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Public Expenditure, Decentralisation and Service Delivery in Papua New Guinea

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Public Expenditure, Decentralisation and Service Delivery in Papua New Guinea Public Expenditure, Decentralisation and Service Delivery in Papua New Guinea: Tracking Budgets to Health Clinics Colin Wiltshire A thesis submitted for the degree of Doctor of Philosophy at the Australian National University October © Copyright by Colin James Wiltshire All Rights Reserved Declaration (i) This thesis comprises my original work towards the PhD except where indicated. (ii) Acknowledgement has been made in the text to all other materials used. (iii) The thesis is fewer than , words in length, exclusive of tables, maps, bibliographies and appendices. Colin Wiltshire October iii Dedication For the people of Deigam Village. v Acknowledgements I am deeply indebted to colleagues, family, and friends who provided exceptional guidance and personal support to me throughout my PhD candidature. I would like to firstly thank my primary supervisor, Associate Professor Nicole Haley. Without her kind‐hearted encouragement and strong commitment to my research I may never have started, let alone managed to submit, this thesis. Professor Stephen Howes, my work supervisor for a significant part of my candidature and thesis panel member, demonstrated to me the leadership and dedication required to produce influential research. Academics from the State, Society and Governance in Melanesia Program (SSGM) in the Coral Bell School of Asia Pacific Affairs at the Australian National University (ANU) provided the ideal multi‐disciplinary academic unit for me to pursue my research. In particular, I thank my PhD panel members from SSGM. Associate Professor Richard Eves always found the time to provide considered advice and gave me the confidence to trust my own research and writing abilities. Anthony Regan provided both encouragement and critical feedback based on his immense knowledge of my subject matter, which challenged me to think deeply about how I interpreted my research findings. I was fortunate that Emeritus Fellow Dr Ronald May and Dr William Standish were able to provide instructive comments on my thesis drafts. I only hope I can build upon the fine research they have produced on Papua New Guinea (PNG) through their many years of dedicated scholarship. ANU management and support staff, particularly those at SSGM and the Development Policy Centre, were invaluable in their on‐going support for my research. They appreciated that I had to work full‐time and part‐time throughout my entire candidature in PNG, Melbourne and Canberra. Their understanding of my personal circumstances, and assistance in accommodating flexible working arrangements, were fundamental to me completing this thesis. In addition to those vii on my supervisory panel, I want to thank Peta Jones, Claire Shrewsbury, Dr Julian Barbara and Associate Professor Sinclair Dinnen. I would also like to acknowledge academics and staff from other schools at the ANU. I thank Emeritus Professor Terry Hull and Professor Janette Lindsey for supporting my original PhD application. Dr Anthony Swan showed enormous patience in teaching me to code and analyse the data collected from fieldwork. Associate Professor Blane Lewis provided instructive feedback on the broader decentralisation literature beyond PNG. I extend my gratitude to the Academic Skills and Learning Centre, in particular to Tess Snowball for her excellent advice on the early draft chapters of this thesis, which greatly developed my academic writing skills. Karina Pelling and the CartoGIS unit also provided tremendous assistance in supporting the production of maps and flow charts. I also thank Candida Spence for help with editing on the final draft. Former colleagues from the Australian Agency for International Development (AusAID), particularly at the Australian High Commission in PNG, provided the initial motivation for me to conduct this research. In particular Steve Hogg, who shares a similar passion for PNG’s development, continues to provide me with exceptional guidance and mentoring. I also want to thank Solstice Middleby, Joanne Choe, Anthony Mason, Bill Costello and Stephanie Copus‐Campbell. I was fortunate to formally collaborate with the National Research Institute of PNG (NRI) throughout my PhD candidature. I gratefully acknowledge Dr Thomas Webster, former Director of NRI, for his leadership in supporting institutional linkages between NRI and the ANU. It was a privilege to conduct joint fieldwork with NRI researchers, particularly Dr Alphonse Gelu and Andrew Mako, who taught me so much during our many fascinating fieldwork adventures in PNG. The Central Province Administration was a great supporter of my research. Spending more than three years in the province as the AusAID representative for the Papuan region was easily the best working years of my life. Their generosity of spirit and willingness to accept me inspired this research. I deeply appreciate the camaraderie and value the life‐long friendships formed. In particular, I thank viii Raphael Yibmaramba, Gai Raga, Marina Faiteli, Mark Chambers, Michael Wise, the late John Here, Baru Morea, the late Rose Isana and Morea Arua. I also gratefully acknowledge the Abau and Goilala District Administrations, particularly Apatia Puri and Titus Girau. I would like to thank the Papua New Guinea Defence Force, particularly the medics, who worked with front‐line health workers to support the remote outreach patrol clinics documented in this thesis. The generosity offered to me from all the provinces and districts visited throughout this research are too numerous to mention, but I will be forever grateful for their support and hospitality. My family was immensely supportive throughout my PhD candidature. I want to thank my parents, Carolyn and Robert, who understood the personal sacrifices and missed family events. My brother, David spent hours of his time to helping me with revisions and provided me with great study music. My sister, Allison updated me on life outside work and made me laugh. My wife’s parents, Adrian and Angela, provided family support so that I could attend to the thesis writing. While I am so fortunate to have close friends that provided personal support, I particularly want to thank Paul Hasler and Linda Gulliford, who showed kindness and understanding when I needed it most. Daniel McKenzie allowed me to vent on our long runs and cared about how I was coping. Sandeep Sangha was someone I could always turn to for a light or deep chat. I also thank Dr Chris Hobson, an academic and friend, who I could turn to for blunt work and personal advice. Finally and most importantly, I thank my wife, Carla, for her incredible love, encouragement and personal sacrifice. The trials and tribulations I experienced in producing this thesis pale into insignificance when compared to what my wife had to endure to survive a major accident. I could only admire her strength of character and determination to make it through our darkest hours, facing months of surgeries, intensive care and a recovery that lasted years. Carla was the one who encouraged me to return to my research and accepted that I had to be away when she really needed me. It is a remarkable blessing that we now have our beautiful daughter, Sadie, who is our light. Neither of us would have made it if it were not for her strength and resilience. Thank you. ix Abstract Forty years post‐independence, Papua New Guinea’s (PNG) development aspirations remain unmet. Important social and human development indicators have stagnated, as has the delivery of basic public services, especially for PNG’s large rural populace. Over the last decade, PNG has experienced strong economic growth from an extended resource boom. Much of the increased revenues generated have been invested into public expenditure reforms aimed at improving service delivery through decentralised governance arrangements. This thesis questions whether the significantly increased public expenditure commitments to service delivery have been translated into improved health services on the ground. A mixed methods approach was adopted that involved undertaking PNG’s largest and most comprehensive health expenditure tracking and facility survey, combined with in‐depth case studies that mapped the implementation of national budgets to front‐line service providers, and actual health delivery to communities. This thesis makes a significant contribution to research on the changing political economy of service delivery in PNG. It delivers a policy relevant and empirically grounded analysis of the state of health services and the politics that have driven decentralisation reforms. New findings are presented on the status of PNG’s health clinics, how they receive funding, raise revenue and the services that are delivered. Comparative survey data indicates that health service delivery has largely declined over the last decade, despite huge increases in recurrent and development health budgets. It is argued that the weak implementation of previous and current decentralisation reforms have contributed to widespread inefficiencies and inequalities in the delivery of health services across PNG. The implications of these findings are analysed in the context of contemporary health expenditure reforms in PNG, which are increasingly politicised and appear destined to repeat past failures. This thesis finds that PNG’s major health policies xi are poorly targeted, misaligned with strengthening the health system, and do not address weaknesses in health financing. In particular, PNG members of parliament have directed ever‐increasing constituency development funds
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