in line with PNG NDoH’s priority health outcome areas1. Figure 6: Health workers attending in-service by topic (until end of 2015)

Looking at the 6 key health areas for New Ireland and in-service topic coverage for rural health workers, the following coverage and gaps are identified: - 68% of health workers have attended an ADI in-service that covers maternal health, 32% have not - 78% of health workers have not attended any lifestyle diseases (diabetes or - respiratory disease prevention) in-service - 61% of health workers have not attended any malaria in-service - 71% of health workers have not attended any child health in-service - 11% of health workers not covered with any TB in-service

Action Point 5 Gap: Health Workers have not received training on critical areas such as Child Health, Diabetes, Malaria and Maternal Health A professional development register needs to be implemented to ensure all NIP Health Workers receive training on these key topics. Recommendation: Target training of health workers previously missed on key health topics (maternal health, lifestyle diseases (diabetes), malaria, child health and TB).

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Using the register, the Education Committee can better develop targeted training plans for future In-Service training programs.

Trainers at In-Service Historically training topics at in-service have been delivery by a mix of PNG and non-PNG presenters. In light of a capacity building agenda, increasing the number of PNG presenters is seen as a valuable goal to pursue, although these presenters need adequate time and support to deliver high quality sessions. This is a topic that can be covered through the Education Committee, in terms of identifying appropriate individuals for delivery of topics and ensuring they have adequate preparation time and skills to deliver high quality content. Unprepared or unskilled presenters can negatively impact upon learnings. The following quotes from annual reports prepared by Lin Locke highlight these points: - In most instances participants were very pleased with the quality of the presenters. Where dissatisfaction was expressed this related more to national colleagues who arrived late, did not adequately answer questions or were inadequately prepared for their session/s. (2013) - In these workshops the success of TB days was negatively impacted on by the quality of the presenters. (2015)

ADI Dr Bruce Slonim with child patient Challenges to Health Delivery in NIP

While health delivery in New Ireland Province benefits from stable government and a strong partnership between the Provincial Government and ADI, a number of challenges must be addressed if we are to achieve even more in the next 5 years of ADIs operations. The following section outlines some of these issues and provides suggested remedies to address them. 31 | P a g e

Health Facilities In 2015 there were 33 health centres, each with associated aid posts, together they are referred to as health facilities. Of the health centres, 19 are government run, 11 church based and three private clinics. In 2015, more of remote/very remote aid posts were closed (8/14), than the close by/less remote aid posts (6/14), the opposite in terms of desirability for providing population health and accessibility.

Figure 7: Aid post remoteness and open/closed status (end-2015)

25

20

s

u

t

a

t 15

s

t

s

o

p 10 Closed aid posts are

d

i

A those further away.

5

0 Close by Less remote Remote Very remote

Closed Closed - Temporary Open Open?

Source: NIPH 2015, ADI analysis of remoteness

Full details of status of health facilities and aid posts for 2015 are available in annexure 1.

Action Point 6 Gap: Some population areas have no access to open health centres or aid posts. Some areas of New Ireland Province are not serviced by Health Centres or even an Aid Post. This situation is extremely fluid and ADI may schedule visits to posts which are already closed. Recommendation: Develop a database of Health Centres and Aid Posts to maximise coverage of the New Ireland population. While ADI is able to provide updates on this post patrol, it would be beneficial to have a robust, updated register of open and closed health facilities maintained by Provincial Administration which could be used by ADI and government for planning and more efficient resource allocation.

Health Workers The availability of health workers in the health system for rural and remote locations provides an understanding of what levers are available to address the unmet health needs of these people. Simply put, a shortage of health workers impedes access to health-care services, slows progress on health indicators and negates achievement of ‘health for all’ goals. New Ireland has an estimated population of 222,000, and 235 health workers in non-Kavieng Hospital settings (including nursing officers, community health workers and health extension officers, and excluding vacant positions) and 313 health workers at Kavieng Hospital (based on personal communications) as at November 2015. Analysis of this data by health facility and aid post shows the following ratios (See Figure 8: Ratio of health worker to population by area).

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Figure 8: Ratio of health worker to population by area

Source: NIPH 2015

Across the board, with only one exception, all health facilities are attempting to service a population well above the benchmark threshold determined by Scheil-Adlung, 2015 to provide universal health coverage and sustainable development. Only two are at the lower (and older) threshold target established by the World Health Organisation in 2006 . Scheil-Adlung, 2015 set the threshold at 41.1 health workers per 10,000 population (or 1 health worker to 243 head of population) as a minimum density to provide universal health coverage 7 8. Until Scheil-Adlung, WHO’s The world health report 2006 target of 22.8 per 10,000 population (or 1 health worker to 438 head of population) – was the most widely used health workforce “target”, and countries with health worker to population ratios lower than this generally fail to achieve the targeted coverage of 80% for skilled birth attendance and child immunization9. While Scheil-Adlung found MMR in rural areas is strongly related to access to health workers, as access to health workers decreases, MMR increases7. If we take the whole population of New Ireland, and factor in the population residing in areas with closed aid posts the ratio is 1:404.

These numbers are supported by feedback patrol staff receive when working with health workers in rural and remote areas of New Ireland, where staff shortages are a consistently mentioned issue going back as far as the original 2011 patrols (ADI Patrol reports 2011-2015).  One staff member at Lamassa Health centre who is often not present for work and personal reasons– leading to the Health Centre’s total closure for weeks on end. He is overworked and over whelmed. This must be rectified urgently, as people are dying and suffering needlessly and there is absolutely no trust by the community in this staff member or the Health Centre. (Konoagil Patrol Report May 2012)  There are inadequate staffing numbers for such a busy aid post (Lelet Aid Post, Sentral Patrol Report Dec 2012)

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Action Point 7 Gap: The New Ireland population is not adequately covered by health workers and particularly there is maldistribution of health workers, leaving some areas more under-serviced than others and skills mismatched to population needs. Recommendation: Conduct a detailed health workforce projection and needs analysis by geographic area. This will ensure that resources are efficiently allocated and that the right skills and infrastructure is in the right place.

ADI’s Dr Druce Slonim conducting case-based training with Allied Health worker Edward Able during rural health patrols

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Health Worker Load and Support Understanding health worker load and support provides insights to the extent the health system is able to respond to population health needs, and the extent the health system is supporting remote and rural workers to provide the needed health services. The table below compares New Ireland data against that published in the Lost Decade report10.

Table 13: Health worker load and support

Health worker load Lost Decade 200210 Lost Decade 2012 New Ireland 2015 Per health centre

Patients in a day 46 37 46*

Patients the day before 40 28 n/a

Number of days open (per 6.2 6.5 7 days (for health week) facilities with 1 staff member, closed if they are out of town)

Support and capacity Lost Decade 200210 Lost Decade 2012 New Ireland 2015 building

Per health centre

Visit from health extension 31% 34% 5/7 said no. The other 2 officer (in last 12 months) have HEO on site.

Visit from LLG manager (in 6/7 said no. 1 has LLG last 12 months) manager on site.

Visit from a doctor (for 19% 11% No doctor visits 2015 New Ireland) other reported: than ADI/NIPH patrol (in

last 12 months) 2 reported drought team visit

1 reported TB DOTS visit

Staff in-service training or Two health facilities attachments other than ADI reported receiving organised in-service training other than ADI training (in last 12 months) organised in-service training. (HIV/AIDS and immunisation)

 Based on sample of 7 New Ireland health centres. Three clinics are church based, four are government based

A 2015 patrol report notes that the ‘lack of opportunity for ongoing professional development of staff is of great concern and cannot be left [solely] to ADI through their inservice programs and patrols. The lack of

35 | P a g e knowledge of some health workers is quite astounding and stories of graduations 15 – 20 years ago with no subsequent retraining are all too common’ (Patrol report, 2015). The clinical survey issued to staff early in 2016 (see annexure 2 for methodological and demographic details and key results) found that when health workers were asked about support for their work, 46% feel supported or very supported, a third feel not very supported, or not supported at all.

Figure 9: Health worker support - results from clinical survey (2016)

30%

25%

20%

15%

10%

5%

0% Very Supported Somewhat Not supported Not very Not supported supported supported supported at all

Action Point 8 Gap: As paralleled in the 2014 Lost Decade report10 supervision and support for health workers in facilities is lacking in New Ireland as in the rest of the country. LLG Manager play a crucial role in the delivery of health services in New Ireland, particularly with regard to:  Ensuring Health Centres and Aid Posts are adequately stocked with medicines and equipment  Ensuring that the staff are appropriate to the needs of their district and arranging for training where necessary  Assisting ADI to inform the community of upcoming patrols These critical functions are generally not well understood by the LLG managers, and they are often surprised to learn of these responsibilities. The logistical functions, particularly in relation to stock management, are complex tasks for which they are inadequately trained. Recommendation: LLG Managers and the District Managers to undertake specific training and upskilling in inventory management and have greater clarity and accountability around their responsibilities. While Health Centre and Aid Post workers may be doing a good job, they are severely constrained by lack of adequate supplies and ongoing professional development. We must first start with training and upskilling the LLG managers and to some extent the District Managers to ensure that those below them are properly supported.

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Financials Provincial Government Funding ADI has received good financial support from the New Ireland Provincial Government, which is matched by the Australian Federal Government, to assist with delivery of the patrols and the In Service training. However, other elements of a successful health system such as health worker salaries, infrastructure and supplies are needed to be funded by the NIPG. The three health minimum priority areas ‘rural health facility operational costs’; ‘integrated health patrols’ and ‘medical supply distribution’ are directly pertinent to the operational mandate of the integrated patrols facilitated by Australian Doctors International in New Ireland. Using data at the provincial level to gauge how the New Ireland Provincial Government fares we observe the following about New Ireland Province (up until 2013): - revenue dipped down in 2012 - provincially generated revenue is enough to cover the cost of provision of basic services (health, education, transport infrastructure, primary production), but this internally generated revenue relies on the provincial government to direct funds to cover basic services - an uplift of spending on priority areas2 is needed following declines in spending 2012, 2013. - New Ireland (and Western and Morobe) are the poorest performers in terms of health and HIV priority spending (including for rural heath)4. In summary, for health spending to increase and the serious health issues that New Ireland faces to be addressed a reprioritisation of spending needs to occur. This financial situation is noticeable and impacting on the frontline health workers in rural New Ireland. There has been a shortage of funds within the Provincial Health System – with the ‘287 budget’ (designed to cover PNG’s minimum priority areas, including health, and within health, rural health facility operational costs, integrated health patrols, medical supply distribution4) not accessible. It is common for health workers to experience delays in salary payment or for their employment to be terminated without warning.

Action Point 9 Gap: Financial support for the provision of health in New Ireland is insufficient to support population needs Recommendation: Conduct a budget needs analysis for future funding requirements and assess where funding may be reallocated from

User Fees In 2014, the National Government implemented free primary health care, the Alotau Accord11. Despite this, and the NIPH announcement to health facilities throughout the province to no longer charge user fees to patients, five of the seven health facilities questioned were charging some user fee. A sample of the user fees charged: - First visit: adult 2 kina, child 1 kina; Second visit no charge - Outpatient: new 2 kina (re-attendance 1 kina) - In patient: 15 kina (+2 kina for guardian) - Maternity fee: 20 kina in hospital delivery; 35 kina if village then hospital visit (charge higher to discourage village delivery)

2 MTDS Sectors includes; rural health and HIV/AIDS, agriculture and fisheries, education, village courts and infrastructure maintenance.

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- Domestic violence charge: 25 kina (Health worker interviews, 2015)

One health centre did stop charging at the time requested (July 2014), but then realized months later ‘they couldn’t run [the health centre] without charging’. (New Ireland health worker, 2015). Note, user fees do not apply on the day(s) the patrol visits. Other research conducted in 2009 in PNG on charging user fees in the health system found 84% of the sampled health facilities were charging some user fees12. Level of fee differed across facilities, as in New Ireland, and where patients were unable to pay they were still provided with health care. Inadequate funding was also cited in the 2009 research as a reason for charging user fees, with revenue raised from fees used to cover operational costs. As stated above, maternal health is a key health issue in PNG and New Ireland, and any impediment, such as charging a delivery or visit fee, to facilitating access to health for pregnant women should be removed. As found in New Ireland, there is a high user fee charge applied to treating domestic violence related injuries across PNG. While this was intended to serve as punishment and disincentive to violent behaviour, it calls into question gender equity where women are the main victims of domestic violence in PNG. Although the PNG National Department of Health has policies and regulation against charging these fees, they have found to be poorly enforced12. This stance is in line with the goals of Universal Health Coverage13, health Sustainable Development Goals14, current global policy15, and is supported by a systematic review of evidence in low and middle income countries that shows reducing or removing user fees increases the utilization of certain healthcare services 16. User fees have three issues associated with them. They are viewed as a barrier, especially to poor people, from accessing health care; as inequitable, especially to poor and women and have been demonstrated to offer little economic return15. Health workers interviewed cited lack of fuel and transport as an impediment to delivering health services. Funding deficiencies may prompt health workers to charge fees to purchase fuel and/or gain access to transport for their patients.

Action Point 10 Gap: Charging of user fees is a barrier to delivering health services, including for maternal health, is inequitable and against Government policy11. While remove of all fees would be ideal, it is also recognised that this is not a financially sustainable practice for many clinics which are performing essential work. However, an approach to fees which lessens barriers to care is still feasible. Recommendation: Consider removing those fees which impede and discourage access to health care, and which unfairly penalise women. Fees which specifically target domestic violence cases and maternal care (eg baby delivery) should be removed.

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ADI’s Dr Tim Baird treating patients at a day clinic during rural health patrol

Costings The following illustrates the estimated cost to place an ADI doctor on patrol and provide services to patients in rural and remote locations of New Ireland. Costs vary depending on both input requirements for the patrol (particular transport costs), and numbers of patients in the catchment area of the patrol.

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Figure 10: Cost per examination (excluding provincial health and hospital staff costs), estimates for ADI staff only – kina

Source: author analysis, NIPG salaries, ADI financials, ADI patrol database

Average cost per examination conducted by ADI doctors is 22 kina (or 21 kina if exclude the expensive transport costs to Murat). The most expensive patrol in terms of cost per patient was to Kabanut (November 2014) where there were relatively fewer patients. This is a good investment in rural health for a population that may not otherwise have access to health services.

Table 14: Patrol costs, and cost centres

2013 2014 2015 2013 2014 2015

Total Total Total Actuals Actuals Actuals Total Actuals Total Actuals Total Actuals 2013 Kina 2014 Kina 2015 Kina Item Cost centre 2013 Kina 2014 Kina 2015 Kina % % %

Sub-total direct costs* NIPG 239,103 197,064 252,144 40% 35% 34%

Sub-total indirect costs* NIPG 73,582 103,761 115,043 12% 19% 16%

Subtotal Provincial Health and Provincial Hospital staff and hospital salary costs staff 137,390 95,002 121,157 23% 17% 16%

Sub-total ADI Integrated Patrol Costs ADI 143,602 164,054 248,738 24% 29% 34%

Total 593,676 559,881 737,081

* NIPG 400,00 kina in annual patrol funding.

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New Ireland funds the largest share of patrols (71%) and ADI covers the remaining 29%. Direct costs (NIPG) represent 37% of patrol costs, ADI costs represent 29% of patrol costs, provincial health and hospital staff costs are 19% of patrol costs, with 16% indirect costs (NIPG). See annexure 3 for details. Average cost per patrol is 47,500 kina (including NIPH costs, ADI costs and staff costs) based on three years of data. The three most expensive patrols were annual trips to Murat where ~40,000 kina was spent on boat transport each year (2013, 2014, 2015). Removing this cost, drops the average patrol cost to 44,000 kina. The expenditure incurred each year is slightly below the funds provided.

Funding balance:

2013 2014 2015

Remaining funds (kina) 87,315 99,175 32,813

See Objective 3 for potential use of these funds.

Members of the Allied Health Team with ADI’s Dr Bronwen Morrison

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Summary of Recommendations for Objective 1

Action Point 1 Gap: low attendance of maternal and child health professionals on patrol Recommendation: Include maternal and child health professional/midwife on patrol

Action Point 2 Gap: Health workers in rural and remote clinics feel unsupported Recommendation: Regularly include LLG managers on patrols occurring in their area

Action Point 3 Gap: Some patrols do not have the right specialists for diagnosing TB and other conditions, and PNG doctors should also be part of patrols Recommendation: Ensure Kavieng Hospital is adequately staffed to allow for release of doctors and specialists to attend to patrol work.

Action Point 4 Gap: 20% of Health Workers in New Ireland are yet to attend ADI In-service Training Recommendation: Identify the 20% of remaining Health Workers and continue to monitor in-service attendance

Action Point 5 Gap: Health Workers have not received training on critical areas such as Child Health, Diabetes, Malaria and Maternal Health Recommendation: Target training of health workers previously missed on key health topics (maternal health, lifestyle diseases (diabetes), malaria, child health and TB).

Action Point 6 Gap: Some population areas have no access to open health centres or aid posts. Recommendation: Develop a database of Health Centres and Aid Posts to maximise coverage of the New Ireland population.

Action Point 7 Gap: The New Ireland population is not adequately covered by health workers and particularly there is maldistribution of health workers, leaving some areas more under-serviced than others and skills mismatched to population needs. Recommendation: Conduct a detailed health workforce projection and needs analysis by geographic area.

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Action Point 8 Gap: As paralleled in the 2014 Lost Decade report10 supervision and support for health workers in facilities is lacking in New Ireland as in the rest of the country. Recommendation: LLG Managers and the District Managers to undertake specific training and upskilling in inventory management and have greater clarity and accountability around their responsibilities.

Action Point 9 Gap: Financial support for the provision of health in New Ireland is insufficient to support population needs Recommendation: Conduct a budget needs analysis for future funding requirements and assess where funding may be reallocated from

Action Point 10 Gap: Charging of user fees is a barrier to delivering health services, including for maternal health, is inequitable and against Government policy11. Recommendation: Consider removing those fees which impede and discourage access to health care, and which unfairly penalise women.

ADI’s Dr Tim Baird treating a patient during rural health patrols

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Additional Recommendations Identified through Objective One:

In Relation to the Patrol Team:

Action Point 11 To increase the capacity and safety of staff in cars, consider roof racks or 4WD trailer

Action Point 12 Non clinical person to act as team leader – consider only having non-clinical staff members of patrol act as team leader as the clinical staff are too busy

Action Point 13 Ensure there are consequences in place for patrol staff breaking the code of conduct

Action Point 14 Consider remoteness factor in strategic planning and schedule of patrol locations

Action Point 15 Use local knowledge of patrol team for route planning and schedule

Action Point 16 Visit schools every second year (not annually)

Action Point 17 Work to ‘ideal’ patrol list in staffing patrols

In Relation to the Doctor Placement:

Action Point 18 Recruit with education of health workers and equal duty to clinical care

Action Point 19 Read through PNG Medical Journals to ensure familiarity with health content and issues. Particular health topis of interest: malaria, TB diabetes and respiratory infections. See: http://pngimr.org.pg/png_med_journal/index.htm

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Action Point 20 On arrival in New Ireland aim to attend three to four rounds in Kavieng Hospital (with permission of hospital staff) before going on patrol or placement in Namatanai. Potentially also attend grand rounds on a regular basis when in Kavieng

Action Point 21 Ensure recruited doctors are willing to be available in a clinical advisory capacity for 6 months post mission to New Ireland for handover to the incoming patrol doctor

New Ireland Governor, The Rt Hon Sir Julius Chan with HEO Dashlyn Chee at Namatanai Rural Hospital

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Objective 2

Define and document a flexible and adaptive model of integrated patrol and in-service programs for potential application in other provinces of PNG and countries in the Asia Pacific region Building a sustainable, integrated, partnership model first requires a trigger of unmet health need, followed by agreement and a joint investment in local systems and institutions to facilitate knowledge exchange and capacity building. Key to this model is the foundation of partnership3, as:  ADI has been and continues to need to be nimble, flexible and responsive to partnerships and operating context  ADI needs to be able to build capacity with local agencies to be effective operators in their own context In establishing partnerships future models need to check for: 1. Permission and mandate from local authority. This must be obtained in order to provide authority to ADI to provide services and programs. This also serves to secure medium to long-term political commitment for the services and programs ADI agrees to provide (as distinct from the organisation itself and in doing so creating an exit strategy from the outset). 2. Scope of services and programs defined by all relevant parties. Each party to both: a) individually document and share organisational VALUES and organisational objectives for the partnership, and b) collaboratively identify the PURPOSE and OBJECTIVES of services and programs to be delivered. For this to take place, ADI needs to have its own clear PURPOSE for each program, and that purpose must align with ADI’s broad strategic goals as well as with PNG’s National Department of Health goals. ADI must also have enough (or gather enough) knowledge of local context to:  identify appropriate organisations and understand their values,  identify key individuals within those organisations and the skills/experience/knowledge they bring to the partnership,  document scope of services to be covered - geographic coverage, population coverage, health worker coverage, disease coverage, (and what is out of scope)  resources required (financial, human),  functional duties of core team  costings (and who’s paying what)  program risks and mitigations,  duration of involvement,  reporting requirements for all organisations,  definitions of success,  potential exit strategies. These elements should make up a due diligence document performed during the initial scoping phase.

3 Influenced by work: ACFID: Partnerships for Effective Development January 2014 https://acfid.asn.au/sites/site.acfid/files/resource_document/Partnerships-for-Effective-Development.pdf 46 | P a g e

Importantly – there is not a one-size-fits-all model, ADI should continue to be responsive to individual provincial needs and contexts while remaining true to the core elements of its successful integrated rural patrol model. Figure 11: ADI adaptive model

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Objective 3

Document a staged handover and transition plan of the New Ireland Patrol and In-service Programs to local partners in New Ireland, and answer: what is required for NIPH to run patrols and in-service programs in the future? The goal of transition is to transfer functional responsibility from Australian Doctors International to New Ireland Provincial Health and Kavieng Hospital while maintaining the same level of patrol and in-service services. Funding is provided to conduct 11 patrols a year at 400,000 kina and two in-service week long sessions. Current plans are in place for New Ireland to form a Provincial Health Authority (PHA). The PHA is a single provincial health authority integrating the management of hospital services and rural (primary) health services (instead of hospitals being managed separately by NDoH and rural health services by provincial governments). The transition plan outlined below takes the formation of a New Ireland PHA into account. Figure 12: Transition plan overview outlines the functional and job transitions to occur during the transition phase as ownership of patrol and in-service services moves from shared responsibility between ADI and NIPH, to primary responsibility with NIPH. These steps take the goals of sustainability, efficiency and effectiveness into account.

Figure 12: Transition plan overview

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Transition of Functions Funding and high-level decision making

- The aim of these transitional steps are: o to secure financial resources for patrols and in-service programs o to establish a decision-making body with financial authority over the patrol and in-service budget items. . Establish an Outreach Committee as a section of the PHA. The Outreach Committee oversees coordination between different groups within hospital and provincial health, arranges patrol schedules at a high level and has funding authority. The Outreach Committee is comprised of Head of PHA, hospital representative, provincial health representative, outreach manager, patrol coordinator and one representative from each of the specialties. LLG managers and/or representatives from the health centres may also join. . Determine need for bank account signatories (in addition to Doug Tsang - Continue to build the structure, focus, remit and authority of the Education Committee. . Feed into the New Ireland Health Education Committee, in-service training topics planned and register of health workers continuing educational status.

New Ireland Health Education Committee The committee meets monthly to consult and determine the topics for in-service, appropriate presenters and to identify rural health staff to attend the in-service. Members are from Provincial Health, Kavieng Hospital, church based services and ADI

Establish regular and sustainable PNG medical participation in patrols

- The aim of these transitional steps are: o to transition Australian doctor participation out, and increase PNG doctor participation in a sustainable way o to ensure staffing models developed for the hospital take into account the requirements for a 0.5 FTE doctor delivering outreach services via patrol. - As the role for the Australian doctor diminishes, greater responsibility is shifted to the ADI Health manager.

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Patrol and in-service management

- The aim of these transitional steps are: o to develop the skills, capacity and professional recognition of patrol coordinator and health manager positions within the functional organization of the PHA (or Provincial Health).

Transition of positions

Current  Change Result Australian patrol doctor  over 2-3 year period PNG patrol doctors – rotating position on identifies roster of local PNG doctors who can patrol (potentially 1 week only). Patrol rotate through patrols. schedule may have to be designed to fit with doctor(s) availability. RMOs to regularly attend patrols to take on responsibility for capacity building and education Suite of RMOs with experience and component of patrols. knowledge to support patrol education and capacity building. Head count of hospital staff takes into account patrol/outreach requirements (0.5 FTE per annum) Kavieng based Health Projects Manager  Permanent position Health Projects position becomes paid (review salary level), Manager with salary 43,000 kina. appointed for 2-3 years in position based in Reports to head of Provincial Health Kavieng. Authority Rationale: Longer term appointment fills current Head of Provincial Health and Health on-the-ground strategic and communications gap, Projects Manager joint management of allows individual to build on knowledge year to funds year, give weight to partner relations and allows them to play a role in securing long-term the patrol/in-service programs. Allows them to mentor NIPH Patrol Coordinator position to become Health Projects Manager. NIPH Patrol Coordinator  current position casual Position budgeted for as part of patrol and paid 26,902 kina per annum. Balance of program. Permanent role. funding from patrol funds used to make this a permanent position at a grade level with an annual salary of 34,000. At the end of the 2-3 year training period, eligible to apply for outreach manager position. Sydney based PNG Programs Manager  with Depending on number of programs in PNG, growing portfolio of PNG based programs, position may have two program managers ideally potentially relocates to PNG as a Country Director. based in PNG. Additional provincial programs to recruit a Health Projects Manager.

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Acronyms

ADI Australian Doctors International ANC antenatal coverage DALYs Disability Adjusted Life Years DOTS Directly Observed Treatment Short course GHEpc Government health expenditure per capita LLG Local Level Government LMIC low and middle income country MMR maternal mortality rate NDoH National Department of Health NIPG New Ireland Provincial Government NIPH New Ireland Provincial Health O&G Obstetrics & Gynaecology RMOs Resident Medical Officers U5MR under-5 mortality rate UN United Nations WHO World Health Organisation

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References

1. Government of PNG. Transforming our health system towards Health Vision 2050: National Health Plan 2011–2020. (2010). 2. WHO. Increasing access to health workers in remote and rural areas through improved retention: Global Policy Recommendations. (WHO, 2010). 3. World Bank. Papua New Guinea: World Bank overview. Available at: http://www.worldbank.org/en/country/png/overview.

4. PNG National Economic and Fiscal Commission & . Raising the Bar: THE 2013 PROVINCIAL EXPENDITURE REVIEW with trend analysis from 2009 to 2013. (2015). 5. Mola, G. & Kirby, B. Discrepancies between national maternal mortality data and international estimates: the experience of Papua New Guinea. Reprod. Health Matters 21, 191–202 (2013). 6. Institute for Health Metrics and Evaluation. GBD PROFILE: PAPUA NEW GUINEA; GLOBAL BURDEN OF DISEASES, INJURIES, AND RISK FACTORS STUDY 2010. (Institute for Health Metrics and Evaluation, 2010). 7. Scheil-Adlung, X. Global evidence on inequities in rural health protection: new data on rural deficits in health coverage for 174 countries. (INTERNATIONAL LABOUR OFFICE, 2015). 8. Scheil-Adlung, X. Health workforce benchmarks for universal health coverage and sustainable development. Bull. World Health Organ. 91, 888–889 (2013). 9. WHO. Spotlight: on health workforce statistics. (2006). 10. Howes, S. et al. A Lost Decade? Service Delivery and reforms in Papua New Guinea 2002-2012. (2014). 11. Department of Health, PNG. FREE PRIMARY HEALTH CARE AND SUBSIDIZED SPECIALIST SERVICES POLICY: Implementing the Alotau Accord. (2013). 12. Sweeney, R. & Mulou, N. Fee or free? Trading equity for quality of care for primary health care in Papua New Guinea. Int. Health 4, 283–288 (2012). 13. World Health Organisation. WHO Questions and answers on Universal Health Coverage. Available at: http://www.who.int/healthsystems/topics/financing/uhc_qa/en/. 14. Sustainable Development Solutions Network. Health in the Framework of Sustainable Development: Technical Report for the Post-2015 Development Agenda. (Sustainable Development Solutions Network: A Global Initiative for the United Nations, 2014). 15. Robert, E. & Ridde, V. Global health actors no longer in favor of user fees: a documentary study. Glob. Health 9, 29 (2013). 16. Lagarde, M. & Palmer, N. in Cochrane Database of Systematic Reviews (ed. The Cochrane Collaboration) (John Wiley & Sons, Ltd, 2011).

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Annexure 1: Health Facilities and Aid Posts (November 2015 status)

Centre Name Run by Supervised Officer in Functioning Remoteness to Organisation by Charge patrol base*

Babase Government Joanne Sianot Open Very remote Banam Government Palie Gervina Tony Open Remote Banasa Government Mapua Closed Less remote Bangalu Government Epo Dickson Riniwan Open Very remote Bol Government Clematsia Kliawi Open Less remote Cape Sena Government Manga Blaise T Open Remote Dalom Government Kimadan Damaris Boski Open Less remote Epo Government Enderlyn Sibia Open Very remote Hilalon Government Lipek Closed Remote Gerard Hitung Government Pukpuk Otokorofi Open Very remote Kabanut Church Eddie Korongon Open Remote Kabil Government Bol Closed Less remote Kait Government Pukpuk Closed Very remote Kamalabo Government Messi Closed Very remote Kapsel Government Lipek Robin Wenzel Open Remote Kapsipau Government Manga Albina John Open Remote Karu Government Kimadan Open Less remote Kavieng Kaselok Government Urban Peter Tuagon Open Close by Catherine Katagan Government Kimadan Kayape Open Less remote Netlymael Katalusae Government Epo Ismael Open Very remote Kavieng Urban Government Jennifer Roberts Open Close by Kimadan Church Anna Rhawes Open Less remote Kokola Government Messi Luke Janget Closed Very remote Kolonoboi Government Namatanai Martin Susuat Open Very remote Closed - Konos Clinic Government Kimadan Johnson Oliver Temporary Less remote KuduKudu Government Namatanai Open Very remote Labur Government Namatanai Pech Segai Open Very remote Lamassa Government Cathy Bulu Open Very remote

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Centre Name Run by Supervised Officer in Functioning Remoteness to Organisation by Charge patrol base*

Lamau Government Panaras Open Very remote Lambom Government Lamassa Rulin Goro Open Very remote Lamusmus Government Lemakot Larusi Pilok Open Less remote Lataul Government Palie Hillary Pinah Open Remote Lavongai Church Jeanett Murat Open Less remote Lemakot Church Cathy Artu Open Close by Lenkaman Government Kimadan Julie Sonnie Open Less remote Lipek Government Andrew Stiphi Open Remote Liuke Government Epo Closed Very remote Kavieng Lokono Government Urban Mati Rangai Open Close by Madina Government Lemakot Simon Marianas Open Close by Mahur Government Masahet Cecilia Anos Open Very remote Albina Mali Government Masahet Matkonos Open Very remote Malo Government Manga Tomar Ladi Elias Open? Remote Maristelle Manga Church Gabriel Open Remote Manggai Government Lemakot Anisain Eserom Open Close by Mapua Church Nick Kopsi Open Less remote Simberi Marai Government Urban Charles Laru Open Very remote Masahet Government Wilson Ezekiel Open Very remote Bartholomew Matantiduk Government Namatanai Tobilisi Open Remote Mazuz Government Palie Balbina Yawi Open Remote Messi Church Lucy Hayai Open Very remote Meteiai Private Taskul Jeffrey Kelep Open Less remote Metemana Government Open Remote Meterankasing Government Puas Shirley Tameluk Open Less remote Metevoi Government Lovangai Josepha Vaitas Open Less remote Augusta Muliama Government Manga Honanang Open Remote Namatanai Government Tulaba Tom Open Remote Natong Government Odilia Sianot Open Remote Kavieng Ngavalus Government Urban Nelson Kelep Open Close by

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Centre Name Run by Supervised Officer in Functioning Remoteness to Organisation by Charge patrol base*

Noi Puas Government Puas John Balane Open Remote Rosemary Olekowa Government Masahet Tohielatz Open Remote Palabong Government Namatanai Open Remote Palie Church Sophie Alip Open Remote Panachais Government Panaras Open Very remote Panaras Government Wilzon Wazami Open Very remote Patipai Government Taskul Closed Less remote Gwynette Piliwa Church Weuta Open Less remote Poliamba Private Open Remote Mathilda Puas Church Lemvaitas Open Less remote Pukpuk Government Tom Roso Open Very remote Put Put Government Masahet Peter Mapat Open Remote Rakupo Government Mapua Closed Less remote Ranmelek Government Lovangai Closed Less remote Rasirik Government Namatanai Elizabert Tabu Open Remote Ratubu Government Kabanut Peteli Tibo Open Remote Sagu/Ramat Bush Clinic Private Open Remote Samo Government Palie Winnie Penias Open Remote Silur Government Joyce Osta Open Remote Silur Government Joyce Osta Open Remote Simberi Mine Clinic Private Jesse James Open Very remote Simberi Urban Government Fidelis Gira Open Close by Sohun Government Namatanai Raphael Nepos Open Remote Sumuna Government Piliwa Closed Less remote Tanaliu Government Epo Closed Very remote Gertrude Tanga Church Funmat Open Very remote Tasingina Government Menson Abel Open Very remote Taskul Government Edward Abel Open Less remote Simberi Tatau Government Urban Georgina Unum Open Close by Tench Government Tasingina Raylyn Abert Open Very remote

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Centre Name Run by Supervised Officer in Functioning Remoteness to Organisation by Charge patrol base*

Tingwon Government Camilla Sabok Open Very remote Closed - Tsoi Government Taskul Julianne Kasi Temporary Less remote Ugana Government Panaras Closed Very remote Ulapatur Government Messi Closed Very remote Umbukul Government Open Less remote Usil Government Lemakot Open Very remote Closed - Vaisavambam Government Taskul Silas Febuar Temporary Less remote Closed - Veitin Valley Government Silur Rita Tomar Temporary Remote Closed - Wang Government Mapua Temporary Less remote

Based on November 2015 data * ADI analysis

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Annexure 2: Clinical Survey Demographics and Scores

Open from early 2016 until end of May 2016. N = 80 respondents

Demographics Female 58 Male 21 unknown 1

Health worker CHW 45 HEO 4 Junior NO 1 NO 16 OIC 1 RMO/SIC 1 RNO 2 SIC 3 unknown 7 LLG Kavieng Urban 6 Konos 4 Lavongai 12 Murat 5 Namatanai 2 Nimamar 3 Sentral 6 Tanir 2 Tikana 29 Murat 1 Sentral Niu Ailan 3 Konoagil 7

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Question 11 was the least correctly answered clinical question, with only 3% of respondents getting it correct. 11. Lower abdominal pain syndrome in women

a. Is always due to an infection either PID or STI and will always require antibiotic treatment

b. Is never related to past abdominal surgery

c. If a period is missed it probably is nothing to worry about

d. Can often be due to chronic abdominal wall strain associated with hard work

The following questions had <50% correct respondents:

2. TB treatment must always commence on every patient with

a. A positive sputum smear

b. A suspicious CXR

c. Chronic cough with shortness of breath and blood stained sputum

d. A family history of TB

e. All of the above

44% correct

7.2 – malaria RDT quiz – 46% correct

8 A mother brings in her 3 month old baby with a two day history of vomiting and diarrhoea and has not been feeding well. The correct management involves all of the following EXCEPT

a. Assess the baby for dehydration and commence IV fluids if indicated

b. Perform a malaria RDT

c. Start antibiotic treatment and ORS and stop breast feeding

d. Take a detailed history and perform an examination looking for other infections

49% correct

17. Management of Hypertension should include all of the following except

a. Weight loss if obese

b. Advice to stop smoking and chewing

c. Gentle exercise

d. Medication such as Enalapril but only until the BP comes back to normal

48% correct

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Annexure 3: Cost categories 2013-2015

2013 2014 2015 2013 2014 2015 Total Total Total Total Actuals Total Total Actuals Actuals Actuals Cost 2013 Actuals Actuals 2013 2014 2015 Item centre Kina 2014 Kina 2015 Kina Kina % Kina % Kina %

Travel allowances NIPG 84,600 62,336 77,999 14% 11% 11% Accommodation/Food NIPG 59,236 59,557 56,039 10% 11% 8% Food NIPG - 19,042 0% 0% 3% Fuel NIPG 20,131 18,030 12,330 3% 3% 2% Plus Fuel card NIPG 9,931 - 7,756 2% 0% 1% Transport hire NIPG 58,978 47,877 70,352 10% 9% 10% Miscellaneous NIPG 6,227 7,976 3,859 1% 1% 1% Education Material NIPG 1,258 - 0% 0% 0% Medical Supplies NIPG 30 4,767 0% 0% 1% Sub-total direct costs NIPG 239,103 197,064 252,144 40% 35% 34% Rent NIPG 48,000 48,000 47,998 8% 9% 7% Electricity NIPG 2,488 5,385 5,979 0% 1% 1%

Stationery, printing, NIPG 209 6,244 177 0% 1% 0% education Materials Telephone NIPG 200 - 1,091 0% 0% 0% Vehicle Costs - Tyres NIPG 1,361 2,548 - 0% 0% 0% Vehicle Costs - Fuel NIPG 7,887 18,073 4,916 1% 3% 1% Vehicle Costs - Rego NIPG 1,678 3,220 11,864 0% 1% 2% Finance Management NIPG 11,000 11,000 10,750 2% 2% 1% Medical Supplies NIPG - 4,931 4,975 0% 1% 1%

Sundries - Shirts for NIPG 638 4,061 698 0% 1% 0% doctors/staff Training Materials NIPG 26,393 0% 0% 4% Bank Fees NIPG 121 298 202 0% 0% 0%

Sub-total indirect costs NIPG 73,582 103,761 115,043 12% 19% 16%

Total NIPG Costs in Kina NIPG 312,685 300,825 367,187 53% 54% 50% Living allowance ADI 28,712 24,737 24,036 5% 4% 3% Food allowance ADI 14,770 19,074 15,884 2% 3% 2% I'tnl Travel/Accomm ADI 12,757 13,391 19,414 2% 2% 3% Syd Staff Cost Alloc ADI 50,505 75,071 85,220 9% 13% 12% Local Ohead Alloc ADI 25,602 21,517 67,105 4% 4% 9% Other ADI 11,255 10,264 37,078 2% 2% 5%

Sub-total ADI Integrated Patrol Costs Kina ADI 143,602 164,054 248,738 24% 29% 34% Subtotal Provincial Provincial Health and Hospital staff and 137,390 95,002 121,157 23% 17% 16% salary costs hospital Total Integrated Patrol staff Costs ADI & NIPG (KINA) 456,287 464,879 615,924 77% 83% 84%

593,676 559,881 737,081

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